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The annual incidence of acute spinal cord injury, as reported in the National Spinal Cord Injury Statistical Center, was estimated to be approximately 40 cases per million, or approximately 11.000 new cases in the United States each year (1). In subjects with spinal cord injury, overstress of the upper extremities occurs not only during daily life activities, but also utilizing wheelchair. The aim of this study is to determine the prevalence of shoulder discomfort in subjects affected by paraplegia living in our country area and evaluate the associated risk factors negatively affecting the shoulder function.A computerized database search for paraplegic patients was performed at the Department of Orthopedic Surgery, Trauma Surgery and Rehabilitation Medicine. Among the 54 selected paraplegic patients, 47 accepted to participate at the study. Once the patients were contacted, the medical records were reviewed to obtain information regarding shoulder, elbow and spine region pain and discomfort.The 60% of all the patients who answered to the questionnaire complain shoulder pain, 90% bilaterally, and the 30% referred elbow pain, 20% bilaterally. 77% complains back pain, involving particularly lumbar region. Only 2% of this population undergoes a shoulder surgery treatment for cuff tear and shoulder disability.The present study is the first in our country that gives an overview of prevalence of upper limb discomfort in paraplegic patients. We have shown the interplay between shoulder elbow and spine with pain, age of patients and type of wheel chair utilized. The previous factors can be corrected and upper limb discomfort relieved.

NTRODUCTION: A hand and wrist disorder affects a patient's overall well-being and health-status. One concept serves as the foundation for all further consideration: in order to have confidence in your results when assessing patients with wrist and hand limitations, the clinician and researcher must choose standardised patient-oriented instruments that address the primary aims of the study. In this paper, we assess the quality of reviews published on patient oriented instruments in current use for assessing function of the hand and wrist joint. We highlight features of commonly used scales that improve readers' confidence in the choice and application of these outcome instruments. METHODS: A literature search (1950-January 2010) was performed using the MESH terms: hand (strength, injuries, joints) and wrist (injuries, joint) combined with outcome and process assessment (questionnaires, outcome assessment, health status indicators, quality of life). Titles and abstracts (n=341) were screened by two reviewers independently. The GRADE approach was used to assess the quality of ten reviews and the inclusion of clinimetric properties were assessed using the COSMIN checklist. RESULTS: We included three systematic reviews rated moderate to high (2 hand injury instrument reviews and 1 wrist fracture outcome review). Recommendations of use and an overview are provided for the disability of the arm, shoulder and hand questionnaire (DASH), QuickDASH, the Michigan hand questionnaire (MHQ), the patient-rated wrist hand evaluation outcome questionnaire (PRWHE) and the carpal tunnel questionnaire (CTQ) scales with established measurement properties. CONCLUSIONS: The DASH, a region-specific 30-item questionnaire is the most widely tested instrument in patients with wrist and hand injuries. The MHQ can provide good value to patients with hand injuries. Although, the CTQ is the most sensitive to clinical change, the DASH and MHQ have shown to be sufficiently responsive to outcome studies of carpal tunnel syndrome. The PRWHE has a good construct validity and responsiveness, which is only slightly better than the DASH to assess patients with wrist injuries. As the quality of patient-oriented validation continues to increase then the instruments can be selected more carefully. We will then be able to see that the future orthopaedic care of patients with hand and wrist injuries may also improve. Introduction A hand and wrist disorder affects a patient's overall well-being and health-status. One concept serves as the foundation for all further consideration: in order to have confidence in your results when assessing patients with wrist and hand limitations, the clinician and researcher must choose standardised patient-oriented instruments that address the primary aims of the study. In this paper, we assess the quality of reviews published on patient oriented instruments in current use for assessing function of the hand and wrist joint. We highlight features of commonly used scales that improve readers’ confidence in the choice and application of these outcome instruments. Methods A literature search (1950–January 2010) was performed using the MESH terms: hand (strength, injuries, joints) and wrist (injuries, joint) combined with outcome and process assessment (questionnaires, outcome assessment, health status indicators, quality of life). Titles and abstracts (n = 341) were screened by two reviewers independently. The GRADE approach was used to assess the quality of ten reviews and the inclusion of clinimetric properties were assessed using the COSMIN checklist. Results We included three systematic reviews rated moderate to high (2 hand injury instrument reviews and 1 wrist fracture outcome review). Recommendations of use and an overview are provided for the disability of the arm, shoulder and hand questionnaire (DASH), QuickDASH, the Michigan hand questionnaire (MHQ), the patient-rated wrist hand evaluation outcome questionnaire (PRWHE) and the carpal tunnel questionnaire (CTQ) scales with established measurement properties. Conclusions The DASH, a region-specific 30-item questionnaire is the most widely tested instrument in patients with wrist and hand injuries. The MHQ can provide good value to patients with hand injuries. Although, the CTQ is the most sensitive to clinical change, the DASH and MHQ have shown to be sufficiently responsive to outcome studies of carpal tunnel syndrome. The PRWHE has a good construct validity and responsiveness, which is only slightly better than the DASH to assess patients with wrist injuries. As the quality of patient-oriented validation continues to increase then the instruments can be selected more carefully. We will then be able to see that the future orthopaedic care of patients with hand and wrist injuries may also improve.

