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

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

The elbow is a complex joint whose biomechanical function is granted by the interplay and synergy of various anatomical structures. Articular stability is achieved by both static and dynamic constraints, which consist of osseous as well as soft-tissue components. Injuries determining instability frequently involve several of these structures. Therefore, accurate knowledge of regional anatomy and imaging findings is fundamental for a precise diagnosis and an appropriate clinical management of elbow instability. This review focuses particularly on the varied appearance of overuse-related elbow injuries at CT-arthrography.

Objective To describe early prosthesis implantations in a cohort of patients with juvenile idiopathic arthritis (JIA) followed in a tertiary referral hospital and to analyze possible factors influencing implant survival. Methods This was a retrospective cohort study. Charts of all patients with JIA who underwent total joint replacement at Gaetano Pini Hospital, Milan, Italy from January 1992 to June 2019 were retrieved, and relevant data were analyzed. Results Eighty-five patients met the inclusion criteria for this study, with a median follow-up period of 17.2 years. The median age at first prosthesis was 22.7 years. The total number of replaced joints was 198 over a period of 27 years. The hip was the most frequently replaced joint, accounting for almost two-thirds of the total number of implants; the other one-third refers mostly to knee implants. Polyarticular JIA and systemic JIA were the most represented JIA categories in the study cohort. A significant upward trend of the age at arthroplasty and of disease duration before arthroplasty over decades was found. The rates of implant survival at 5, 10, and 15 years were comparable (from 84% to 89%); 50% of implants lasted ≥20 years. Conclusion We reported retrospective data on early joint replacement in a cohort of patients with JIA. We observed a progressive and significant upward trend of both age at arthroplasty and disease duration before the first arthroplasty over time. The JIA category, year of implant, and presence of complications significantly affected implant survivorship.

Purpose The treatment of acromioclavicular joint (ACJ) osteoarthritis during shoulder arthroscopy is a discussed topic. The aim of this scoping review is to report the current recommendations regarding the management of this disorder in patients undergoing surgery for rotator cuff tears. Methods A scoping review was performed in Pubmed\Medline and Embase in March 2017, restricted to English language literature. The following keywords were used: (“rotator cuff tear” OR ” rotator cuff” OR “rotator cuff repair”) AND (“acromioclavicular joint arthritis” OR “ac joint arthritis” OR “ac joint” OR “acromioclavicular joint”). Inclusion criteria were randomized controlled trials, prospective cohort studies, retrospective trials, and therapeutic case series. Exclusion criteria were reviews, meta-analyses, and expert opinions. Results Two retrospective studies and three randomized controlled trials were identified. Clinical studies reported results of 443 shoulders, with an average age of 60.48 years and a mean follow-up of 31.7 months. Many differences were found regarding the design of the studies, patient's selection, surgical procedures, and instrumental and clinical evaluations. No statistically significant differences were found in clinical outcome scores between patients that underwent rotator cuff repair in association with distal clavicular resection and patients with isolated rotator cuff repair. Conclusion Results of this scoping review underline a lack of evidence-based recommendations about the management of ACJ osteoarthritis in association with arthroscopic rotator cuff repair. Surgical procedures such as distal clavicle resection (DCR) should be performed carefully in this cohort of patients. More prospective randomized studies are needed to reach a consensus about the correct surgical approach to DCR in patients with signs of ACJ osteoarthritis and rotator cuff tears. Level of Evidence Level III.

Introduction Elbow bony stability relies primarily on the high anatomic congruency between the humeral trochlea and the ulnar greater sigmoid notch. No practical tools are available to distinguish different morphotypes of the proximal ulna and herewith predict elbow stability. The aim of this study was to assess inter-observer reproducibility, evaluate diagnostic performance and determine responsiveness to change after simulated coronoid process fracture for three novel elbow radiographic indexes. Methods Ten fresh-frozen cadaver specimens of upper limbs from human donors were available for this study. Three primary indexes were defined, as well as two derived angles: Trochlear Depth Index (TDI); Posterior Coverage Index (PCI); Anterior Coverage Index (ACI); radiographic coverage angle (RCA); olecranon–diaphisary angle (ODA). Each index was first measured on standardized lateral radiographs and subsequently by direct measurement after open dissection. Finally, a type II coronoid fracture (Regan and Morrey classification) was created on each specimen and both radiographic and open measurements were repeated. All measurements were conducted by two orthopaedic surgeons and two dedicated musculoskeletal radiologists. Results All three indexes showed good or moderate inter-observer reliability and moderate accuracy and precision when compared to the gold standard (open measurement). A significant change between the radiographic TDI and ACI before and after simulated coronoid fracture was observed [TDI: decrease from 0.45 ± 0.03 to 0.39 ± 0.08 (p = 0.035); ACI: decrease from 1.90 ± 0.17 to 1.58 ± 0.21 (p = 0.001)]. As expected, no significant changes were documented for the PCI. Based on these data, a predictive model was generated, able to identify coronoid fractures with a sensitivity of 80% and a specificity of 100%. Conclusion New, simple and easily reproducible radiological indexes to describe the congruency of the greater sigmoid notch have been proposed. TDI and ACI change significantly after a simulated coronoid fracture, indicating a good responsiveness of these parameters to a pathological condition. Furthermore, combining TDI and ACI in a regression model equation allowed to identify simulated fractures with high sensitivity and specificity. The newly proposed indexes are, therefore, promising tools to improve diagnostic accuracy of coronoid fractures and show potential to enhance perioperative diagnostic also in cases of elbow instability and stiffness. Level of evidence Basic science study. Clinical relevance The newly proposed indexes are promising tools to improve diagnostic accuracy of coronoid fractures as well as to enhance perioperative diagnostic for elbow instability and stiffness.

