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Background Failure of conservative treatment in patients over 70 years of age with a rotator cuff tear makes surgery a possible option, considering the increase in life expectancy and the high functional demands of elderly patients. The purpose of this systematic review of the literature was to evaluate the subjective and objective outcomes after arthroscopic rotator cuff repair in patients over 70 years of age. Methods A systematic review was performed to identify all the studies reporting subjective and objective outcomes in patients aged 70 years or older undergoing arthroscopic rotator cuff repair. Constant Murley Score (CMS), visual analog scale (VAS), American Shoulder and Elbow Surgeons Score (ASES), and Simple Shoulder Test (SST) were used to detect any clinical improvement after surgery. Retear and satisfaction were also analyzed. Results Out of 941 studies identified, only 6 papers have been included in the review. All studies reported improvements in postoperative functional outcome scores that exceed the minimal clinically relevant difference. The mean retear rate amounts to 21.9%, which is in line with the failure rate of rotator cuff repair in general population. Moreover, postoperative satisfaction is very high (95%). Conclusion This systematic review suggests that arthroscopic rotator cuff repair in patients over 70 years of age could be a valid treatment option after failure of conservative approach. Level of evidence: 4 Trial registration The study was registered on PROSPERO (registration ID: CRD42018088613)

Musculoskeletal research is mostly clinical and participation of human subjects is extremely common. It shares most features with all the surgical research fields, with studies on operative procedures largely prevailing over those on pharmacological interventions. In the orthopedic research scenario, prostheses and other implantable hardware often correspond to the role that drugs play in medical research, with no less potential harm for the populations studied. Not rarely, vulnerable categories are involved, for instance children in pediatric orthopedics. In the emerging branch of musculoskeletal regenerative medicine, embryonic stem cells are not used, but only adult somatic stem cells, which considerably reduces but does not remove the ethical issues connected with these new applications. Given these premises, guaranteeing human subjects protection is mandatory for authors, editors and publishers, firstly because “the health of my patient will be my first consideration” (from the World Medical Association Declaration of Geneva [1]), but also because biomedical publishing is not exempt from possible litigation. Since editors are ultimately responsible for what is published, they have to enforce strict requirements to ensure that proper ethical standards are fulfilled. Sometimes such requirements seem to subject authors to a burden of paperwork that equals the scientific effort, but intolerance of this is generated by a misinterpretation: science and ethics cannot stand alone, nor can they be neatly separated in any research project. There are three milestones of ethical human research: the Declaration of Helsinki, informed consent and ethics committee approval. Most journals, as we do at Journal of Orthopaedic Traumatology, ask authors to make a precise statement under their own responsibility to guarantee that these requirements are met. But formally reporting adequate ethical standards cannot be considered sufficient for publication, if anywhere along the process of manuscript review relevant concerns are raised about the substantive ethical conduct of the investigators.

Purpose: To build a post-arthroscopy outcome-predictive score (POPS) associated with the likelihood of lasting benefit after arthroscopic treatment of femoroacetabular impingement (FAI) and based solely on unambiguous preoperative information. Methods: A population of 220 FAI patients, operated on with standard techniques by orthopaedic surgeons trained in hip arthroscopy in 6 different centres, was evaluated physically or by telephone interview 2 to 5 years after surgery. The criteria of successful mid-term outcome (SMO) were agreed upon by all authors. A multivariate logistic regression, adjusted for patient’s age and centre, was applied to predict SMO. In the model, the variables associated with the outcome were included and the relative ORs (odds ratios) were used to compute the FAI-POPS (FAI - post-arthroscopy outcome-predictive score). A ROC (receiver operating characteristic) curve was plotted and the optimum cut-off was calculated. Results: 155 patients out of 220 showed a successful mid-term outcome. The optimum cut-off of FAI-POPS was calculated to be 6.3 and with this threshold it proved a sensitivity of 0.66 and a specificity of 0.69, a positive predictive value of 0.84 and a negative predictive value of 0.46. Conclusions: The standard arthroscopic treatment of FAI resulted in satisfactory persistent symptom relief for about 70% of patients. No or minimal osteoarthritis, short time elapsed from the appearance of symptoms and high preoperative modified Harris Hip Score are independent predictive factors of SMO. The FAI-POPS is obtained as sum of 3 odds ratios corresponding to the above prognostic factors and is a useful predictor of mid-term outcome after conventional arthroscopic FAI treatment.

