Luigi Murena

Follow-up of collagen meniscus implant patients: clinical, radiological, and magnetic resonance imaging results at 5 years.

This study investigated at medium term follow-up the clinical outcomes and any progression of knee osteoarthritis in a population of patients that underwent arthroscopic placement of a collagen meniscus implant. Thirty-four patients underwent arthroscopic placement of a collagen meniscus implant for a symptomatic deficiency of medial meniscal tissue. Follow-up evaluation included Lysholm II score and Tegner activity scores and MR arthrography of the knee at 2 and 5 years after surgery. Plain radiographs were also obtained at 5 years. Six patients were excluded. In eight cases arthroscopic second look evaluation was performed. Lysholm and Tegner activity scores at 2 and 5 years after surgery improved significantly compared to the preoperative score. These patients showed good to excellent clinical results after 5 years from a CMI placement. The chondral surfaces of the medial compartment had not degenerated further since placement of the CMI. MR signal had continued to mature between 2 and 5 years after implant, progressively decreasing signal intensity but in any case comparable to the low signal of a normal meniscus. In most of cases the CMI-new tissue complex had a slight reduction in size, compared to a normal medial meniscus, but the new tissue had no apparent negative effects.

Italian cross-cultural adaptation and validation of the Oxford shoulder score

BACKGROUND The Oxford Shoulder Score (OSS) is an English-language questionnaire specifically designed to evaluate patients affected by shoulder pain. Although this scoring system has been translated into other languages, an Italian version of it is still not available. The aim of the present study was to translate, culturally adapt, and validate the Italian version of the OSS. MATERIALS AND METHODS We recruited 140 patients with shoulder pain caused by degenerative or inflammatory state or disorder of the shoulder. Patients completed the following questionnaires: Italian OSS, University of California, Los Angeles (UCLA) Shoulder Rating Scale, Constant-Murley shoulder assessment, and the Medical Outcome Study Short-Form 36 Health Survey (MOS SF-36). Internal consistency was tested using Cronbach coefficient alpha. Reproducibility was assessed by asking 110 patients to complete another OSS 48 hours after the first. Correlation between the total results of both tests was determined by the Pearson correlation coefficient. Validity was assessed by calculating the Pearson correlation coefficient between the OSS and the UCLA, Constant-Murley, and SF-36 assessments. RESULTS Cronbach alpha was 0.95. The Pearson correlation coefficient was r=0.97. With respect to validity, there was a significant correlation between the Italian OSS and the individual scores of UCLA, Constant-Murley, and SF-36. DISCUSSION Psychometric properties of the Italian OSS compared well with those reported for the English OSS. As demonstrated by the high values of Cronbach alpha and Pearson correlation coefficients, in accordance with the English version of the OSS, the Italian version proved to be a reliable, valid, and reproducible measure of shoulder pain perception in Italian-speaking patients.

The unstable total hip replacement

Background: Dislocation is one of the most common complications of total hip arthroplasty with a reported dislocation rate of 3.2%. Despite increased experience with hip replacement, the overall rate has not yet changed. The aim of this paper is to review the most recent literature published on this topic and indexed in Medline, in order to clarify the main risk factors, and to standardize a treatment protocol of such an important complication of prosthetic surgery. Materials and Methods: Medline database was searched using key words: “hip dislocation”, “hip instability” from 1980-2007. Studies were eligible for review and included if they met the following criteria: (1) publication in English, (2) clinical trials (3) review papers. Results: The risk of first-time dislocation as a function of time after the surgery is not well understood. Most, but not all, series have demonstrated that the risk of dislocation is highest during the first few months after hip arthroplasty; however, first-time late dislocation can also occur many years after the procedure. Several risk factors were described, including the surgical approach, the diameter of the head, impingement, component malposition, insufficient abductor musculature. In addition, there are also many treatment options, such as long-term bracing after closed reduction, component reorientation, capsulorraphy, trochanteric advancement, increasing offset, exchange of the modular head and the polyethylene liner, insertion of constrained liner. Conclusion: Preventing hip dislocation is obviously the best strategy. Surgeons must take into account patient and surgical risk factors. For patients at high risk for dislocation the surgeon should accurately restore leg length and femoral offset; the use of larger femoral heads, posterior transosseous repair of the capsulotendinous envelope if posterior approach is chosen or the use of a lateral approach should be considered. Proper patient education and postoperative care are very important.

Analysis of bone ingrowth on a tantalum cup.