Introduction The coronoid process plays a key-role in preserving elbow stability. Currently, there are no radiographic indexes conceived to assess the intrinsic elbow stability and the joint congruency. The aim of this study is to present new radiological parameters, which will help assess the intrinsic stability of the ulnohumeral joint and to define normal values of these indexes in a normal, healthy population. Methods Four independent observers (two orthopaedic surgeons and two radiologists) selected lateral view X-rays of subjects with no history of upper limb disease or surgery. The following radiographic indexes were defined: trochlear depth index (TDI); anterior coverage index (ACI); posterior coverage index (PCI); olecranon–coronoid angle (OCA); radiographic coverage angle (RCA). Inter-observer and intra-observer reproducibility were assessed for each index. Results 126 subjects were included. Standardized lateral elbow radiographs (62 left and 64 right elbows) were obtained and analysed. The mean TDI was 0.46 ± 0.06 (0.3–1.6), the mean ACI was 2.0 ± 0.2 (1.6–3.1) and the mean PCI was 1.3 ± 0.1 (1.0–1.9). The mean RCA was 179.6 ± 8.3° (normalized RCA: 49.9 ± 2.3%) and the mean OCA was 24.6 ± 3.7°. The indexes had a high-grade of inter-observer and intra-observer reliability for each of the four observers. Significantly higher values were found for males for TDI, ACI, PCI and RCA. Conclusion The novel radiological parameters described are simple, reliable and easily reproducible. These features make them a promising tool for radiographic evaluation both for orthopaedic surgeons and for radiologists in the emergency department setting or during outpatient services. Level of evidence Basic Science Study (Case Series). Clinical relevance The novel radiological parameters described are reliable, easily reproducible and become handy for orthopaedic surgeons as well as radiologists in daily clinical practice.

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)

Introduction Preventing nerve injury is critical in elbow surgery. Distal extension of medial approaches, required for coronoid fracture fixation and graft-replacement, may endanger the median nerve. This study aims to describe an easily identifiable and reproducible anatomical landmark to localize the median nerve distal to the joint line and to delineate how its relative position changes with elbow flexion and forearm rotation. Materials and methods The median nerve and the ulnar insertion of the brachialis muscle were identified in eleven fresh-frozen cadaveric specimens after dissection over an extended medial approach. The elbow was brought first in full extension and then in 90° flexion, and the shortest distance between the two structures was measured while rotating the forearm in full pronation, neutral position and full supination. Results The distance between the median nerve and the brachialis insertion was highest with the elbow flexed and the forearm in neutral position. All distances measured in flexion were larger than those in extension, and all distances measured from the most proximal point of the brachialis insertion were larger than those from the most distal point. Distances in pronation and in supination were smaller than to those in neutral forearm position. Conclusions The ulnar insertion of the brachialis is a reliable landmark to localize and protect the median nerve at the level of the coronoid base. Elbow flexion and neutral forearm position increase significantly the safety margins between the two structures; this information suggests some modifications to the previously described medial elbow approaches. Level of evidence Basic Science Study.

This study aims to evaluate the clinical and radiological outcomes of a modified technique of Kinematically Aligned Total Knee Arthroplasty (KA TKA) using a cruciate sacrificing (CS) medially stabilised prosthesis at a minimum 24-months follow-up. 59 patients with a varus HKA angle who underwent a TKA from May, 2016 to April, 2017 were retrospectively enrolled. Radiological and clinical evaluations were assessed after 40 days, 6 months and at a minimum follow-up of 24 months. Long leg standing X-rays were performed pre-operatively and the Hip–Knee–Ankle (HKA) angle, the mechanical Lateral Distal Femoral Angle (mLDFA), the mechanical Medial Proximal Tibial Angle (mMPTA) and the Knee Joint Line Obliquity Angle (KJLOA) were analysed. At a minimum follow-up of 24 months, the patients were evaluated subjectively based on the Western Ontario and McMaster Universities Osteoarthritis Index Score (WOMAC) and the Oxford Knee Score (OKS). The post-operative range of motion (ROM) was measured. To reduce flexion instability, an original technique was used, with more posterior positioning of the femoral component, called the “virtuous mistake”. Results were compared to the data reported in the literature in patients treated with standard kinematic alignment (KA) technique. No difference was found between the mean pre-operative and post-operative angles regarding mLDFA (p value = 0.410) and mMTPA (p value = 0.242). A difference of 0.8° in HKA angle between males and females was found, with more varus results in males. At a minimum follow-up of 24 months, the WOMAC was 87 (SD 4.3), the OKS was 41 (SD 2.4), and the flexion was 124°, which was similar to the data reported in literature with standard KA. There were not any cases of aseptic failures. The modified KA TKA surgical technique proposed in this study can achieve good clinical results at minimum 24 months of follow-up, reproducing accurately native mLDFA and mMPTA. Level III, therapeutic study.

