Guglielmo Torre

The management of osteomyelitis in the adult.

BACKGROUND AND PURPOSE Osteomyelitis (OM) is considered one of the most challenging medical conditions an orthopaedic surgeon has to face. Much debate is present concerning diagnosis and treatment, especially about differences between acute and chronic forms of the condition. The main aim of the present work is to show the key points where research should be implemented. METHODS Online database were searched to find evidence about the clinical management of osteomyelitis. Clinical randomized trials, case series, prospective cohort studies reporting on diagnosis and treatment of acute and chronic osteomyelitis were taken into consideration. Cadaveric studies, laboratory studies, case reports, review articles and meta-analyses were excluded. Furthermore, studies concerning implant related OM were excluded. Studies in English, Spanish and French were considered in this process of inclusion. The cohorts of all the included studies were composed of adult patients. RESULTS The main growpoints concerning OM are the identification of a correct laboratory test array to allow a prompt diagnosis and provide a sensitive and specific detection of the bacterial species involved, along with antibiotic drug resistance; optimal imaging techniques, according to the phase of the infection, have to be performed, to avoid unnecessary medical expenses; the identification of a suitable compromise between intravenous and oral drugs administration. A flow chart is proposed for optimal clinical management of this pathology. CONCLUSION More work should be carried out to clarify the main issues concerning the clinical management of osteomyelitis in adult patients.

Bone bruises in anterior cruciate ligament injured knee and long-term outcomes. A review of the evidence.

Background Bone bruises are frequently associated with anterior cruciate ligament (ACL) tears as a result of trauma or direct shear stress of the bone. Purpose To review the evidence regarding the characteristics of the bone bruise associated with ACL tears, its relevance on clinical outcomes, and its progression over time. In particular, the long-term effects of the bone bruise on the knee osteochondral architecture and joint function were evaluated. Study design Review; level of evidence: 4. Methods An electronic search was performed on PubMed. Combinations of keywords included: “bone bruise AND knee”; “bone bruise AND anterior cruciate ligament”; “bone bruise AND osteo-chondral defects”. Any level of evidence studies concerning bone bruises in patients with partial or complete ACL tears were retrieved. Results A total of 25 studies were included; three of them investigated biomechanical parameters, seven were concerned with clinical outcomes, and 15 were radiological studies. Evaluation of the bone bruise is best performed using a fat-saturated T2-weighted fast spin echo exam or a short tau inversion recovery sequence where fat saturation is challenging. The location of the injury has been demonstrated to be more frequent in the lateral compartment of the joint (lateral femoral condyle and lateral tibial plateau). It is associated with ACL tears in approximately 70% of cases, often with collateral ligament or meniscal tears. Mid- and long-term outcomes demonstrated a complete healing of the marrow lesions at magnetic resonance imaging, but chondral defects detected with T1ρ sequences are still present 1 year after the ACL injury. Functional examination of the knee, through clinical International Knee Documentation Committee scores, did not show any correlation with the bone bruise. Conclusion Although bone bruise presence yields to higher pain levels, no correlation with functional outcomes was reported. Most studies have a short-term follow-up (<2 years) compared to the length of time it takes to develop post-traumatic osteoarthritis, so it still remains unclear whether the initial joint injury and bone bruise have a direct relationship to long-term function.

Tourniquet in knee surgery

INTRODUCTION The tourniquet is a surgical device composed of a round pneumatic cuff in which air at high pressure can be inflated with an automatic programmable pump to avoid bleeding and technical impediment. SOURCES OF DATA Comprehensive searches of Medline, Cochrane and Google Scholar databases were performed for studies regarding tourniquet application in arthroscopic and open surgery of the knee. The methodological quality of each study was evaluated using the Coleman methodology score (CMS). AREAS OF AGREEMENT The use of a tourniquet does not lead to significant increase in the risk of major complications, and there is no difference in clinical outcome in the medium term. The inflated cuff does prevent intraoperative blood loss, but hidden blood loss is not avoided completely. There is a statistically significantly higher occurrence of deep vein thrombosis in patients who undergo surgery with tourniquet, but the clinical relevance of this finding is uncertain. AREAS OF CONTROVERSY The heterogeneity in terms of inflating pressure and duration of application of tourniquet in the single studies makes it very difficult to compare the outcomes of different investigations to draw definitive conclusions. GROWING POINTS Standardization of pressure and application time of the cuff could allow a comparison of the data reported by the trials. Better study methodology should be also implemented since the mean CMS considering all the reviewed articles was 57.6 of 100. RESEARCH More and better designed studies are needed to produce clear guidelines to standardize the use of tourniquet in knee procedures.