Background: Trabecular Metal (TM) is a new highly porous material made of tantalum (Zimmer, Warsaw, Indiana, USA). Its three-dimensional structure is composed of a series of interconnected dodecahedron pores that are on average 550 μm in diameter. This size is considered optimal for bone ingrowth and is similar to trabecular bone. The elastic modulus of TM (3 GPa) is more similar to that of cancellous (0,1-1,5 GPa) or cortical (112-18 GPa) bone and is significantly less similar to that of Titanium (110 GPa) and Co-Cr alloys (220 GPa). These features enable bone apposition and remodeling. The purpose of the present study was to evaluate the histology of the bone-implant interface in a human specimen. Materials and Methods: A highly porous tantalum cup (Zimmer, Warsaw, Indiana, USA) was removed for recurrent dislocations three years after implantation. In order to obtain a slice of the cup, two cuts were made on the centre using an Exakt cutting machine. Then the slice was embedded in a Technovit resin and a Hematoxylin-eosin stain was used to study the bone tissue. Bone ingrowth was calculated using a method based on simple calculations of planar geometry. Results: The histological evaluation of the periprosthetic tissues revealed a typical chronic inflammation with few particles of polyethylene that were birefringent using polarized light. The quantitative evaluation of bone ingrowth revealed that more than 95% of voids were filled with bone. Discussion: In the literature, a lot of studies focused on tantalum were carried on animal model. Up to now little information is available about the histology of the bone-tantalum interface in a human artificial joint. We had an opportunity to remove a well integrated cup hence this study. The histology confirmed the strong relationship between the structure of this material and bone. The morphometric analysis revealed a high percentage of bone ingrowth.

Surgical treatment of an aseptic fistulized acromioclavicular joint cyst: a case report and review of the literature

An acromioclavicular joint cyst is an uncommonly reported condition, which seems to result from a massive rotator cuff tear and degenerative osteoarthritis of the acromioclavicular joint. We present the case of an 81-year-old man affected by an acromioclavicular joint cyst, associated to a massive rotator cuff tear, proximal migration of the humeral head and osteoarthritis of the gleno-humeral joint. The mass was 7 × 2.5 cm in size and the overlying skin presented a fistula that drained clear synovial-like fluid. Plain X-ray examination of the left shoulder showed proximal migration of the humeral head migration and osteoarthritis of the gleno-humeral joint, and further MRI evaluation confirmed the clinical diagnosis of a complete rotator cuff tear and observed a large subcutaneous cyst in communication with the degenerative acromioclavicular joint. The patient underwent surgical excision of the cyst and lateral resection of the clavicle to prevent disease recurrence. To the best of our knowledge, this is the first reported case of an acromioclavicular joint cyst complicated by an aseptic fistula resulting from multiple aspirations.

Two stage fracture of a polyethylene post in a 9-year-old posterior-stabilized knee prosthesis: a case report

IntroductionSeveral cases of tibial post breakage are reported in the literature. To the best of our knowledge, only three cases of NexGen knee prosthesis (Zimmer, Warsaw, Indiana, USA) tibial post failure have been reported.Case presentationIn November 1999, a 63-year-old Caucasian woman from Italy with a history of symptomatic left knee osteoarthritis underwent a total knee arthroplasty. In March 2008, while rising from a chair, she felt a sudden pain and instability in her left knee. She reported a fracture of the polyethylene post of the tibial insert. No malposition or malalignment of either the femoral or tibial components were identified. The polyethylene tibial insert was studied under light microscopy and scanning electron microscopy. The fracture was also noted to have occurred without any notable polyethylene wear.ConclusionScanning electron microscopy revealed two different damage patterns that could be explained with a two-stage rupture of our patients polyethylene post. This could have been caused by a non-optimal ligamentous balancing during first implant surgery. Her knee probably developed a varus instability that weakened the post, and then a posterior anterior stress finally broke the polyethylene.

Bilateral iliopsoas intramuscular bleeding following anticoagulant therapy with heparin: a case report

Iliopsoas haematoma is an uncommon complication that may arise during anticoagulant therapy, especially with heparin and warfarin. Besides determining patient distress secondary to femoral nerve compression, this event may progress to life-threatening complications and require expensive treatments. We describe the case of a 70-year-old healthy man complaining of severe bilateral groin, lumbar and thigh pain, and paralytic ileus after therapy with heparin. The angio-computed tomography scan observed bilateral iliopsoas haematomas. In view of the clinical and radiological scenarios, we ordered a diagnostic and therapeutic angiography of the bleeding vessels by trans-catheter arterial embolization of the fourth right lumbar artery trunk. The treatment proved to be beneficial from a clinical, radiological and laboratory point of view. To the best of our knowledge, this is the first reported case of bilateral iliopsoas haematoma occurring in a male treated with therapeutic levels of heparin alone.