Rotator cuff tears are common musculoskeletal disorders, and surgical repair is characterized by a high rate of re-tear. Regenerative medicine strategies, in particular mesenchymal stem cell–based therapies, have been proposed to enhance tendon healing and reduce the re-tear rate. Autologous microfragmented adipose tissue (μFAT) allows for the clinical application of cell therapies and showed the ability to improve tenocyte proliferation and viability in previous in vitro assessments. The hypothesis of this study is that μFAT paracrine action would reduce the catabolic and inflammatory marker expression in tendon cells (TCs) derived from injured supraspinatus tendon (SST). TCs derived from injured SST were co-cultured with autologous μFAT in transwell for 48 h. Metabolic activity, DNA content, the content of soluble mediators in the media, and the gene expression of tendon-specific, inflammatory, and catabolic markers were analyzed. μFAT-treated TCs showed a reduced expression of PTGS2 and MMP-3 with respect to untreated controls. Increased IL-1Ra, VEGF, and IL-6 content were observed in the media of μFAT-treated samples, in comparison with untreated TCs. μFAT exerted an anti-inflammatory action on supraspinatus tendon cells in vitro through paracrine action, resulting in the reduction of catabolic and inflammatory marker expression. These observations potentially support the use of μFAT as adjuvant therapy in the treatment of rotator cuff disease.

Background: From February 21, the day of hospitalisation in ICU of the first diagnosed case of Covid-19, the social situation and the hospitals’ organisation throughout Italy dramatically changed. Methods: The CIO (Club Italiano dell’Osteosintesi) is an Italian society devoted to the study of traumatology that counts members spread in public and private hospitals throughout the country. Fifteen members of the CIO, Chairmen of 15 Orthopaedic and Trauma Units of level 1 or 2 trauma centres in Italy, have been involved in the study. They were asked to record data about surgical, outpatients clinics and ER activity from the 23rd of February to the 4th of April 2020. The data collected were compared with the data of the same timeframe of the previous year (2019). Results: Comparing with last year, overall outpatient activity reduced up to 75%, overall Emergency Room (ER) trauma consultations up to 71%, elective surgical activity reduced up to 100% within two weeks and trauma surgery excluding femoral neck fractures up to 50%. The surgical treatment of femoral neck fractures showed a stable reduction from 15 to 20% without a significant variation during the timeframe. Conclusions: Covid-19 outbreak showed a tremendous impact on all orthopaedic trauma activities throughout the country except for the surgical treatment of femoral neck fractures, which, although reduced, did not change in percentage within the analysed timeframe.

The aim of this study was to evaluate the radiographic effect of sagittal tibial osteotomy (STO), flexion tibial osteotomy (FTO) and deflexion tibial osteotomy (DTO) around the knee. It has been hypothesized that proximal STO modifies patellar height and could cause varus/valgus changes of the anatomical tibial axis: The purpose of the study was to verify this and to analyse these modifications. Patients underwent proximal STO in our department between 2007 and 2018: overall 28 consecutive patients (19 males, 9 females; 28 knees). Twelve patients underwent DTO, and 16 patients underwent FTO. Two independent observers measured the pre-operative and post-operative radiological indexes: posterior tibial slope, Caton-Deschamps Index (CDI) and Modified Insall-Salvati Index (MISI) in the lateral views; medial Tibial Plateau-Tibial Shaft (mTPTS) and medial Femoral Shaft-Tibial Shaft (mFTA) anatomical angles were measured in the frontal plane. No complications were reported at the average follow-up of 1.6 ± 1.1 years. The mean mTPTS significantly increased from 0.6° ± 2.4° pre-operatively to 2.9° ± 2.6° of varus post-operatively (DTO (pre-operative 0.3 ± 3.1°, post-operative 2.4 ± 2.1°, ns); FTO (pre-operative 0.9 ± 1.9°, post-operative 3.2 ± 3.0°, P

This article aims to share northern Italy’s experience in hospital re-organization and management of clinical pathways for traumatic and orthopaedic patients in the early stages of the COVID-19 pandemic. Authors collected regional recommendations to re-organize the healthcare system during the initial weeks of the COVID-19 pandemic in March, 2020. The specific protocols implemented in an orthopaedic hospital, selected as a regional hub for minor trauma, are analyzed and described in this article. Two referral centres were identified as the hubs for minor trauma to reduce the risk of overload in general hospitals. These two centres have specific features: an emergency room, specialized orthopaedic surgeons for joint diseases and trauma surgeons on-call 24/7. Patients with trauma without the need for a multi-disciplinary approach or needing non-deferrable elective orthopaedic surgery were moved to these hospitals. Authors report the internal protocols of one of these centres. All elective surgery was stopped, outpatient clinics limited to emergencies and specific pathways, ward and operating theatre dedicated to COVID-19-positive patients were implemented. An oropharyngeal swab was performed in the emergency room for all patients needing to be admitted, and patients were moved to a specific ward with single rooms to wait for the results. Specific courses were organized to demonstrate the correct use of personal protection equipment (PPE). The structure of the orthopaedic hubs, and the internal protocols proposed, could help to improve the quality of assistance for patients with musculoskeletal disorders and reduce the risk of overload in general hospitals during the COVID-19 pandemic.