Animal studies have demonstrated the efficacy of the use of bisphosphonates to enhance screw fixation in bone. In this prospective, randomized study of pertrochanteric fractures treated with external fixation, we tested whether systemic administration of bisphosphonates would improve the fixation of hydroxyapatite-coated screws implanted in osteoporotic bone.Sixteen consecutive patients with a pertrochanteric fracture were selected. Inclusion criteria were female gender, an age of at least sixty-five years, and a bone mineral density T-score of less than -2.5 standard deviations. Exclusion criteria included bisphosphonate treatment during the two-year period prior to the fracture. Fractures were fixed with a pertrochanteric fixator and four hydroxyapatite-coated pins. Two pins were implanted in the femoral head (pin positions 1 and 2), and two were placed in the femoral diaphysis (pin positions 3 and 4). The patients were randomized either to therapy with alendronate for a three-month postoperative period (Group A) or to no therapy (Group B). The Group-A patients received an oral dose of 70 mg of alendronate per week. The fixators were removed after three months.All of the fractures healed, and no loss of reduction, nonunion, or delayed union was observed. The combined mean extraction torque (and standard deviation) of the pins implanted at positions 1 and 2 (cancellous bone) was 2558 +/- 1103 N/mm in Group A and 1171 +/- 480 N/mm in Group B (p0.0005). The combined mean extraction torque of the pins implanted at positions 3 and 4 (cortical bone) was 4327 +/- 1720 N/mm in Group A and 4075 +/- 1022 N/mm in Group B.These data show that weekly systemic administration of alendronate improves pin fixation in cancellous bone in elderly female patients with osteoporosis. We observed a twofold increase in extraction torque with the pins implanted in cancellous bone. These results support the use of alendronate in the treatment of osteoporotic pertrochanteric fractures to improve screw fixation in the femoral head.

The aim of this review is to report on studies of hydroxyapatite-coated external fixation pins as a solution to enhance pin fixation. In a highly loaded animal study, three tapered pin types were compared: Type A uncoated, Type B coated with hydroxyapatite and Type C coated with titanium. There was a 13-fold increase in the extraction torque of Type B pins compared with Type A, and a twofold increase compared with Type C pins. Extraction torque was significantly lower compared with the corresponding insertion torque in both Types A (p0.001) and C (p = 0.003). Conversely, with the hydroxyapatite-coated pins there was no difference between extraction and insertion torque. In a clinical study of 76 external fixation pins in 19 patients treated with hemicallotasis for osteoarthritis on the medial side of the knee, pin insertion and extraction torque forces were measured. The patients were randomized to be treated with either standard tapered pins or tapered pins coated with hydroxyapatite. Extraction torque of the hydroxyapatite-coated pins was higher than the extraction torque of the standard pins in both cancellous and cortical bone (p0.005). In a prospective, randomized clinical study of osteoporotic wrist fractures, extraction torque of the coated pins was higher than with standard pins (p0.0001). These studies demonstrate that with the use of hydroxyapatite-coated pins, no deterioration of pin fixation occurs, and that there is no significant pin loosening and infection, regardless of bone type and loading conditions.