Developing a sound research methodology is a pre-requisite to produce publishable results. New authors should focus on finding original topics, that are not only novel, but also clinically relevant, on designingsound study protocols with possible assistance of a biostatistician and on writing reports (Original Article) conforming to the rules of Academic writing. Basic statistical knowledge, familiarity with Academic writing and training about bioethical issues are propaedeutic to producing good-quality manuscripts.

Acetabular bone loss is a relevant concern for surgeons dealing with a failed total hip arthroplasty. Since the femoral head is no longer available, allografts represent the first choice for most reconstructive solutions, either as a structural buttress or impacted bone chips. Even though fresh-frozen bone is firmly recommended for structural grafts, freeze-dried and/or irradiated bone may be used alternatively for impaction grafting. Indeed, there are some papers on freeze-dried or irradiated bone impaction grafting, but their number is limited, as is the number of cases. Xenografts do not represent a viable option based on the poor available evidence but bioactive bioceramics such as hydroxyapatite and biphasic calcium phosphates are suitable bone graft extenders or even substitutes for acetabular impaction grafting. Bone-marrow-derived mesenchymal stem cells and demineralised bone matrix seem to act as reliable bone graft enhancers, i.e. adjuvant therapies able to improve the biological performance of standard bone grafts or substitutes. Among these therapies, platelet-rich plasma and bone morphogenetic proteins need to be investigated further before any recommendations can be made.Cite this article: EFORT Open Rev 2016;1:431-439. DOI:10.1302/2058-5241.160025

In 2000 Francesco Pinino founded the Journal of Orthopaedics and Traumatology (JORT), with the plain intention of providing the Italian Society of Orthopaedics and Traumatology (SIOT) with a powerful communication tool, through which Italian authors could spread the results of their research activity beyond the borders of Italian language, and contemporarily the contributions of foreign scientists could be published in an Italian-based journal with a clear propensity for a worldwide circulation. At the beginning the former effect was more evident, mostly because the journal still needed to be acknowledged by the international community, but in recent years the latter became largely prevalent and made JORT a globally recognized scientific journal dealing with all aspects of musculoskeletal medicine and surgery. The submissions analysis confirms this development: in 2010, 191 manuscripts were submitted, 68.6 % of which had foreign authorship, while in 2013, 223 manuscripts were received, and 81.6 % of them had a foreign corresponding author. This positive trend seems to be confirmed in 2014, with further rise of submissions and a remarkable increase of contributions originating from countries with top quality scientific production.

Absorbable sutures are widely used for wound closure after total hip replacement. Here we present two cases of suture-related foreign-body reaction that perfectly mimicked a periprosthetic joint infection, with sterile abscess formation and physical and laboratory signs of inflammation acutely presenting 7-8 weeks after surgery, at the time of suture absorption. Both recurred with analogous timing after irrigation and debridement, likely due to re-using the same suture material. Multiple negative microbiological samples and positive histological samples showing a foreign-body reaction are the fundamental steps towards the diagnosis of a suture-related pseudoinfection (SRPI). Only three other cases have been reported to date, but the recurrence, together with the self-healing course after relapse, represents a completely novel feature and possibly the strongest demonstration of the supposed aetiopathogenesis. The knowledge of this possible complication leads to some clinical implications: all potential periprosthetic joint infections should routinely undergo not only microbiological but also histological sampling; caution should be used when recommending prosthesis exchange for potential infections occurring in the time range of suture absorption; lastly, if SRPI is suspected, a suture with low propensity to induce foreign-body reactions should be chosen after irrigation and debridement and the volume of absorbable material left in the wound should be as small as possible.

Background Pelvic posture and kinematics influence acetabular orientation and are therefore expected to be involved in the pathomechanics of femoroacetabular impingement (FAI). This systematic review aims to determine whether FAI patients show pelvic postures or patterns of motion contributing to impingement or, conversely, develop compensatory postures and patterns of motion preventing it. Materials and methods PubMed/MEDLINE, Embase, Google Scholar and the Cochrane Library were systematically searched to find all the studies that measured pelvic positional and/or kinematic data in humans (patients or cadaveric specimens) affected by FAI. Results Twelve items were selected and grouped according to the main field of investigation. No quantitative data synthesis was allowed due to methodological heterogeneity. Pelvic posture and kinematics seem to play a relevant role in FAI. The patients, especially if symptomatic, show a paradoxical lack of pelvic back tilt in standing hip flexions, i.e., in squatting, that enhances femoroacetabular engagement. Such an aberrant pattern might depend on a lower pelvic incidence. On the contrary, active hip flexion in decubitus elicits a compensatory, more pronounced back tilt to facilitate hip flexion without impingement. Stair climbing shows a compensatory pattern of augmented pelvic axial rotation and augmented peak forward tilt to reduce painful hip motions, namely internal rotation and extension. Conclusion In FAI patients, pelvic posture and kinematics are sometimes an expression of compensatory mechanisms developed to reduce pain and discomfort, and sometimes an expression of paradoxical responses that further enhance the impingement pathomechanism. Level of evidence IV. Electronic supplementary material The online version of this article (doi:10.1007/s10195-016-0439-2) contains supplementary material, which is available to authorized users.

