Lorenzo Mattei

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.

Erratum to “Fibromyalgia Syndrome: Etiology, Pathogenesis, Diagnosis, and Treatment”

In this paper which appeared in Pain Research and Treatment (Volume 2012, Article ID 426130) the affiliations have been switched. The affiliations should appear as shown above. Moreover in Table 3 on page 10 the NNTs of Milnacipran and of Duloxetine have been switched. The NNTs should appear as follows: Milnacipran NNT 19 (95% CI 7.4, 20.5) and Duloxetine NNT 7.2 (95% CI 5.2, 11.4). The corrected full Table 3 is shown later. Table 3 Comparison between American Pain Society (APS) and Association of the Scientific Medical Societies in Germany (AWMF) with European League Against Rheumatism (EULAR).

Predominance of the critical shoulder angle in the pathogenesis of degenerative diseases of the shoulder

HYPOTHESIS The critical shoulder angle (CSA) could be responsible for cuff tears and concentric osteoarthritis. We aimed to assess this association when potential confounding factors were excluded and to test the hypothesis that more extreme CSAs are associated with larger tears and more severe osteoarthritis. METHODS The study cohort was composed of 200 patients with primary concentric osteoarthritis (40 patients), isolated supraspinatus tears (40 patients), cuff tears involving at least the supraspinatus and infraspinatus (40 patients), and no history of shoulder problems (control group, 80 patients). Data pertaining to CSA, age, gender, dominant arm, smoking, hypertension, body mass index, and type of work were collected. RESULTS The average CSA angle was 34° ± 3° in the control group, 36° ± 3° with supraspinatus tears, 40° ± 3.5° with supraspinatus and infraspinatus tears, and 28° ± 2° with concentric osteoarthritis. Patients with large cuff tears had a significantly greater CSA compared with those with isolated supraspinatus tears (P = .03). The CSA (odds, 1.7; confidence interval [CI], 1.4-2.0) was the most relevant risk factor for cuff tears. The Spearman coefficient between CSA and grade of eccentric osteoarthritis was 0.4 (P = .01). The 2 significant risk factors for concentric osteoarthritis were the CSA (odds, 0.5; CI 0.4-0.6) and age (odds, 1.1; CI, 1.0-1.2). CONCLUSION Larger CSAs are associated with increased risk of symptomatic cuff tears, larger cuff tears, and the severity of eccentric osteoarthritis. Smaller angles increased the risk and severity of concentric symptomatic osteoarthritis. These associations remained significant even after removal of some of the potentially confounding variables.

Patient specific instrumentation in total knee arthroplasty: a state of the art

Patient specific instrumentation (PSI) is a modern technique in total knee arthroplasty (TKA) aiming to facilitate the implant of the prosthesis. The customized cutting blocks of the PSI are generated from pre-operative three-dimensional model, using computed tomography (CT) or magnetic resonance imaging (MRI). A correct surgical plan is mandatory for a good surgical implant. The PSI guide takes into account any slight deformities or osteophytes and applies preoperative planning for bone resection, using the pre-determined implant size, position, and rotation. The apparent benefits of this technology are that neutral postoperative alignment is more reproducible, surgical time is decreased, and the entire procedure results more efficient and cost-effective. The use of PSI is indicated when advanced osteoarthritis, severe pain, and limited function/walking ability are present, such as in a standard instrumentation TKA. In addition to that, PSI finds its indication when intra-medullary guides cannot be used. For example, when there is a post-traumatic femoral deformity. Large debates have taken place about this topic during the last years and, at the moment, there is no consensus in literature regarding the accuracy and reliability of PSI as many studies have shown controversial and inconsistent results. Literature does not suggest PSI techniques as a gold standard in TKA, and therefore it cannot be recommended as a standard technique in standard, not complicated primary TKA. Moreover, literature does not underline any improvement in components alignment, surgical time, blood loss or functional outcomes. Nevertheless, many patients who underwent TKA suffered a previous trauma. In case of deformities, like femoral or tibial fractures healed with a malalignment, preoperative planning may result difficult, and some intra-operative technical difficulties can occur, such as the use of intra-medullar rod. In these selected cases, PSIs may be very useful to avoid errors in alignment and planning.