This study was done to determine if elderly patients with trochanteric fractures and with osteoporosis could benefit from treatment with a dynamic hip screw fixed with HA-coated AO/ASIF screws. One hundred twenty patients with AO, A1, or A2 trochanteric fractures were selected. Patients were divided into two groups and randomized to receive a 135 degree-four-hole dynamic hip screw fixed with either standard lag and cortical AO/ASIF screws (Group A), or HA-coated lag and cortical AO/ASIF screws (Group B). Lag screw cutout occurred in four patients in Group A, but not in any patients in Group B. In Group A, the femoral neck shaft angle was 134 degrees +/- 5 degrees postoperatively and 127 degrees +/- 12 degrees at 6 months. In Group B, the femoral neck shaft angle was 134 degrees +/- 7 degrees postoperatively and 133 degrees +/- 7 degrees at 6 months. The Harris hip score at 6 months was 60 +/- 25 in Group A and 71 +/- 18 in Group B. The superior results of Group B can be attributed to the increased screw fixation provided by the HA-coated screws. We recommend lag screws coated with HA for dynamic hip screw fixation, especially in osteoporotic bone.

Background Implantable cardioverter-defibrillator (ICD) represents the main tool for prevention of sudden cardiac death. Different kinds of postimplant complications have been described; however, little is known about shoulder functional impairment and its impact on quality of life. Methods Patients with standard indications for elective prepectoral subcutaneous ICD insertion were enrolled during a 1-year period. The impact of ICD implantation on shoulder motility, pain, general disability, and quality of life was evaluated prospectively at baseline, and after 2 weeks, 3 months, 1 year, and 5 years using the Constant score, the Numeric Pain Rating Scale, the Disabilities of the Arm, Shoulder, and Hand scale, and the Short Form-36 Health Survey questionnaire. Results A total of 50 patients underwent insertion of single, dual chamber, or biventricular ICDs. Two weeks after implantation, functional impairment and mild pain were observed in ipsilateral shoulder movements, with a reduction in the Short Form-36 Health Survey score. Shoulder functional impairment improved at the third-month evaluations, with almost normalization at 1-year and 5-year assessments, as well as pain and quality of life. Conclusions Prepectoral subcutaneous ICD implantation may be associated with ipsilateral shoulder functional impairment that regresses partially after 3 months and completely at 1-year and 5-year assessments. The less invasive implantation technique and the relatively small size of modern ICDs, independently from types and volumes, may be relevant to the degree of postimplantation shoulder functional impairment and recovery time. Shoulder function should be assessed at routine checks, especially soon after ICD implantation because of potential functional impairment and subsequent impact on quality of life.

BACKGROUND: Subcutaneous almost substituted subpectoral approach of implantable cardioverter-defibrillator (ICD) implantation as a less invasive surgical technique. However, the impact of this change in placement site on procedure-related shoulder impairment is poorly understood. METHODS: Candidates for ICD implantation were prospectively evaluated at baseline, 2-weeks and 3-months after the procedure. Assessment of shoulder function included: Constant Score, Numeric Rating Scale (NRS) for pain and the Disability of the Arm, Shoulder and Hand (DASH) scoring method. The Short Form-36 (SF-36) questionnaire was adopted for quality of life. RESULTS: Fifty consecutive patients were enrolled (21 single-chamber, 5 dual-chamber and 24 biventricular ICD). Significant changes in the short term were observed: physical component summary (regarding SF-36) decreased from 44.5±9.1 to 41.8±11.4 (p=0.016), patients with NRS >1 increased from 14% to 44% (p

