Davide Blonna

Fibromyalgia syndrome: etiology, pathogenesis, diagnosis, and treatment.

Fibromyalgia syndrome is mainly characterized by pain, fatigue, and sleep disruption. The etiology of fibromyalgia is still unclear: if central sensitization is considered to be the main mechanism involved, then many other factors, genetic, immunological, and hormonal, may play an important role. The diagnosis is typically clinical (there are no laboratory abnormalities) and the physician must concentrate on pain and on its features. Additional symptoms (e.g., Raynauds phenomenon, irritable bowel disease, and heat and cold intolerance) can be associated with this condition. A careful differential diagnosis is mandatory: fibromyalgia is not a diagnosis of exclusion. Since 1990, diagnosis has been principally based on the two major diagnostic criteria defined by the ACR. Recently, new criteria have been proposed. The main goals of the treatment are to alleviate pain, increase restorative sleep, and improve physical function. A multidisciplinary approach is optimal. While most nonsteroidal anti-inflammatory drugs and opioids have limited benefit, an important role is played by antidepressants and neuromodulating antiepileptics: currently duloxetine (NNT for a 30% pain reduction 7.2), milnacipran (NNT 19), and pregabalin (NNT 8.6) are the only drugs approved by the US Food and Drug Administration for the treatment of fibromyalgia. In addition, nonpharmacological treatments should be associated with drug therapy.

External rotation lag sign revisited: Accuracy for diagnosis of full thickness supraspinatus tear

HYPOTHESIS This study reassessed the sensitivity and the specificity of the external rotator lag sign (ERLS) for diagnosis of supraspinatus tears in a large cohort of patients. MATERIALS AND METHODS The ERLS was used to assess 401 consecutive patients with 406 painful shoulder conditions. The clinical diagnosis was controlled either arthroscopically or by open surgery. RESULTS For isolated full-thickness supraspinatus tears, the ERLS had a sensitivity of 56% and a specificity of 98%. When the lesion involved the infraspinatus and the teres minor the sensitivity improved substantially. There was a strong correlation between the extension of the tear and the amount of the lag. The lag increased from 7 degrees for an isolated rupture of the supraspinatus tendon to 26 degrees in case of extension to the teres minor. CONCLUSION The ERLS is highly specific and acceptably sensitive for diagnosis of full-thickness tears, even in case of an isolated lesion of the supraspinatus tendon. LEVEL OF EVIDENCE Level 2; Prospective cohort treatment study.

Medial Opening Wedge High Tibial Osteotomy for Medial Compartment Overload/Arthritis in the Varus Knee Prognostic Factors

Background: Medial opening wedge high tibial osteotomy (OWHTO) is a widely accepted procedure for the treatment of medial compartment arthritis of the knee. Compared with closing wedge HTO, however, the outcomes of OWHTO reported in the literature are incomplete. Purpose: To identify the positive and negative prognostic factors related to the outcomes of OWHTO through an evaluation of midterm study results and survivorship analysis. Study Design: Case series; Level of evidence, 4. Methods: From January 2001 to December 2009, a total of 141 consecutive OWHTOs were performed in 123 patients. Only patients with symptomatic medial knee overload/arthritis were included. The patients were evaluated preoperatively and at every follow-up visit with (1) the Knee Society score, (2) the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, (3) another self-evaluation scale, (4) long-leg radiographs, and (5) plain radiographs. Preoperative, intraoperative, and postoperative variables were investigated to find an association with the outcomes. Results: Of the 123 patients, 15 were lost to follow-up, and 24 were excluded from the study, leaving 84 patients (99 OWHTOs) for the present study. The mean age of the patients at the time of surgery was 54.5 ± 9.2 years. The mean follow-up was 51.5 ± 23.8 months. The Knee Society and WOMAC scores significantly improved after surgery (P < .001). The variables significantly related to a poor outcome were (1) age >56 years (P = .008) and (2) postoperative knee flexion <120° (P < .001); the variables significantly related to a good outcome were (1) Ahlbäck grade 0 arthritis of the medial compartment (P < .001) and (2) excellent preoperative Knee Society score (P < .001). The Kaplan-Meier analysis showed a survival rate of 98.7% at 5 years and 75.9% at 7.5 years. Conclusion: With correct indications, OWHTO is a reliable procedure for medial knee arthritis/overload. The outcomes reported are similar to those from other studies, although the variables related to outcomes are slightly different.

Treatment of medial and posteromedial knee instability: indications, techniques, and review of the results.

Until recently, the posterolateral corner of the knee was noted both for its complex anatomy and diagnostic challenges. To improve the understanding of the posterolateral knee, we completed a comprehensive and stepwise research program with a focus on five primary areas: (1) surgical approach and relevant anatomy; (2) diagnosis; (3) clinically relevant biomechanics; (4) natural history; and (5) surgical treatment. Based on this comprehensive research program, the diagnosis and outcomes following treatment of posterolateral knee injuries have been significantly improved comparing the preoperative state to the state of the knee at a minimum 2 year follow‐up in the cases series presented here.