A comprehensive review of the existing literature, related to treatment options and management principles of pilon fractures was performed, and its results are presented. The identified series advocate in favour of a number of different treatment strategies and fixation methods. Decision making was mostly dependent on the severity of the local injury, the fracture pattern, the condition of the soft tissues, patient's profile and surgical expertise. External fixation and conservative treatment did not provide sufficient articular congruence in many cases. Internal fixation allowed excellent restoration of joint congruity in Ruedi type I and II fractures. A staged approach, consisting of fibular plating and temporary bridging external fixation, later substituted by an internal minimal invasive osteosynthesis or by a definitive external fixation, was favourable for Ruedi type III fractures. Closed pilon fractures with bad soft tissue conditions (Tscherne ≥ 3) or open pilon fractures are regarded as contraindication of open reduction plate fixation. Anatomic reduction of the fracture, restoration of joint's congruence, reconstruction of the posterior column, with minimal soft tissue insult, were all highlighted as of paramount importance.

Internal snapping hip is a syndrome caused by recurrent subluxation of the iliopsoas tendon. There is little agreement regarding the impinging sites responsible for the jerky motion of the tendon. Thus far, the lesser trochanter, anterior capsule, and iliopectineal eminence are considered the most likely catching sites.We report an unusual case in which a calcific tendinitis of the rectus femoris direct head impinged against the overlying iliacus muscle, resulting in a painful coxa saltans. The exclusive involvement of the direct head hid the calcium deposit on standard radiographs, whereas MRI suggested but poorly showed the tendon disease. Dynamic ultrasonography and CT scanning allowed a precise diagnosis and subsequent treatment with CT-guided steroid injection.Calcific tendinitis of the rectus anterior direct head has not been reported as a possible cause of snapping hip; involvement of the direct head in rectus anterior calcific tendinitis was described in one case.Our case shows the rectus anterior direct head may be involved in the etiology of coxa saltans. Theoretically any thickening of the tendon might activate the same pathomechanism. Physicians should consider this possible new cause of internal snapping hip when the most common ones have been excluded, especially as it may be managed easily with steroid injection.

Femoroacetabular impingement has emerged as a cause of osteoarthritis of the young hip. This article presents a modified open procedure for cases that cannot be completely managed arthroscopically.

Purpose The direct anterior approach (DAA) for total hip arthroplasty (THA) is claimed to be as effective but less invasive than the conventional posterior approach (PA). However, the higher risk of femoral fracture and soft tissue damage cannot be underestimated. The present authors believe that the difficult femoral exposure and the surgeon's knowledge of possible complications related to femoral preparation may result in a higher rate of undersized stems when compared to PA, even when a short femoral component is employed to minimise these risks. Methods A retrospective study was performed to compare the effective adherence of surgical sizing to preoperative planning in a series of 112 short stem THAs, of which 59 were implanted through PA and 53 through DAA without intraoperative imaging, by a single surgeon skilled in both techniques. Results the frequency of stems smaller than expected was 3-times higher with DAA than with PA (54.72% vs 16.95%, pConclusions The technical difficulty of femoral preparation and the surgeon's knowledge of possible related complications might lead to implant undersized stems more frequently through DAA than through PA, especially if intraoperative imaging controls are not used.