In recent years, a variety of new technologies have been proposed that allow rapid qualitative and quantitative microbiological analyses. In this paper we discuss the urgent needs for reliable and rapid microbiological analytical techniques in different applicative fields involving the research, production and medical application of implant materials, and the potential benefits derived from the use of new methods for rapid bacterial quantification. Current compendial methods are easy to perform and have gained confidence over their long period of use, but the supplemental use of new technologies could represent real breakthroughs whenever sensitive and rapid responses are urgently required and not met by the tests currently in use. Overall, the new microbiological methods require critical evaluation depending on their specific type of application and they may still not be thought of as totally substitutive, but they certainly exhibit considerable potential for different areas of biomaterials, as well as for advanced therapy medicinal and tissue engineering treatments.

External fixation has proven to be a viable minimally invasive treatment option for elderly patients with trochanteric fractures. Postoperative complications has limited external fixation in relation to inadequate pin fixation. We compared Orthofix pertrochanteric fixator (OPF) with hydroxyapatite-coated pins to dynamic hip screw (DHS) with AO/ASIF stainless-steel screws in osteoporotic trochanteric fractures. Methods: Forty patients were divided into two groups and randomized for treatment with 135° 4-hole DHS (Group A) or OPF with four hydroxyapatite-coated pins (Group B). Inclusion criteria was: female, age ≥ 65 years, AO fracture type A1 or A2 and BMD lower than -2.5 T-score. All fixators were removed at 3 months. Results: There were no differences in patient age, fracture type, BMD, ASA, hospital stay and reduction quality. Average number of blood transfusions was 2.0 ± 0.1 in Group A, whereas there were none in Group B (p < 0.0001). Operative time was 64 ± 6 minutes in Group A and 34 ± 5 in Group B (p < 0.005). Post-operative femoral neck shaft angle was 134 ± 6° in Group A, and 132 ± 4° in Group B (ns). In Group A, fracture varization at 6 months was 6 ± 8°, in Group B 2 ± 1° (p = 0.002). Harris hip score was 62 ± 20 in Group A and 63 ± 17 in Group B. (n.s.) In Group B, no pin infection occurred. Pin fixation was maintained over time, as shown by no significant difference between pin extraction and corresponding insertion torque. Discussion and Conclusion: In external fixation with hydroxyapatite-coated pins there was no need for blood transfusions and fixation was superior, as confirmed by less varization at long-term.

Biofilm formation is broadly recognized as an important virulence factor in many bacterial species implicated in implant-related opportunistic infections. In spite of a long history of research and many investigative efforts aimed at elucidating their chemical composition, structure, and function, the nature of bacterial biofilms still remains only partly revealed. Over the years, different extracellular polymeric substances (EPS) have been described that contribute functionally and structurally to the organization of biofilms. Recently extracellular DNA (eDNA) has emerged as a quantitatively conspicuous and potentially relevant structural component of microbial biofilms of many microbial species, Staphylococcus aureus and S. epidermidis among them. The present study aims at comparatively investigating the amount of eDNA present in the biofilm of 55 clinical isolates of S. epidermidis from postsurgical and biomaterial-related orthopedic infections. Quantification of eDNA was performed by a non-destructive method directly on bacterial biofilms formed under static conditions on the plastic surface of 96-well plates.

This report focuses on the molecular characterization of a Staphylococcus aureus strain isolated from a knee arthroprosthesis infection and recognized retrospectively as a carrier of the Panton-Valentine leukocidin gene. The stored microbiological isolate, which belonged to the strain collection of the Research Unit on Implant Infections of the Rizzoli Orthopaedic Institute, was retrieved for molecular analysis. Genotyping was carried out, revealing an interesting profile. In addition to the positivity for the Panton-Valentine toxin gene, the results indicated that the isolate belonged to the agr III group and was endowed with bbp and cna genes, both encoding for staphylococcal adhesins that bind bone proteins. The strain had the mecA gene for methicillin resistance, even though it was unable to resist any of the β-lactam or other antibiotics. Its gene configuration matched that of other community-acquired methicillin-resistant and methicillin-susceptible Staphylococcus aureus (CA-MRSA and CA-MSSA) strains which have recently been reported worldwide. As far as we know, this is the first report on a PVL-positive S. aureus strain associated with an orthopedic implant (knee arthroprosthesis) infection.

