Davide Edoardo Bonasia

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.

Postoperative complications of posterior ankle and hindfoot arthroscopy.

BACKGROUND Posterior ankle and hindfoot arthroscopy, performed with use of posteromedial and posterolateral portals with the patient in the prone position, has been utilized for the treatment of various disorders. However, there is limited literature addressing the postoperative complications of this procedure. In this study, the postoperative complications in patients treated with posterior ankle and hindfoot arthroscopy were analyzed to determine the type, rate, and severity of complications. METHODS The study included 189 ankles in 186 patients (eighty-two male and 104 female; mean age, 37.1 ± 16.4 years). The minimum duration of follow-up was six months, and the mean was 17 ± 13 months. The most common preoperative intra-articular diagnoses were subtalar osteoarthritis (forty-six ankles), an osteochondral lesion of the talus (forty-two), posterior ankle impingement (thirty-four), ankle osteoarthritis (twenty), and subtalar coalition (five). The most common extra-articular diagnoses were painful os trigonum (forty-six), flexor hallucis longus tendinitis (thirty-two), and insertional Achilles tendinitis (five). RESULTS The most common intra-articular procedures were osteochondral lesion debridement (forty-four ankles), subtalar debridement (thirty-eight), subtalar fusion (thirty-three), ankle debridement (thirty), and partial talectomy (nine). The most common extra-articular procedures were os trigonum excision (forty-eight), tenolysis of the flexor hallucis longus tendon (thirty-eight), and endoscopic partial calcanectomy (five). Complications were noted following sixteen procedures (8.5%); four patients had plantar numbness, three had sural nerve dysesthesia, four had Achilles tendon tightness, two had complex regional pain syndrome, two had an infection, and one had a cyst at the posteromedial portal. One case of plantar numbness and one case of sural nerve dysesthesia failed to resolve. CONCLUSIONS Our experience demonstrated that posterior ankle and hindfoot arthroscopy can be performed with a low rate of major postoperative complications.

Meniscal Allograft Transplantation A Systematic Review

Background: Meniscal allograft transplantation (MAT) was developed as a means of treating the symptoms of compartmental overload after meniscectomy. Despite more than 20 years of research in this field, many controversies still exist regarding meniscal transplantation. Purpose: The aims of this study were to assess (1) the quality of the published studies on MAT; (2) the indications for this type of surgery; (3) the methods used for preservation, sizing, and fixation of the allograft; and (4) the clinical and radiographic outcomes of this procedure and its role in preventing osteoarthritis. Study Design: Systematic review. Methods: Inclusion criteria for the articles were (1) English language, (2) peer-reviewed clinical studies with evidence levels 1 to 4, (3) reported clinical and/or radiological outcomes of MAT isolated or combined with other procedures, (4) minimum 12-month follow-up, (5) case series of at least 10 patients, and (6) a follow-up rate of at least 80% (no more than 20% of patients lost to follow-up). Results: A total of 55 studies matched the inclusion criteria (2 level 2, 7 level 3, and 46 level 4). The average Coleman methodology score was 49.73 ± 12.41 (range, 24-81). There was agreement in the literature regarding the indications for MAT: joint line pain and tenderness correlated with previous meniscectomy, young patients, without diffuse Outerbridge grade III and no grade IV cartilage damage, and a stable and well-aligned knee. Different graft types have been used: viable, fresh frozen, cryopreserved, and lyophilized. The most common method for graft sizing was plain radiography. Different fixation techniques have been described, with only a few studies comparing the clinical results of the different techniques and with no proven superiority of one method over the other. All the studies showed clinical improvement at last follow-up visit compared with preoperatively. The chondroprotective effect of MAT is still unclear. Conclusion: Meniscal allograft transplantation seems to provide good clinical results at short-term and midterm follow-up, with improvement in knee function as well as acceptable complication and failure rates. Higher quality studies are necessary to better assess the potential chondroprotective effect of MAT and to identify differences in terms of outcomes between different surgical techniques.

The role of high tibial osteotomy in the varus knee.

&NA; High tibial osteotomy (HTO) is a widely performed procedure, and good results can be achieved with appropriate patient selection and precise surgical technique. Clinical indications include varus alignment of the knee associated with medial compartment arthrosis, knee instability, medial compartment overload following meniscectomy, and osteochondral defects requiring resurfacing procedures. Coronal alignment (ie, varus, valgus) and sagittal alignment (ie, tibial slope) should be thoroughly evaluated in all cases. Many techniques have been described for HTO, whether alone or in combination with other procedures (eg, anterior cruciate ligament reconstruction, meniscal transplant, cartilage resurfacing). Little direct evidence exists regarding the effectiveness of HTO alone or in combination with other procedures because of the lack of randomized controlled studies. However, it is commonly accepted that correct alignment is essential in achieving durable results.

The Role of Arthroscopy in the Management of Fractures About the Ankle

Abstract Anatomic restoration of the joint is the goal of management in fractures about the ankle. Open reduction and internal fixation (ORIF) is the standard of care for unstable ankle fractures; however, arthroscopic management has been proposed. The use of arthroscopic reduction and internal fixation (ARIF) is surgeondependent. Reported indications for ARIF include transchondral talar dome fracture, talar fracture, low‐grade fracture of the distal tibia, syndesmotic disruption, malleolar fracture, and chronic pain following definitive management of fracture about the ankle. Among the potential benefits are less extensive exposure, preservation of blood supply, and improved visualization of the pathology. Although arthroscopy is increasingly used in the setting of trauma, the effectiveness of ARIF compared with ORIF for management of fractures of the distal tibia, malleolus, displaced talar neck, and talar body has yet to be determined. Most of these fractures are effectively managed with open procedures.

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.

Arthroscopic Resection of Talocalcaneal Coalitions

Excision of symptomatic talocalcaneal coalitions, after failure of an adequate conservative treatment, is a widely accepted surgical treatment when less than 50% of the subtalar joint is involved and in the absence of degenerative changes to the subtalar or surrounding tarsal joints. Favorable results have been reported in 80% to 100% of patients with open resection. The traditional medial incision to the subtalar joint provides excellent exposure of the middle facet but inadequate visualization of the posterior facet. Other common disadvantages of the traditional open technique include (1) risk of incisional neuroma formation, (2) risk of superficial wound infection and delayed wound healing, and (3) prolonged hospitalization for wound management and pain control. Prone ankle/subtalar arthroscopy has been reported to yield excellent results in the treatment of numerous hindfoot pathologies, with the advantage of reducing postoperative pain, hospital stay, infection rates, wound complications, and recovery time. A posterior arthroscopic technique for posterior-facet talocalcaneal coalition excision has been developed in an attempt to reduce the complications of the traditional open resection. Possible disadvantages of the arthroscopic procedure may include (1) longer learning curve, (2) increased surgical time, (3) possible tibial neurovascular bundle damage, and (4) difficulties in using interposition material.

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.