The incidence of fragility fractures in Italy.

Osteoporosis can significantly impact on the risk of developing a fracture. Thus, fragility fractures represent a challenge for health professionals and decision makers of the twenty-first century. The aim of this work is to review the literature concerning osteoporotic fractures in Italy in terms of incidence, rate of hospitalization, relative risk of a new fragility fracture, and costs for the national health system. It was estimated that the costs of treating proximal femur fragility fractures in 2002 summed up to 1 billion Euros. The number of fragility fractures in Italy was calculated as follows: 91.494 hip fractures, 61.009 clinical vertebral fractures, 57.401 humeral fragility fractures, and 94.045 forearm/wrist fragility fractures. The incidence of fragility fractures in Italy is very high, and osteoporosis is the leading cause of morbidity in the Italian population.

The "Double-Pulley" Technique for Arthroscopic Fixation of Partial Articular-Side Bony Avulsion of the Supraspinatus Tendon: A Rare Case of Bony PASTA Lesion.

We report the use of the double-pulley technique for arthroscopic fixation of the bony PASTA (partial articular surface tendon avulsion) lesion. Arthroscopic examination documented a 15-mm-long and 8-mm-wide comminuted bony avulsion with 2 main fragments. Two double-loaded suture anchors were placed with a transtendinous technique at the anterior and posterior edges of the lesion respecting the tendon insertion to the avulsed fragment. The medial sutures were retrieved through the intact supraspinatus tendon medially to the fracture. The sutures were initially coupled in a double-pulley configuration generating 2 sutures oriented from anterior to posterior; then a simple suture for each anchor oriented from medial to lateral was obtained. At the end of the procedure, the adequacy of reduction and stability of the fragments were confirmed. At 2 months from surgery, radiographic healing of the fracture was noted and integrity of the supraspinatus tendon insertion to the footprint was confirmed by arthro-magnetic resonance imaging, with full recovery of daily activities and complete active range of motion confirmed at 6 and 12 months. The double-pulley technique allows optimal reduction of bony fragments and reconstruction of normal footprint anatomy even in comminuted fractures. Moreover, it creates a waterproof reduction of the fragments, protecting the fracture site from synovial fluid.

Treatment of complex regional pain syndrome

Complex Regional Pain Syndrome (CRPS) is a multifactorial and disabling disorder with complex etiology and pathogenesis. Goals of therapy in CRPS should be pain relief, functional restoration, and psychological stabilization, but early interventions are needed in order to achieve these objectives. Several drugs have been used to reduce pain and to improve functional status in CRPS, despite the lack of scientific evidence supporting their use in this scenario. They include anti-inflammatory drugs, analgesics, anesthetics, anticonvulsants, antidepressants, oral muscle relaxants, corticosteroids, calcitonin, bisphosphonates, calcium channel blockers and topical agents. NSAIDs showed no value in treating CRPS. Glucocorticoids are the only anti-inflammatory drugs for which there is direct clinical trial evidence in early stage of CRPS. Opioids are a reasonable second or third-line treatment option, but tolerance and long term toxicity are unresolved issues. The use of anticonvulsants and tricyclic antidepressants has not been well investigated for pain management in CRPS. During the last years, bisphosphonates have been the mostly studied pharmacologic agents in CRPS treatment and there are good evidence to support their use in this condition. Recently, the efficacy of intravenous (IV) administration of neridronate has been reported in a randomized controlled trial. Significant improvements in VAS score and other indices of pain and quality of life in patients who received four 100 mg IV doses of neridronate versus placebo were reported. These findings were confirmed in the open-extension phase of the study, when patients formerly enrolled in the placebo group received neridronate at the same dosage, and these results were maintained at 1 year follow-up. The current literature concerning sympathetic blocks and sympathectomy techniques lacks evidence of efficacy. Low evidence was recorded for a free radical scavenger, dimethylsulphoxide (DMSO) cream (50%). The same level of efficacy was noted for vitamin C (500 mg per day for 50 days) in prevention of CRPS in patients affected by wrist fracture. In conclusion, the best available therapeutic approach to CRPS is multimodal and is based on the use of several classes of drugs, associated to early physiotherapy. Neridronate at appropriate doses is associated with clinically relevant and persistent benefits in CRPS patients.