Francesco Ioppolo

Extracorporeal Shock-Wave Therapy Compared with Surgery for Hypertrophic Long-Bone Nonunions

BACKGROUND The authors of several studies have recommended extracorporeal shock-wave therapy as an alternative to surgical treatment for long-bone nonunions. This study was performed to compare the results of extracorporeal shock-wave therapy produced by two different devices with those of surgical treatment in the management of long-bone nonunions. METHODS One hundred and twenty-six patients with a long-bone nonunion were randomly assigned to receive either extracorporeal shock-wave therapy (Groups 1 and 2) or surgical treatment (Group 3). The patients in the shock-wave groups received four treatments with 4000 impulses of shock waves with an energy flux density of 0.40 mJ/mm(2) (Group 1) or 0.70 mJ/mm(2) (Group 2). The patients in the three groups had similar demographic characteristics, durations of nonunion, and durations of follow-up. Radiographic results (the primary outcome) and clinical results (the secondary outcomes) were determined before and three, six, twelve, and twenty-four months after treatment. RESULTS The radiographic findings did not differ among the three groups of patients. At six months, 70% of the nonunions in Group 1, 71% of the nonunions in Group 2, and 73% of the nonunions in Group 3 had healed. Three and six months after treatment, the clinical outcomes in the two shock-wave groups were significantly better than those in the surgical group (p < 0.001). However, at both twelve and twenty-four months after treatment, there were no differences among the three groups, with the exception of the DASH score, which differed significantly between Groups 1 and 3 (p = 0.038) and between Groups 2 and 3 (p = 0.021) at twelve months. CONCLUSIONS Extracorporeal shock-wave therapy is as effective as surgery in stimulating union of long-bone hypertrophic nonunions and yields better short-term clinical outcomes.

Extracorporeal Shock-Wave Therapy for Supraspinatus Calcifying Tendinitis: A Randomized Clinical Trial Comparing Two Different Energy Levels

Background Extracorporeal shock-wave therapy (ESWT) represents a valid intervention in the treatment of people with supraspinatus calcifying tendinitis (SCT), but there is limited evidence for the useful range of ESWT doses. Objective The aim of this study was to compare 2 different ranges of energy flux density in treatment of SCT with ESWT. Design This study was designed as a single-blind randomized clinical trial. Setting This study was performed in a university hospital. Patients Forty-six patients with SCT were randomly assigned to 2 groups that received different therapeutic energy doses of ESWT: (1) group A received ESWT at an energy level of 0.20 mJ/mm2, and (2) group B received ESWT at an energy level of 0.10 mJ/mm2. Intervention The treatment protocol consisted of 4 sessions performed once a week. Measurements The change in mean Constant Murley Scale (CMS) scores at 3 and 6 months was the primary endpoint. The change in the mean visual analog scale (VAS) scores from baseline to 3 and 6 months after the intervention and radiographic change in size of calcium deposits were evaluated as secondary endpoints. At 12 months, pain relief was assessed using a numeric rating scale. Results Significant clinical improvement based on mean CMS scores was observed after 6 months in group A (X̅=79.43, SD=10.33) compared with group B (X̅=57.91, SD=6.53). Likewise, after 6 months, a significant decrease in VAS scores was found in group A (X̅=2.09, SD=1.54) compared with group B (X̅=5.36, SD=0.78). Calcific deposits disappeared in the same percentage of patients in both groups. Limitations The small sample size and lack of a control group were limitations of the study. Conclusions In ESWT for SCT, an energy level of 0.20 mJ/mm2 appears to be more effective than an energy level of 0.10 mJ/mm2 in pain relief and functional improvement.

Ultrasound-guided aspiration and corticosteroid injection of Baker's cysts in knee osteoarthritis: a prospective observational study.

Di Sante L, Paoloni M, Ioppolo F, Dimaggio M, Di Renzo S, Santilli V: Ultrasound-guided aspiration and corticosteroid injection of Bakers cysts in knee osteoarthritis: A prospective observational study. Objective:To determine the effect on pain, function, and ultrasonographic findings of ultrasonography-guided Bakers cyst aspiration followed by corticosteroid injection in a group of patients with Bakers cyst secondary to knee osteoarthritis. Design:Prospective observational study. Results:Twenty-six subjects participated in this study. Clinical and instrumental evaluations were performed at baseline (T0), 1 wk (T1), and 4 wks (T2) after procedure. Mean Visual Analog Scale scores significantly dropped after the procedure (T0 = 6.2 [1.2]; T1 = 4.48 [1.5]; T2 = 4.32 [1.3]; T0 vs. T1 and P < 0.0001). A significant difference between preprocedure and postprocedure Western Ontario and McMaster Universities scores was found for pain (P < 0.0001) but not for joint stiffness (P = 0.7239) and disability (P = 0.6318). Ultrasonographic evaluation showed a significant reduction for both axial (P = 0.006) and sagittal (P = 0.01) areas of Bakers cyst, but no correlation was found between pain relief and Bakers cyst volume reduction. Conclusions:Cyst aspiration with corticosteroid injection give pain relief and cyst volume reduction in patients with Bakers cyst and concomitant knee osteoarthritis. However, when compared with current literature, our results are similar to those obtained with intra-articular knee corticosteroid injection.