Cocultures of Adult and Juvenile Chondrocytes Compared With Adult and Juvenile Chondral Fragments In Vitro Matrix Production

Background: The use of allogenic juvenile chondrocytes or autologous chondral fragments has shown promising laboratory results for the repair of chondral lesions. Hypothesis: Juvenile chondrocytes would not affect matrix production when mixed with adult chondrocytes or cartilage fragments. Study Design: Controlled laboratory study. Methods: Cartilage sources consisted of 3 adult and 3 juvenile (human) donors. In part 1, per each donor, juvenile chondrocytes were mixed with adult chondrocytes in 5 different proportions: 100%, 50%, 25%, 12.5%, and 0%. Three-dimensional cultures in low-melt agarose were performed. At 6 weeks, biochemical and histologic analyses were performed. In part 2, isolated adult, isolated juvenile, and mixed 3-dimensional cultures (1:1) were performed with chondral fragments (<1 mm), both with low-melt agarose and a hyaluronic acid scaffold. At 2 and 6 weeks, cultures were evaluated with biochemical and histologic analyses. Results: Part 1: Biochemical and histologic analyses showed that isolated juvenile cultures performed significantly better than mixed and isolated adult cultures. No significant differences were noted between mixed cultures (1:1) and isolated adult cultures. Part 2: Biochemical and histologic results at 6 weeks showed that mixed cartilage fragment cultures performed better than isolated adult cultures in terms of proteoglycans/DNA ratio (P = .014), percentage of safranin O–positive cells (P = .012), Bern score (P = .001), and collagen type II. No statistically significant difference was noted between juvenile and mixed cultures. Conclusion: Extracellular matrix production of juvenile chondrocytes is inhibited by adult chondrocytes. The addition of juvenile cartilage fragments to adult fragments improves matrix production, with a positive interaction between the 2 sources. Clinical Relevance: Even if the underlying mechanisms are still unknown, this study describes the behavior of juvenile/adult cocultures using both chondrocytes and cartilage fragments, with potential for new research and clinical applications.

Anteromedial Elbow Arthroscopy Portals in Patients With Prior Ulnar Nerve Transposition or Subluxation

PURPOSE The purpose of this study was to document management strategies and complications relating to the use of anteromedial portals for elbow arthroscopy in a series of patients with subluxating or previously transposed ulnar nerves. METHODS A review of 913 elbow arthroscopies showed that 59 elbows with a subluxating or previously transposed ulnar nerve required anterior compartment arthroscopic surgery. The patients with subluxating nerves had proximal anteromedial portals established by reducing and holding the nerve behind the epicondyle with a thumb while establishing or entering the portal. In cases of prior nerve transposition, the following techniques were used if, by palpation, localization of the ulnar nerve was considered to be (1) unequivocal, (2) equivocal, or (3) impossible: In group 1 (unequivocal) the proximal anteromedial portal was established in the normal antegrade fashion. In group 2 (equivocal) a 1-cm incision was made at the planned proximal anteromedial portal site and blunt dissection down to the capsule was performed without identification of the nerve. In group 3 (impossible) a 2- to 4-cm skin incision was made and the nerve was identified before placement of the portal. RESULTS We found that 59 elbows in 56 patients had a subluxating ulnar nerve (31 elbows) or previous ulnar nerve transposition (28 elbows). The transposition had been subcutaneous in 21 and submuscular in 7. The proximal anteromedial portal was used in all but 3 cases (2 patients) of submuscular transposition that were early in the series. In those cases only 2 lateral portals were used for anterior compartment surgery. There were no operative ulnar nerve injuries related to the use of the proximal anteromedial portal. CONCLUSIONS Neither elbow arthroscopy nor specifically the use of the proximal anteromedial portal is contraindicated in patients with prior transposition or subluxation of the ulnar nerve. The management of the nerve can be based on the degree of certainty with which the nerve can be localized by palpation in the region of the planned portal. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Prospective follow-up of a simple arthroscopic-assisted technique for lateral tibial plateau fractures: Results at 5 years