Surgical Treatment for Failure of Repair of Patellar and Quadriceps Tendon Rupture With Ipsilateral Hamstring Tendon Graft.

Tears of the patellar and quadriceps tendon are common in the active population, especially in athletes. At present, several techniques for surgical repair and reconstruction are available. When reruptures occur, a reconstruction is mandatory. In the present paper, we describe a surgical technique for patellar and quadriceps tendon reconstruction using ipsilateral hamstring autograft. After routine hamstring tendon harvesting, the tendon ends are prepared using a whip stitch. A transverse tunnel is drilled in the midportion of the patella, the hamstring graft is passed through the patella, and firmly secured to the patellar tunnel openings with sutures. The details of the technique are fully described. Autologous ipsilateral hamstring tendon grafts provide a secure sound means to manage these challenging injuries.

Surgical management of osteonecrosis of the humeral head: a systematic review

PurposeOsteonecrosis of the humeral head is a rare diagnosis. The aim of this systematic review was to identify published studies and analyse the best clinical evidence available related to the surgical management of osteonecrosis of the humeral head.MethodsA systematic electronic search was performed using the PubMed (MEDLINE), EMBASE and Cochrane Library databases. Published studies that reported the outcomes for adult patients treated surgically for osteonecrosis of the humeral head were included. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was followed.ResultsTwelve studies were included: five prospective case series and seven retrospective case series. A total of 309 patients, comprising 382 shoulders, were included. Three main surgical procedures were evaluated: core decompression, hemi-arthroplasty and total shoulder arthroplasty.ConclusionsBased on the current available data, core decompression is a safe and effective option for treating low-grade osteonecrosis of the humeral head, while hemi-arthroplasty and total shoulder arthroplasty should be considered for high-grade osteonecrosis. More studies and better-designed trials are needed in order to enrich the evidence and enable researchers to draw stronger conclusions. Since osteonecrosis is an uncommon, though challenging disease, a proper knowledge of its treatment is needed.Level of evidenceIV.

Are Platelet Rich Plasma Injections More Effective in Tendinopathy orEnthesopathy

Introduction: Chronic overuse insertional tendinopathy (entesopathy) is highly prevalent, but is an extremely difficult condition that generates a high medical expense. Alternative and co-adjuvant therapies to improve the quality of life and physical function of affected patients are currently being sought. Materials and Methods: A total of 31 patients affected by entesopathy at different anatomical sites (elbow tendinopathy, greater trochanter pain syndrome and plantar fasciopathy) were treated with three peritendinous injections of autologous platelet rich plasma (PRP) and included in the present investigation. VAS scale and segmental scores for the affected site before the first injection of PRP and at 6 months after the last injection were used. One hundred and seven patients that underwent the same injection protocol in the same time lapse were used as a control group, and were represented by patients with non-insertional tendinopathy (shoulder and at Achilles tendon). Results: Significantly lower values between pre-treatment and follow-up pain scores at all-time points were found in the patients affected by entesopathy compared to tendinopathy (p<0.001). As a confirmative finding, the segmental scores at the shoulder and ankle did not improve overtime, differently from what occurred in patients with entesopathy. Conclusion: At 6 months following peritendinous injections of PRP in patients with entesopathy there was a significant reduction of pain, associated to a significant improvement in recorded segmental scores. Conversely, the treatment was not effective in patients with pure tendinopathy at the shoulder and ankle level. These favorable findings point to consider PRP as a promising therapy for patients affected by entesopathy.