Peripheral nerve conduction abnormalities in nonparetic side of ischemic stroke patients

Cardiovascular diseases manifest similar age and sex distribution in the general population and have some commons risk factors with some neuropathies. The aim of this study is to verify whether standard nerve conduction studies show significant differences in a group of poststroke hemiplegic patients, when compared with a control group, in the hypothesis that stroke, as a primary cardiovascular event, could be strongly associated with peripheral nervous system disease. Nerve conduction studies were performed in 15 hemiplegic patients and 10 aged matched control subjects. Percentage of patients showing slowed ulnar and common peroneal motor nerve conduction and lower ulnar sensory nerve action potential was significantly higher in hemiplegic patients. These findings suggest that an overall increased risk of neuropathies could be detected among stroke patients.

17-Italian Foot Function Index with numerical rating scale: development, reliability, and validity of a modified version of the original Foot Function Index.

BACKGROUND Clinical research quantifies symptoms and signs of pain. OBJECTIVE To develop a brief outcome measure to assess foot and ankle conditions, the psychometric properties of a modified version of the original Foot Function Index (FFI) were examined. METHODS Eighty-six subjects with musculoskeletal foot and ankle disorders were enrolled. The internal consistency and test-retest reliability were evaluated by using Cronbachs α and intraclass correlation coefficient (ICC). Criterion validity was tested by Pearsons correlation coefficient between 17 items of the Italian FFI (17-IFFI) and the Lower Extremity Functional Scale (LEFS). The responsiveness was calculated using the receiver operating characteristic curve (ROC). RESULTS Cronbachs Alpha was 0.95 (95% CI: 0.92, 0.99). The intra-interviewer and inter-interviewer ICC values were, respectively, 0.92 (95% CI: 0.88-10 0.96) and 0.90 (95% CI: 0.89-0.94). Correlations between the 17-IFFI scores and the LEFS scores were -0.564 and -0.456 at the initial and at the end of the treatment, respectively. The ROC analysis revealed an area under the curve of 0.732 (95% CI: 0.61-0.82) for the 17-IFFI and 0.633 (95% CI: 0.52-0.71) for the LEFS score. CONCLUSIONS The 17-IFFI is a reliable and valid scale and we recommend its application to evaluate the effectiveness of a treatment in patients with musculoskeletal foot and ankle disorders.

Ultrasound in tarsal tunnel syndrome: Correct diagnosis for appropriate treatment

We have read with interest the study, by Kim and colleagues, entitled “A Case of Lateral Calcaneal Neuropathy: Lateral Heel Pain”, about the utility of ultrasound (US) for diagnosis of entrapment of the lateral calcaneal branch of the sural nerve. They performed US examination in a 29-year-old patient, finding increased crosssectional area (CSA) of the aforementioned nerve branch. The patient had a 3-month history of pain in the lateral heel and was treated with extracorporeal shock wave therapy (ESWT), because plantar fasciitis was suspected. After treatment, sensory impairment occurred. The study is very important and stimulating for different reasons. First, the study shows and confirms the ability of US to find lesions even in very small nerves. This is a crucial point, because US is an extension of the clinical examination and allows depiction of morphological changes in peripheral nerves. We would like to report a similar case, in which ESWT was performed for misdiagnosed tarsal tunnel syndrome, and US was crucial to plan the most appropriate treatment. A 67-year-old man came to our attention from another hospital, because he complained of pain in the right foot plantar region and was suspected to have plantar fasciitis. The patient was treated with 2 cycles of ESWT (3 weekly administrations of 2400 shocks, 0.15 mJ/mm, 4 HZ on the painful region) without benefits. Clinical history and examination revealed burning pain and paresthesia in the anterior part of the right sole. A Tinel sign was evoked on percussion the area behind the right medial malleolus. Bilateral US evaluation at the level of the tarsal tunnel, in the region of the medial malleolus, revealed increased size of the right tibial nerve in comparison with the contralateral side (right CSA, 17 mm, left CSA, 12 mm, see Fig. 1). The right nerve showed a single large and hypoechoic

Complete remission of plantar fasciitis with a gluten-free diet: Relationship or just coincidence?