The aim of this study was to propose and validate a new six-item topographical classification of knee bone marrow lesions in coronal MRI images, to provide an easy-to-use aid to describe their location in a more reproducible and accurate way. This study was conducted in four phases. The first was to do a literature search for methods of describing bone marrow lesions in MRI of the knee. The second was creation of a six-area topographic classification of bone marrow lesions in coronal MRI of the knee. The third phase was selection of cases with bone marrow lesions on knee MRI performed in a single hospital between January of 2017 and December of 2018. The fourth phase was categorization of the bone marrow lesions’ location according to the new proposed classification by three independent examiners, two orthopedic surgeons and one radiologist. Patient’s demographic data and associated lesions were collected. The inter-observer and intra-observer reliability of the proposed classification was then calculated. MRI examination of 4000 patients were studied and in 520 patients a total of 666 bone marrow lesions were identified and their location classified using the new system. The inter-observer and intra-observer reliability analysis found a Fleiss’ Kappa value of 0.96 (0.95–0.97) and 0.97 (0.96–0.97), respectively, confirming the high reproducibility of the proposed classification. The proposed six-location classification of bone marrow lesions is highly reproducible and can help researchers develop studies and share information in a more accurate and reliable way. The correct classification of bone marrow lesions can lead to a more accurate description of this pathology and help clinicians to propose appropriate therapies for this group of patients. V.

Elbow instability can occur as post-traumatic sequelae or due to chronic overuse syndromes. Patients with chronic instability classically present with pain, apprehension, or mechanical symptoms after movements that result in joint subluxation. Arthroscopic plication of R-LCL and aMCL is an innovative surgical technique that enables an anatomic and minimally invasive ligament retensioning. Arthroscopic assisted MCL plication is indicated in medial elbow pain with valgus instability. Arthroscopic plication of radial component of LCL is indicated in lateral elbow pain recalcitrant to at least 6 months of conservative treatment. Several arthroscopic signs of minor elbow instability should be assessed during the procedure and their negativization at the end of the procedure corresponds to a restored stability of the elbow.

Coronoid process (CP) fractures are relatively uncommon, yet critical injuries to recognize. Arthroscopic reduction and fixation of coronoid process has been proposed to overcome these limitations of open approaches. Currently, arthroscopy is used to assist insertion of retrograde guide wire for a retrograde cannulated screw. This method is widely used; however it is technically challenging to direct the guide wire from dorsal aspect of ulna towards the tip of the coronoid. This chapter describes a new surgical procedure for arthroscopic-assisted fracture reduction and fixation of coronoid fractures. A technical modification of a standard elbow portal (anteromedial) allows the surgeons to obtain a better working angle for reduction of these fractures without requiring a cruciate ligament guide. This new accessory anteromedial portal permits fixation of the CP fracture using a more perpendicular angulation to the fracture line as compared to a standard anteromedial portal. This approach also abolishes completely the need for an anterior incision and dissection of the elbow capsule.

Background Calcific tendinitis of the shoulder has a tendon involvement that could evolve to rotator cuff tear and shoulder osteoarthritis. This study aimed to evaluate the prevalence of glenohumeral osteoarthritis and rotator cuff tears in patients affected by calcific tendinitis at a minimum follow-up of 10 years after diagnosis. Methods Patients diagnosed with calcific tendinitis of the shoulder with a minimum follow-up of 10 years were contacted and invited for a clinical and radiological evaluation. Information on the demographics, affected and dominant side, bilateral shoulder pain, type of treatment, habits, systemic or musculoskeletal diseases, reoperation of the index shoulder, and subjective satisfaction was collected. The clinical evaluation was performed using Constant–Murley score (CMS), American Shoulder and Elbow Surgeons Score (ASES), and numerical rating scale (NRS); isometric strength in forwarding flexion and abduction was also measured. Each patient also underwent an ultrasound examination to evaluate rotator cuff tendon integrity and a shoulder radiograph to evaluate osteoarthritis. Results Seventy-nine patients were available for a phone interview, and 35 agreed to be examined. The mean age was 58.89 (± 7.9) years at follow-up. The prevalence of glenohumeral osteoarthritis was 17.14% in the study population, with significant progression in 14.29% of the cases, without rotator cuff full-thickness tears. x-Ray examination showed residual calcifications in 31 patients, with a mean diameter of 5.54 mm. In 30 cases, there was a reduction of the diameter; in 4 cases, the calcification increased in size; and in 1 case, the size did not change. The mean ASES score was 74.1 (± 22.7) in the group with calcifications larger than 2 mm and 89.4 (± 8.2) in patients with smaller calcifications (p = 0.08) without correlation with the type of treatment performed. Conclusions Calcific tendinitis is a self-resolving disease without rotator cuff tears at long-term follow-up or degenerative glenohumeral progression. Level of Evidence: 3, cohort study.