Scopo: Questo studio si propone di verificare l’esatta corrispondenza tra punti di repere cutanei ed ossei al fine di proporre una metodologia di reperizzazione manuale. Metodo: 30 soggetti sono stati selezionati casualmente tra un vasto gruppo di pazienti. Per ogni soggetto il chinesiologo individua manualmente il margine mediale della scapola ed evidenzia due punti ad esso corrispondenti. Il paziente viene posizionato dal tecnico radiologo per eseguire l’esame radiografico programmato per accertamenti clinici indipendenti da questo studio. Con apposito software (Autocad Light) è stato calcolato l’angolo formato dal margine mediale vero (MMv) e quello formato dal margine mediale reperizzato (MMr). Risultati: L’analisi statistica ha evidenziato una differenza non significativa (p>0,8) tra MMv ed MMr. Discussione: Il nostro studio propone una semplice metodologia della reperizzazione manuale. I dati ottenuti dimostrano che non esistono differenze significative fra i reperi cutanei e i reperi ossei. Conclusioni: la metodologia da noi proposta è risultata di facile applicabilità, assolutamente non invasiva e ripetibile. Parole chiave: scapola, punti di repere

To evaluate whether fixing a locking compression plate (LCP) with hydroxyapatite (HA)-coated screws provides improved biomechanical fixation and healing compared with standard screws under loaded conditions.Ten sheep were randomly divided into 2 groups. A resection osteotomy of 8 mm was performed in the sheep's right tibiae. Five tibiae were fixed with a 9-hole LCP and 8 standard unicortical locking screws (Group Non-HA), and 5 tibiae were fixed with a 9-hole LCP and 8 HA-coated unicortical locking screws (Group HA). All screws were implanted at the same insertion torque of 4000 Nmm. Three months after surgery, all the sheep were euthanized. Bone segments after screw removal were randomly chosen from each group for histologic analysis (Group Non-HA=5, Group HA=5).Mean screw extraction torque was 438+/-288 Nmm in Group Non-HA (n=40) and 2317+/-657 Nmm in Group HA (n=40) (P0.0005). The tibial torque resistance of the resected tibiae was 24+/-8 Nm in Group Non-HA (n=5) and 31+/-3 in Group HA (n=5) (P=0.045). In Group Non-HA, histology showed bone resorption and fibrous tissue encapsulation in all the samples, but this was not found in any of the Group HA samples.This study shows that an LCP with HA-coated screws provides improved biomechanical fixation than an LCP with similar standard screws as shown by a 5-fold greater screw extraction torque (P0.0005). Furthermore, the higher tibial torque resistance is potentially beneficial for improved gap healing, as shown by higher tibial torque resistance.

Several species belonging to Staphylococcus genus, other than Staphylococcus aureus and Staphylococcus epidermidis (nonSau/ nonSep species), exhibit increasing abilities as opportunistic pathogens in the colonisation of periprosthetic tissues. Consequently, the availability of means for accurate identification is crucial to assess the pathogenic characteristics and to clarify clinical relevance of the individual species. Here, 146 clinical staphylococcal isolates belonging to nonSau/ nonSep species from prosthesis-associated orthopedic infections were analyzed by conventional enzymatic galleries and by automated ribotyping. Twelve different species were recognised: S. capitis, S. caprae, S. cohnii, S. equorum, S. haemolyticus, S. hominis, S. lugdunensis, S. pasteuri, S. sciuri, S. simulans, S. warneri, S. xylosus. Ribotype identifications were compared with the phenotypes obtained by the Api 20 Staph system and/or ID 32 Staph system. ID 32 Staph profiles were more consistent with ribotyping results than Api Staph profiles. Across the different staphylococcal species investigated, correct identifications with Api Staph were 45%, while with ID 32 Staph they were 59%. It has, however, to be mentioned that ID 32 Staph was mostly applied to discriminate unmatched ribotyping and Api Staph identifications, thus to a subpopulation of strains with “atypical” metabolic profile. Automated ribotyping provided a correct identification for 91% of the isolates. These results confirm automated ribotyping as a convenient rapid technique, still subject to improvements, which will accurately and rapidly recognise the newly emerging staphylococcal pathogens in implant-related orthopedic infections.