Anatomic shoulder arthroplasty: an update on indications, technique, results and complication rates.

A shoulder replacement is indicated in patients affected by glenohumeral arthropathy with severely reduced range of motion, persistent pain, especially at night, and loss of strength. There is much discussion in the scientific community about the prosthetic options for these cases: hemiarthroplasty, anatomic total shoulder arthroplasty, and reverse total shoulder arthroplasty. We analyzed the indications for, results of, and complications associated with this kind of surgery, focusing on anatomic arthroplasty and on the concept of modularity.

Efficacy and Safety of Subacromial Corticosteroid Injection in Type 2 Diabetic Patients

Purpose In type 2 diabetic patients affected by chronic shoulder pain, subacromial injection with corticosteroid could be an effective treatment. The aim of this study was to measure the risk-benefit ratio of this treatment. Methods Twenty patients with well-controlled diabetes were included in a prospective study. In a first preinjection phase, patients were asked to measure glycemia for 7 days, before breakfast and dinner, and then 2 hours after lunch and dinner. Baseline data including Constant Score (CS), Subjective Shoulder Value (SSV), and Numerical Rating Scale (NRS) for pain were collected. Patients were treated with subacromial injection with 40 mg of Methylprednisolone Acetate and 2 ml of Lidocaine. At discharge, patients were asked to remeasure glycemia for the following week. Results The overall pain improved and patients graded their shoulder as “greatly improved”. At 30-day follow-up, the SSV and the CS improved, considering pain but not ROM. The average daily glycemia was 136 mg/dl before injection, 161 mg/dl the day of the injection (p<0.001), and 170 mg/dl one day after injection (p<0.001). Glycemia was not statistically different 3 days after injection. Conclusion Subacromial injection is an effective short-term treatment in type 2 diabetic patients affected by shoulder pain, but a closed follow-up is recommended in all these patients. This trial is registered with NCT03652480. The Protocol ID is SHOULDERDM2013.

Anatomy and Specimens

The elbow is a complex anatomical district, and every orthopedic surgeon who approaches its pathologies has to be aware of the noble structures that surround and are so close to the bony and ligamentous structures. First of all, the surgeon must start his experience on cadaver specimen. The first thing to know is the anatomy of the peripheral nerves of the elbow to prevent any injuries during surgical approaches. So the young surgeon has to explore and understand the position of the principal nerves of the upper arm through dissection on specimen. This practice permits to the surgeon to predict the position of the nerves especially in pathological settings. The second part of the chapter is focused on the surgical approaches to the elbow. In our description, we focused the attention to the most employed routes to the joint. For the posterior and medial approach, it is fundamental to know where the ulnar nerve is. In lateral approach, care has to be taken to the lateral collateral ligament complex and to the posterior interosseous nerve. The anterior approach is dangerous for humeral artery, but also posterior interosseous nerve is at risk, especially during reinsertion of the distal biceps tendon. Every surgeon who approaches the elbow has to know the risks that incur if the anatomy is not strictly respected.

Perspectives: How to Deal with Fever (38 °C) After Arthroplasty: The Surgeon’s Point of View

As we know from the literature and from clinical practice, fever after a total hip arthroplasty and knee replacement is common in the first 3 postoperative days (POD), but the clinical importance is still unclear. The pathophysiology and the role of interleukin-1β, interleukin-6, and tumor necrosis factor are well described. The characteristics of the fever, its trend, and the risk factors were analyzed. POD fever is common from 15 to 50 % of the patients; it appears most commonly during the first or the second postoperative day. The role of diagnostic exam is controversial. There are a lot of studies showing that urinalysis, chest X-ray, and blood culture are totally useless and not cost effective in the absence of symptoms, even if in the presence of temperature of more than 38 °C. PCR and ESR became useful to find an infection when assayed after 21 days. All the authors recommend to perform a clinical examination before starting a complete workup. We also reported a sample of diagnostic algorithm.