We report the case of a 46-year-old woman with no known history for gluten sensitivity who presented severe heel pain, and was successfully managed with a gluten-free diet. Previously she had been unsuccessfully treated with several conservative remedies. The presence of musculoskeletal problems in patients with gluten sensitivity is not rare. To the best of our knowledge, however, this is the first case report mentioning the successful management of plantar fasciitis with a gluten-free diet. The case report highlights the importance of considering gluten sensitivity among other possible differential diagnosis for musculoskeletal pain insensitive to traditional therapies.

Reliability of the Cervical Spine Device for the Assessment of Cervical Spine Range of Motion in Asymptomatic Participants

Objective: The purpose of this study was to assess the inter‐ and intra‐assessor reliability of the cervical spine device (Formetric, DIERS International GmbH, Schlangenbad, Germany) in measuring cervical range of motion. Methods: The cervical spine device was used to measure the cervical range of motion of 65 asymptomatic participants. Flexion‐extension, right and left rotation, and right and left lateral flexion were analyzed. Two different assessors performed the measurements on the same day to estimate inter‐assessor reliability and 2 days later to examine intra‐assessor reliability. Intra‐assessor and inter‐assessor reliability was assessed using the intraclass correlation coefficient (ICC). The standard error of measurement (SEM) and the smallest detectable difference (SDD) were also estimated. Results: Inter‐assessor reliability ICCs for flexion + extension and total lateral flexion movements were >0.90. The ICCs for rotation movements and for left lateral flexion were >0.70. The ICCs for flexion (0.64), extension (0.58), and right lateral flexion (0.56) indicated moderate correlation. Mean SEMs ranged from 2.28° (SDD = 6.31°) for left rotation to 8.08° (SDD = 22.38°) for total rotation. As for intra‐assessor test‐retest reliability, all ICCs were >0.70. Mean SEMs ranged from 3.14° (SDD = 8.70°) for total lateral flexion to 7.50° (SDD = 20.77°) for extension. Conclusion: Both inter‐ and intra‐observer reproducibility correlation values are moderate to high for measurements obtained using the cervical spine device.

Comparison Between Extracorporeal Shock Wave Therapy and Intra-articular Hyaluronic Acid Injections in the Treatment of First Carpometacarpal Joint Osteoarthritis

Objective To compare extracorporeal shockwave therapy (ESWT) with hyaluronic acid (HA) intra-articular injections in terms of pain relief, improvement in hand function, and strength in subjects with first carpometacarpal (CMC) joint osteoarthritis. Methods Fifty-eight patients received either focused ESWT or HA injection once a week for 3 consecutive weeks. In the ESWT group, 2,400 consecutive pulses were performed during each treatment session using a frequency of 4 Hz and an energy flux density of 0.09 mJ/mm2. The HA group underwent one cycle of three injections of 0.5 cm3 HA. The main outcome measures were pain and hand function as measured by the visual analogue scale (VAS) and Duruoz Hand Index (DHI), respectively. The secondary outcomes were grip and pinch strength. Each assessment was performed at baseline, at the end of treatment, and at 3- and 6-month follow-up visits. Results According to VAS and DHI scores, a significant change in test performance was observed over time in both groups (p<0.001), with a greater average improvement in painful symptomatology at the 6-month follow-up in the ESWT group. A significant improvement in strength was observed in both groups, but the ESWT group showed better results on the pinch test starting immediately at the end of treatment. Conclusion The use of ESWT in patients with first CMC joint osteoarthritis leads to a reduction in pain, an improvement in pinch test performance that persists for at least 6 months, and a decrease in hand disability up to the 6-month follow-up visit.

A rare localization of neurothekeomas of radial nerve: A case report.

Neurothekeoma is a very rare benign connective tissue tumour that presumably derived from nerve sheath cells. We described the case of a rare localization of neurothekeoma in the upper limb with a strange presentation. A 49 years-old woman presented to the Physical Medicine and Rehabilitation Division of the Umberto I Hospital referring an intensive pain associated to paresthesias at the left forearm lasting from six months. The patient had a history of epicondylitis confirmed with an elbow RMN showing an increased thickness of the tendon insertions on the epicondiloidea region of the elbow. Rehabilitative and physical therapy has been done without symptoms remission. An ultrasound evaluation showed an oval formation well circumscribed in the context of the radial nerve. It was easy to demonstrate the relevance of the radial nerve, following it from the arch of Frohse until the humeral sulcus of the radial nerve. A MRI that showed a mass, mildly hypointense on T1- weighted sequences and hyperintense on T2-weighted images, with nonhomogeneous enhancement post-contrast, attributable to expansionary pathology of the radial nerve. A biopsy was done and the lesion was described as a benign tumor of nerve sheath, i.e., a Neurothekeoma of the radial nerve. Patients was surgically treated, the tumor has been removed and she referred the resolution of symptomatology.