Role of VEGF, Nitric Oxide, and Sympathetic Neurotransmitters in the Pathogenesis of Tendinopathy: A Review of the Current Evidences

Chronic tendinopathy is a painful common condition affecting athletes as well as the general population undergoing to tendon overuse. Although its huge prevalence, little is known about tendinopathy pathogenesis, and even cloudier is its treatment. Traditionally, tendinopathy has been defined as a lack of tendon ability to overcome stressing stimuli with appropriate adaptive changes. Histologic studies have demonstrated the absence of inflammatory infiltrates, as a consequence conventional antinflammatory drugs have shown little or no effectiveness in treating tendinopathies. New strategies should be therefore identified to address chronic tendon disorders. Angiofibroblastic changes have been highlighted as the main feature of tendinopathy, and vascular endothelial growth factor (VEGF) has been demonstrated as one of the key molecules involved in vascular hyperplasia. More recently, attention has been focused on new peptides such as Substance P, nitric oxide, and calcitonin gene-related peptide (CGRP). Those new findings support the idea of a nerve-mediated disregulation of tendon metabolism. Each of those molecules could be a target for new treatment options. This study aimed to systematically review the current available clinical and basic science in order to summarize the latest evidences on the pathophysiology and its effect on treatment of chronic tendinopathy, and to spread suggestions for future research on its treatment.

Achilles insertional tendinopathy: state of the art

Achilles tendon pathology is a most common musculoskeletal condition in active individuals and athletes. Almost 6% of the general population will suffer from such ailment in their lifetime. Insertional Achilles tendinopathy (IAT) differs in its physiopathology, clinical features and treatment from midportion tendinopathy. The literature has mainly focused on assessment, outcome evaluation and treatment of IAT, although differences in management according to different geographical regions have not been addressed. The principles of clinical evaluation and imaging assessment of IAT are well established, with a major role of clinical assessment and soft tissue imaging, including ultrasonography and MRI. Conservative management options include eccentric training, extracorporeal shockwave therapy and prolotherapy, or a combination of these modalities. Recently, regenerative medicine has been more widely used, with at times dubious results. Surgery is advocated where conservative treatment is not beneficial within 6 months. Surgery includes more or less extensive debridement of peritendinous bony and soft tissue structures. To improve our knowledge about IAT, more evidence should be provided concerning innovative treatments, especially considering growth factors injections and percutaneous surgery.

No difference between tenotomy vs tenodesis for the long head of the biceps tendinopathy in rotator cuff repair: a systematic review

Importance There is no consensus concerning the management of long head of the biceps (LHB) tendon pathology when this is concomitant to repairable rotator cuff (RC) tears. Objective The present systematic review collected and analysed the available evidence concerning the management of LHB tendinopathy associated with repair of RC tears. Evidence review An electronic search was performed through PubMed – MEDLINE database, Google scholar and Cochrane central. All types of studies were considered for inclusion, except for case report, systematic review and meta-analyses. No time interval of publication was set. Articles had to focus on the surgical treatment of LHB tendinopathy associated with RC arthroscopic repair in adult subjects. Furthermore, cadaver studies, in vitro or animal model studies, were not considered for inclusion. Findings The literature provided heterogeneous evidence regarding study design and methodology, evaluation outcome tools and surgical techniques. All the studies included subjects with RC pathology associated with LHB tendinopathy, managed by tenotomy or tenodesis. Different types of tenodesis were reported, including open subpectoral technique and arthroscopic intracuff tenodesis. Conclusion and relevance The results of either tenotomy or tenodesis are equivalent, in terms of clinical features and biomechanical characteristics, when LHB tendinopathy is concomitant to RC tears. This should be interpreted as a relevant stimulus for further research on this topic, focusing to the clinical outcomes of tenotomy and tenodesis, and restoration of muscle force and function of the shoulder–elbow complex. Level of evidence III