Femoro-acetabular impingement (FAI) is a common hip disease, recently recognized more and more frequently due to the wider circulation of its knowledge among orthopedists and radiologists. Very active children and adolescents are prone to develop hip pain if the femoral head–neck junction is dysmorphic and/or the acetabular coverage is augmented, either focally or globally. The former case is named cam-FAI, since the cervical deformity acts as a cam within the socket; the latter is named pincer-FAI, since the overhanging acetabular wall crushes the labrum against the femoral neck just like a pincer. Most FAIs become symptomatic after the second decade of life. When it occurs earlier, usually the deformity is quite severe and is secondary to slipped capital femoral epiphysis or to Perthes disease. Sometimes mild deformities show themselves early due to extremely intensive sports training, involving deep, and repetitive flexion of the hip. Conservative management is recommended till physeal closure, and then selected patients will benefit from corrective surgery.

Pelvic avulsion fractures are indirect injuries that may involve the ischial tuberosity (IT), the two anterior iliac spines, the iliac crest (IC), or the trochanters of adolescent athletes usually after sudden eccentric muscular contractions. Most of these fractures will heal with conservative treatment, but recognizing excessive displacement is essential to select those few patients who might benefit from surgical fixation, avoiding long-term functional impairment. Diagnosis, treatment options, and potential sequelae are discussed.

Acetabular both-column fractures are challenging articular injuries. They usually require operative treatment. We report on fundamental elements of pathoanatomy and radiology that are reviewed as far as they may influence treatment planning and surgical intervention. Surgical strategy, choice of the most suitable approach, reduction manoeuvres and fixation techniques are presented, together with some tips and tricks that are worth knowing in the surgical reconstruction of these difficult fractures.

As a result of reading this article, physicians should be able to: 1. Describe the clinical and radiological features of thigh pain related to femoral total hip components. 2. Discuss the pathophysiology of thigh pain in total hip replacement (THR) patients. 3. Describe the classification system for thigh pain according to the underlying pathomechanisms, 4. Discuss the available therapeutic solutions for thigh pain following THR.

Osteonecrosis after neck fractures or hip dislocation may constitute a severe complication, able to compromise the final result of previous treatments. This event could evolve towards important secondary osteoarthritis, with head collapse, reduction of chondral lining, subsequent morphological changes in the acetabular cavity, and complete articular disruption.

Background Open hip surgery is known to be a risk for heterotopic ossification (HO), and nonsteroidal anti-inflammatory drugs (NSAIDs) have been widely recognized as an effective prevention. Hip arthroscopy is gaining popularity thanks to the possibility of treating femoroacetabular impingement (FAI) with a minimally invasive technique, however little is known about its rate of postoperative HO. The aim of the present study is to evaluate HO prevalence after hip arthroscopy for FAI and its relationship with NSAID prophylaxis. Materials and methods We retrospectively reviewed 300 FAI cases who have been managed with hip arthroscopy in two different hospitals from April 2006 to May 2009. All medical records and indications at discharge were analyzed, focusing on administration of NSAIDs, as well as follow-up roentgenograms with regard to presence of HO around the hip joint. The patients were divided into two groups: a treatment group of 285 hips which received NSAID prophylaxis and a control group of 15 hips which did not. Results Five hips presented HO, with overall prevalence of 1.6%. All five patients with HO belonged to the control group. No HO was observed in the treatment group. Thus, HO rate turned out to be significantly higher (P

Background Fractures of the distal third of the leg are increasingly common and are often handled by open reduction and internal fixation. Exposure and infection of internal hardware could occur, especially after high energy traumas, requiring hardware removal and delayed soft tissue reconstruction. Nevertheless immediate soft tissue reconstruction without internal hardware removal is still possible in selected patients. In this study the effectiveness and the complications of immediate soft tissue reconstruction without internal hardware removal is analyzed. Methods 13 patients, affected by internal hardware exposure in the distal leg, treated with immediate soft tissue reconstruction with pedicled flaps and hardware retention, are retrospectively analyzed, with special regard to flap survival and wound infection. Results Wound infection was observed in 10 cases before surgery and in 5 cases surgical debridement was necessary before reconstruction which was performed in a separate operative session. After reconstruction, wound dehiscence and infection occurred in 5 cases, and in 3 cases removal of internal hardware was necessary in order to achieve the complete healing of dehiscence. In one case the previous flap failed but prompt reconstruction with a sural fasciocutaneous flap was performed without hardware removal and without complications. Pre-operative infection and late reconstructive surgery are predictive for higher rates of post-operative complications (respectively p 0.018 and p 0.028). Conclusion Our approach achieved full recovery in 53.8% of the treated cases after one-step surgery, therefore reducing hospitalization and allowing early mobilization. Controlled trials are needed to confirm the effectiveness of this strategy, although the present case series shows encouraging results.