Less invasive direct anterior approach (DAA) and dual mobility cup (DMC) are increasingly adopted in practice over the last decade. Their use aims to reduce, as much as possible, soft tissue dissection and dislocation rate. This study aims to present a novel surgical technique to reduce a DMC prosthesis during a DAA easily. A mildly modified version of the direct anterior approach is proposed. When leg lengths, stability, impingement, and tension have been checked, the trial stem is disassembled in situ, dislocated, and removed, leaving the space to exchange the trial double mobility head with the definitive one. When the definitive stem is inserted, the surgeon guides and helps the assistant to match the trunnion in the double mobility head. As soon as the components are matched, the traction is released, and the unit is impacted by an alternation of axial traction and release. Of 164 patients who underwent primary total hip arthroplasty (December 2016–May 2017) by a single surgeon, a double mobility cup through DAA and the “head-first” technique was performed in 26 patients (15.8%). The mean operative time was 130 min (85–220 min; SD 34.28). No significant complications occurred during the mean follow-up of 23.6 months. Specific difficulties can be anticipated when pairing dual mobility cup and direct anterior approach. The “head-first” technique is a useful technique in reducing the possible difficulties related to the reduction of double mobility cup through a less invasive direct anterior approach.

Background:Arthroscopic techniques are now considered the gold standard for treatment of most rotator cuff (RC) tears; however, no consensus exists on the maintenance of results over time, and long-term follow-up data have been reported for few cohorts of patients.Purpose:To present the long-term results associated with the arthroscopic treatment of RC tears and to evaluate associations between preoperative factors and RC integrity at final follow-up.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 169 patients were contacted at least 10 years after arthroscopic RC surgery and were invited to a clinical evaluation. Information on preoperative conditions, tear size, subjective satisfaction, and functional scores was collected; isometric strength and range of motion were also measured; and each patient underwent an ultrasound examination to evaluate supraspinatus integrity and a shoulder radiograph to evaluate osteoarthritis.Results:A total of 149 patients (88.2% of the eligible patients) were available for a complete telephonic interview, and 102 patients were available for the final evaluation. Ultrasound revealed an intact supraspinatus in 54 patients (53.47%). By adding the 10 patients who underwent revision surgery to the nonintact group, this percentage would drop to 48.65%. Tear size was associated with supraspinatus integrity in univariate analysis (hazard ratio, 3.04; 95% CI, 1.63-5.69; P = .001) and multivariable analysis (hazard ratio, 2.18; 95% CI, 1.03-4.62; P = .04). However, no significant differences were encountered in the subjective and functional scores collected, with the exception of the Constant-Murley Score, which was significantly higher in patients with smaller tears at the index procedure. Strength testing also revealed significantly superior abduction and flexion strength in this group, and radiographs showed a significantly higher acromion-humeral distance and lower grades of osteoarthritis. Patients with an intact supraspinatus at final follow-up showed superior results in all functional scores, greater satisfaction, superior abduction and flexion strength, higher acromion-humeral distance, and lower grades of osteoarthritis.Conclusion:RC tear size at the time of surgery significantly affects supraspinatus integrity at a minimum follow-up of 10 years. However, a larger tear is not associated with an inferior subjective result, although it negatively influences abduction and flexion strength, range of motion, and osteoarthritis progression. Intraoperative efforts to obtain a durable RC repair are encouraged, since supraspinatus integrity at final follow-up influences clinical and functional outcomes, patient satisfaction, and osteoarthritis progression.

In over a century of history, shoulder prosthetics has seen numerous developments in terms of both design and surgical indications: from the first monobloc hemiarthroplasty proposed by Neer, many innovations have occurred, which led to the development of complete modular prostheses. Nowadays, anatomic shoulder arthroplasties are able to adapt to patient-specific anatomical characteristics. Reverse shoulder arthroplasty, which revolutionised articular biomechanics, has provided a possible solution for the treatment of patients with rotator cuff failure. The attempt to reduce complications related to traditional implants and the desire to guarantee greater bone stock preservation have pushed the research towards a progressive reduction in humeral stem length until its complete elimination. At the same time, researchers have studied and developed surface implants that reduce pain with minimal changes in the original anatomy. Humeral head resurfacing consists in a metal cap that covers the articular portion of the proximal humeral epiphysis without any substantial osteotomy of the humeral head. Despite their recent introduction, the results offered by the so-called small implants appear to be very promising and it is reasonable to expect their significant diffusion in the future.