This study reports the 5-year clinical and radiological outcomes of a simple arthroscopic-assisted technique for Schatzker types II and III tibial plateau fractures, without bone grafting. Forty six patients (46% males, 54% females, average age 48 years, SD 13.6 years), with tibial plateau fractures Schatzker types II (41%) and III (59%), underwent an arthroscopic-assisted technique conceived to use a compacted cancellous bone graft, taken from the medial metaphyseal side of the tibia, and a percutaneous fixation. The patients were prospectively followed-up at 1, 3 and 5 years from surgery. Independent assessments were carried out using Knee Society Score, HSS score and Rasmussens clinical and radiological scores. At 5-year follow-up patients underwent a weight-bearing radiograph of both limbs. At last follow-up evaluation Knee Score (average 93.2, SD 7.7) was excellent in 37 patients (80%), good in six (13%), fair in three (7%). Function Score (average 94.8, SD 8.51) was excellent in 38 patients (83%), good in five (11%), fair in three (6%). HSS score (average 93.4, SD 8.23) was excellent in 41 patients (89%), good in five (11%). The average Rasmussen clinical score was 28.2 (SD 1.4). The radiological Rasmussen score was excellent in five patients (11%), good in 39 (85%) and fair in two (4%). In the weight-bearing radiographs a valgus deviation was present in four patients (8.7%). This technique has outcomes encouraging and comparable to the results of other techniques that use either iliac crest graft or bone substitutes.

Minced Umbilical Cord Fragments as a Source of Cells for Orthopaedic Tissue Engineering: An In Vitro Study

A promising approach for musculoskeletal repair and regeneration is mesenchymal-stem-cell- (MSC-)based tissue engineering. The aim of the study was to apply a simple protocol based on mincing the umbilical cord (UC), without removing any blood vessels or using any enzymatic digestion, to rapidly obtain an adequate number of multipotent UC-MSCs. We obtained, at passage 1 (P1), a mean value of 4, 2 × 106 cells (SD 0,4) from each UC. At immunophenotypic characterization, cells were positive for CD73, CD90, CD105, CD44, CD29, and HLA-I and negative for CD34 and HLA-class II, with a subpopulation negative for both HLA-I and HLA-II. Newborn origin and multilineage potential toward bone, fat, cartilage, and muscle was demonstrated. Telomere length was similar to that of bone-marrow (BM) MSCs from young donors. The results suggest that simply collecting UC-MSCs at P1 from minced umbilical cord fragments allows to achieve a valuable population of cells suitable for orthopaedic tissue engineering.

Can we improve the reliability of the Constant-Murley score?

HYPOTHESIS The Constant-Murley score (CMS) is one of the most used scales for shoulder dysfunction. The aim of this study is to determine whether the reliability of the CMS can be improved by enhancing the standardization of the items. METHODS Two consecutive series of 55 patients with shoulder dysfunction were enrolled in a test-retest study and examined by 2 orthopedic surgeons with different levels of expertise. The following scores were measured: CMS, individual relative CMS, relative CMS, and standardized CMS. For each variable, the intraobserver and interobserver reliability was calculated. RESULTS The less experienced observer had worse intraobserver reliability using the CMS (error, 4 points; 95% limit of agreement, 22) than the expert observer (error, 2.4 points; 95% limit of agreement, 16). The standardized CMS showed better intraobserver reliability, with an error of 0.4 points and 95% limits of agreement of 9 for the expert observer and 13 for the less experienced observer. The correction against the contralateral unaffected side and the reference population determined a worsening of reliability in both observers. Interobserver reliability showed an improvement similar to that of intraobserver reliability (systematic error, 4; 95% limit of agreement, 24) by use of the CMS and improved to 1 point when the standardized CMS was adopted (95% limit of agreement, 12). CONCLUSIONS This study showed that the standardization of the items significantly improved both the intraobserver reliability and interobserver reliability of the CMS. The level of expertise of the observer has less of an effect on reliability when the score is applied with a higher level of standardization.

Prevention of nerve injury during arthroscopic capsulectomy of the elbow utilizing a safety-driven strategy.

BACKGROUND A major factor limiting the use of elbow arthroscopy for contracture release is concern regarding nerve injury. The purpose of this report is to document the risk of nerve injury in a large series of arthroscopic contracture releases utilizing a safety-driven strategy. METHODS A series of 502 arthroscopic elbow contracture releases (including 388 osteocapsular arthroplasties) performed in 464 patients by one surgeon was reviewed retrospectively. The safety-driven step-wise strategy had been carried out in a standardized sequence: (1) Get In and Establish a View, (2) Create a Space in Which to Work, (3) Bone Removal, and (4) Capsulectomy. Neurologic complications were assessed and were followed until resolution. RESULTS No patient had a permanent nerve injury. Twenty-four patients (5%) had a transient nerve injury, associated with prolonged tourniquet time, cutaneous dysesthesia attributed to open incisions, simultaneous ulnar nerve transposition, or retractor use. All nerve deficits resolved after one day to twenty-four months, with one patient lost to follow-up. CONCLUSIONS Utilizing the technique described, arthroscopic contracture release and debridement of the elbow was performed with a low risk of nerve injury. LEVEL OF EVIDENCE Therapeutic level III. See instructions for authors for a complete description of levels of evidence.