Aim:This study compared fracture treatment with plaster cast vs external fixation.Methods:Forty elderly female osteoporotic wrist fracture patients were randomized to be treated with either plaster cast (Group A) or external fixation (Group B). Bone mineral density less than −2.5 T-score was among the inclusion criteria.Results:In Group A, four redisplacements occurred, whereas in Group B there were none (p = 0.005). Horesh score was higher in Group B (p < 0.006) than in Group A. Volar angle deformity (p < 0.0005) and radial angle deformity (p = 0.008) were lower in Group B.Conclusions:This study shows that external fixation improves stability in elderly osteoporotic wrist fracture patients.

Staphylococcus warneri is a coagulase negative Staphylococcus (CNS) commonly present in the flora of human epithelia and mucosal membranes. Over the last two decades, similarly to other CNS species, S. warneri has been reported as a new emerging pathogen, capable of causing serious infections usually in association with the presence of implant materials, but, at times, even in the absence of a foreign body and in patients considered immunocompetent. At present, there is still a lack of scientific data on the pathogenesis and epidemiology of this species. The present study investigated a collection of 26 clinical isolates derived from orthopedic infections, some associated with implant materials and others not. Automated ribotyping showed the existence of 5 distinct ribogroups. Except for the least numerous ribogroup consisting of a single isolate, all other ribogroups included at least one strain obtained from an infection not associated with implant materials, suggesting that putative virulence factors necessary for infections even in the absence of a foreign body could be transversal to most ribogroup categories. Orthopedic infections were found to involve S. warneri strains with low antibiotic resistance potential, differing in this respect from the strains isolated at neonatal intensive care units, where this species has been described to figure among the principal causative agents and exhibit an alarming profile of antibiotic resistance.

Several species belonging to Staphylococcus genus (nonSau/nonSep species) exhibit increasing abilities as opportunistic pathogens in colonisation of periprosthesis tissues. Here we report on antibiotic resistance of 193 strains, belonging to nonSau/nonSep species, consecutively collected from orthopedic implant infections in a period of about 40 months. The 193 strains (representing 17% of all staphylococci isolated) were analysed for their antibiotic resistance to 16 different drugs. Five species turned out more prevalent, ranging from 1 to 5%: S. hominis (4.2%), S. haemolyticus (3.7%), S. capitis (2.7%), S. warneri (2.6%), and S. cohnii (1.6%). Among these, the prevalence of antibiotic resistance to penicillins was similar, ranging from 51% to 66%. Conversely, significant differences were observed for all the remaining antibiotics. For S. haemolyticus the resistances to oxacillin and imipenem, the four aminoglycosides and erythromycin were at least twice that of the other three species which were compared. S. warneri was on the contrary the species with the lowest occurrence of resistant strains. Ten species appeared only rarely at the infection sites: S. lugdunensis, S. caprae, S. equorum, S. intermedius, S. xylosus, S. simulans, S. saprophyticus, S. pasteuri, S. sciuri, and S. schleiferi. The behaviours of these species, often resistant to penicillins, were individually analysed. Differences in both the frequencies and the panels of antibiotic resistances observed among the nonSau/nonSep species: i) suggest that horizontal spreading of resistance factors, if acting, was not sufficient per se to level their bio-diversities; ii) highlight and confirm the worrisome appearance within the Staphylococcus genus of emerging “new pathogens”, not homogeneous for their virulence and antibiotic resistance prevalence, which deserve to be recognised and treated individually.