Purpose The purpose of this systematic review and pooled analysis was to evaluate incidence and risk factors for glenohumeral osteoarthritis (OA) in patients who underwent Latarjet procedure with a minimum of 5-year follow-up. Methods The PRISMA guidelines were followed to perform this systematic review. PubMed and EMBASE were searched up to February 29, 2020 for English, human in vivo studies that evaluated glenohumeral OA in patients undergoing Latarjet procedure at least 5 years after surgery. A pooled analysis on the included databases sent by authors was performed to evaluate the risk factors influencing the development or progression of dislocation arthropathy after the Latarjet procedure. Results Four studies, including a total of 280 patients (213 males and 67 females), were analysed. In our study population, the median age at surgery was 25.0 years (range 20.8–32.6 years). and 92.1% were athletes. In 90% of the cases, the number of dislocations before surgery were fewer than 5. The recurrence of instability after Latarjet procedure was observed only in seven patients (2.5%). The position of the bone graft resulted flush to the anterior glenoid rim in 238 cases (85.3%), medial in 8 (2.9%) and overhanging in 33 (11.8%). Radiological signs of development or progression of shoulder OA were observed in 25.8% of the patients, of which 88.6% presented a grade 1 of OA according to Samilson and Prieto classification. The overhanging position of the bone graft resulted statistically significant for onset or worsening of OA. The age at surgery, the number of dislocations before surgery and the Hill–Sachs lesion were not significantly associated with joint degeneration. Instead, hyperlaxity showed a prevention role in the development of OA after open Latarjet procedure. Conclusion The Latarjet procedure is a valid and safe surgical treatment in recurrent anterior shoulder instability with a low risk of developing moderate or severe OA also at long-term follow-up. The overhanging position of the bone graft represents the principal risk factor of joint degeneration, whereas the hyperlaxity seems to be protective. Finally, age, gender, time between first dislocation and surgery, and number of dislocations do not seem to affect the onset of OA after Latarjet procedure. Therefore, an accurate execution of the Latarjet procedure can be considered a valid treatment even in young and athletes thanks to the low recurrence rates and the low development of major long-term complications. Level of evidence IV.

Purpose The lateral elbow musculature conveys a dynamic valgus moment to the elbow, increasing joint stability. Muscular or tendinous lesions to the anterior half of the common extensor origin (CEO) may provoke a deficiency in the elbow dynamic stabilizers, regardless of their traumatic, degenerative, or iatrogenic aetiology. Furthermore, a role for the radial band of the lateral collateral ligament (R-LCL) has been postulated in the aetiology of lateral elbow pain. This study aimed to evaluate the effects of sequential lateral releases with dynamic ultrasound, evaluating its capability to detect lesions of the CEO and of the R-LCL. Methods Ultrasound investigation of the lateral compartment of the elbow was performed on nine cadaveric specimens with a 10 MHz linear probe in basal conditions, after the release of the anterior half of the CEO and after complete R-LCL release. The lateral joint line widening (λ) was the primary outcome parameter, measured as the linear distance between the humeral and radial articular surfaces. Results The release of the anterior half of the CEO significantly increased λ by 200% compared to the starting position (p = 0.0008) and the previously loaded position (p = 0.0015). Conversely, further release of the R-LCL caused only a marginal, non-significant increase in λ. Conclusions Ultrasound evaluation can detect changes related to tendon tears or muscular avulsions of the CEO and can depict lateral elbow compartmental patholaxity by assessing articular space widening while scanning under dynamic stress. However, it cannot reliably define if the R-LCL is injured. Iatrogenic damage to the CEO should be carefully avoided, since it causes a massive increase in compartmental laxity.

Background: An elongation of the radial lateral collateral complex (R-LCL) can provoke symptomatic minor instability of the lateral elbow leading to lateral elbow pain. Biomechanical models investigating the effects of elongation and partial or complete lesions of the R-LCL on lateral elbow stability are lacking. Purpose: To evaluate how partial and complete R-LCL release affects radiocapitellar joint stability in a setting of controlled varus load and progressive soft tissue release. Study Design: Controlled laboratory study. Methods: Ten fresh-frozen cadaveric specimens were obtained and mounted on a custom-made support to control elbow flexion and extension and to allow for controlled varus loading. Stress tests were performed on all intact specimens under gravity load alone, a 0.5-kg load applied to the hand, and a 1-kg load applied to the hand. After load application, anteroposterior radiographs were obtained. The following release sequence was applied to all specimens: release of the anterior half of the common extensor origin, pie crusting of the R-LCL, and R-LCL release. After each release, stress tests and radiographs were performed. The varus joint angulation of the elbow (α) was measured by 2 examiners as the main outcome parameter. Results: Significant changes in α from the initial condition occurred after each release, and a significant effect of varus load on α was documented for all release steps. A significant effect of the releases on α could be documented for all identical varus load conditions. A linear regression model was generated to describe the effect of varus load on α. Conclusion: Varus loads simulating everyday activities produce changes in the varus joint angulation of the elbow already in the intact specimen, which are linearly dependent on the applied moment and persist after release of the lateral stabilizing structures. With progressive load, a pie crusting of the R-LCL is the minimal procedure able to provoke a significant change in the varus joint angulation, and a complete R-LCL release produces additional increase in the varus joint angulation in all testing conditions. Clinical Relevance: These findings confirm the role of the R-LCL as static lateral stabilizer, supporting a pathological model based on its insufficiency and culminating with a symptomatic minor instability of the lateral elbow.

A Symptomatic Minor Instability of the Lateral Elbow (SMILE) is a possible etiology of recalcitrant lateral elbow pain: in this condition, the deficiency of the radial band of the lateral collateral ligament as a static elbow stabilizer plays a relevant role, determining hypermobility of the radial head, chondral abrasions, and synovitis associated to intra-articular pain and tendinopathy of the extensor carpi radialis brevis associated to extra-articular pain.

Arthroscopic-assisted radial head and coronoid fracture fixation can be a valid alternative to the classic open reduction and internal fixation in selected fracture types. Arthroscopy improves visualization of the articular surfaces, permitting better understanding of the fracture’s morphology and more precise anatomical reduction. Nevertheless, compared to open surgery, some specific risks and pitfalls should be considered. This chapter provides a concise overview on the relevant advantages and disadvantages of each elbow arthroscopy portal in addressing radial head fractures with arthroscopic lag screw fixation and presents an innovative arthroscopic technique for antegrade direct reduction and retrograde fixation of coronoid process fractures through an accessory anteromedial portal.

Medial elbow instability is usually due to trauma or overload. Post-traumatic instability implies rupture of the medial collateral ligament (MCL); sometimes there are some associated injuries such as bone fractures or soft-tissue lesions (flexor-pronator muscles). When MCL becomes insufficient, pathological contacts between bony surfaces of the elbow may occur during valgus-stress activities.

Background The study aim is to share our experience in hospital re-organization and management of paediatric traumatology in the early stage of COVID-19 pandemic. We centralized paediatric traumatology supposing a reduction of ER admissions, with increased severity of conditions, and a change in fracture patterns and consequently re-organized our structure. The COVID-19 epidemic in Europe has seen Italy as the first focus starting from the 21st of February 2020. Lombardy has been the most affected area. The initial NHS approach determined a high percentage of hospital admissions that led to early overload of hospitals, and we had to reorganize our structure to face the emergency. Methods We retrospectively evaluated the admission and treatment data to observe the epidemiological evolution of paediatric trauma during the lockdown ordinance and compared them with the same period in 2019. Results We found a reduction of 78% paediatric visits in the ER but no decrease in the amount of paediatric fractures, rather we found a rate of paediatric fractures increased by 21,62 %. The upper limb fractures being the most representative. Conclusions Our expectations were confirmed. We believe that the reorganization and the guidelines by us designed has been effective to spare resources and subtract the paediatric traumatology load from those hospitals dealing with an unexpected number of critical COVID-19 patients. Even if we experienced a significant reduction of paediatric admissions to our trauma E.R., the presence of a determined number of fractures justifies the necessity of a specialized hub to collect all paediatric fractures.

Tendons are exposed to mechanical stress constantly during movements and thus they are frequently subjected to injuries. Rotator cuff tears are common musculoskeletal disorders, mainly involving the supraspinatus tendon. The characterization of the tenocytes derived from this tendon and the comparison to cells isolated from the long head of the biceps tendon obtained from donors affected by rotator cuff disease may improve the knowledge of the cellular mechanisms involved in the initiation and progression of the pathology. Thus, the aim of the present study was to characterize and compare donor-matched human tendon cells (TCs) isolated from the long head of the biceps (LHB-TCs) and the supraspinatus tendons (SSP-TCs) of patients affected by rotator cuff tears.donor-matched LHB-TCs and SSP-TCs were isolated and cultured up to passage 3. Phenotypic appearance, metabolic activity, DNA content, production of soluble mediators (IL-1Ra, IL-1β, IL-6, and VEGF) and gene expression of tendon markers (LHB-TCs showed an elongated fibroblast-like shape, while SSP-TCs appeared irregular with jagged membrane. SSP-TCs gene expression revealed an augmented production ofSSP-TCs showed higher cellular stress and expression of inflammatory markers with respect to donor-matched LHB-TCs, suggesting that addressing the physio-pathological state of supraspinatus tendon cells during treatment of rotator cuff tears could favor tissue healing and possibly prevent relapses.

INTRODUCTION: The strength of forearm in pronation and supination (P/S) is an important clinical assessment during pre-operative examination as well as in post-operative evaluation. Many clinical trials concerning the measurement of forearm P/S strength were performed using a dynamometer fixed on the wall. The aim of this study was to bring out a simple and reliable technique for the measurement of P/S strength using a dynamometer manually supported and stabilized by an examiner. We hypothesized that there are no differences in evaluation of elbow P/S strength using the dynamometer fixed or the dynamometer stabilized by an operator in healthy people. METHODS: The study was performed on a cross-sectional cohort of 100 healthy subjects without any history of injuries or previous surgery of the upper limbs. Isometric forearm P/S strengths were measured on the dominant and non-dominant forearms, using the dynamometer fixed on a table, and using the same dynamometer kept by an operator. The measurements were repeated in triplicate at 45°, 90° and 120° of elbow flexion in both upper limbs for all patients. RESULTS: A total of 100 subjects (50 females, 50 males) were included in the study group. The mean age was 46.5 years (range 25–52 years). Female and male subjects showed no significant differences concerning the mean age (F/M ratio 0.50/0.50). The mean body mass index of all participants was 24.34 ± 3.66 kg/m(2). No significant statistics difference was reported between the P/S strength measured using the two detection methods in our study group (45°, 90° and 120° of elbow flexion and both upper limbs). CONCLUSION: The manually stabilized technique is a valid and reliable technique to assess the P/S strength of the forearm. This is a simple and effective method that may be reproduced in our daily clinical practice as well as in sportive practice.

Introduction: Distal Femoral Osteotomy (DFO) is a common procedure for correcting lower limb valgus deformity and lateral compartment overload. Low 20-year survivorship rate was reported with a consequent need for total knee arthroplasty (TKA). This study aims to review literature and to analyse the influence of a previous distal femoral osteotomy on outcomes of patients undergoing TKA.Methods: A systematic literature review was performed in PubMed/Medline and Embase in May 2020. Papers were selected based on the following criteria: patient with a previous distal femoral osteotomy; total knee replacement; Pre- and Postoperative outcomes; surgical outcomes: clinical scores, range of motion, radiographic evaluation and revisions for any cause; case series, retrospective studies, observational studies, open-label studies, randomized clinical trials; systematic reviews and meta-analyses were included to extract primitive studies.Results: 306 articles were found, of which five papers were considered eligible for this review. In every study included, postoperative clinical outcomes (Knee Society Score or Hospital for Special Surgery score) statistically improved from the preoperative. Complications were not uncommon; implant survivorship at the available follow-up seems to be similar to primary TKA, although being too short to draw any conclusions.Conclusions: Limited and highly heterogeneous evidence is currently available on the influence of DFO on outcomes after TKA. Knee replacement improves clinical middle-term outcomes in patients with previous distal femoral osteotomy. In this complex surgery, the use of technical tips and tricks could help surgeons to obtain an accurate knee balancing and better long-term results.

SHOULDER ARTHROPLASTY IN THE TREATMENT OF PROXIMAL HUMERAL FRACTURESShoulder arthroplasty is currently the gold standard in the treatment of complex displaced proximal humeralfractures with high risk of avascular necrosis. Hemiarthroplasty was extensively used in the past; however, it presentsa wide variability of clinical outcomes. Recently, reverse total shoulder arthroplasty showed good results in elderlypatients with severe osteoporosis and rotator cuff tears.

Despite the recent advances in surgical techniques, the percentage of painful shoulder arthroplasties is still high (more than 10%). The causes of residual pain after shoulder arthroplasty, and the resulting treatment solutions, are many and different. The most common complications of shoulder prosthesis are infections, aseptic loosening, modular components disassembling, metal hypersensitivity, and instability. There are also implant-related complications such as glenoid wear in hemiarthroplasty, rotator cuff tear in anatomical total shoulder arthroplasty, scapular notching, and acromion fracture in reverse shoulder arthroplasty. Several of these complications can be avoided with a careful selection of the implants, a proper surgical technique and a precise implant positioning. The execution of a more accurate preoperative planning and the possible use of patient-specific implants are expected to translate into better clinical results in the future. We provide the reader with recent evidence on the causes and therapeutic options of this condition.

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

The purpose of this study was to investigate the pathogenesis, the incidence, and the results of arthroscopic treatment of os acetabuli (OSA) in a group of patients with diagnosis of femoro-acetabular impingement (FAI). We retrospectively analyzed the full documentation of 294 hips in 273 patients (21 bilateral) operated for FAI through hip arthroscopy. We reviewed all radiographs and arthro-MRI in order to identify the incidence of OSA. All patients with OSA were then assessed with a modified Harris hip score (MHHS) pre-operatively and at the final follow-up. Twenty-one patients (7.7%), 20 (95%) of them were male, were diagnosed with concomitant FAI and os acetabuli. In 21 cases, OSA was excised and FAI was treated with rim trimming, femoral osteoplasty, or both. In one case, a large OSA fragment was fixed with a 4 mm screw avoiding an acetabular uncoverage if excised. The average follow-up was 31 months (range from 6 to 69 months). The MHHS showed an improvement from a pre-operative MHHS of 57.5 (range from 39 to 82) to 95 (range from 73 to 100). Os acetabuli is not uncommon and certainly associated with FAI and male gender. The etiology is probably microtraumatic. The arthroscopic OSA removal or fixation and concomitant FAI treatment showed very good results. Interestingly, these outcomes seem better than FAI treatment alone. Further studies with a wider number of patients and a longer follow-up are needed to confirm these results and understand the real role of OSA in this setting.