Arthroscopic treatment of ankle multiligamentous injuries provides similar clinical outcomes to the treatment of isolated lateral ligament injury at the 2-year follow-up.

PURPOSE: Rotational ankle instability is a multiligamentous injury defined as an overload injury of the deltoid ligament caused by a long-standing injury of the lateral collateral ligament in patients affected by chronic ankle instability. The purpose of the study was to compare the clinical outcomes of combined arthroscopic repair of lateral and medial ankle ligaments for rotational ankle instability versus isolated arthroscopic lateral ligament repair for lateral ankle instability at 2 years' follow-up. METHODS: Between 2019 and 2021, 108 patients with chronic ankle instability were consecutively treated by arthroscopy. Of this group, 83 patients (77%) [median age: 26 (range, 14-77) years] underwent an isolated all-inside lateral ligament repair for lateral ankle instability (group A). In the remaining 25 patients (23%) [median age: 27 (range, 17-58) years], rotational ankle instability was clinically suspected and confirmed during arthroscopy; thus, a combined all-inside repair of lateral and medial ligaments was performed (group B). The same postoperative protocol was utilised for both groups. Patients were prospectively evaluated before surgery, at 3, 6, 12 and 24 months with Foot Functional Index (FFI) score, visual analogue scale (VAS) and Foot and Ankle Ability Measure-Sports subscale (FAAM-SS). At the latest follow-up, the satisfaction rate and complications were also recorded. RESULTS: In both groups, FFI, VAS and FAAM-SS scores significantly improved compared to preoperative values (p < 0.001). In addition, according to all the scores evaluated, there was no significative difference (n.s) between groups at the final follow-up or at any of the intermediate follow-up. No major complications were observed in both groups. CONCLUSIONS: Arthroscopic ligament repair in case of ankle multiligamentous injuries, such as in rotational ankle instability, provides excellent clinical outcomes and is comparable to isolated lateral ligament repair at 2 years' follow-up. Therefore, when treating ankle instability, arthroscopic repair of each and every ligament that appears injured provides the best potential outcomes and is the recommended treatment. LEVEL OF EVIDENCE: Level II, prospective comparative.

Rat bone healing induced by natural nanocrystalline carbonated hydroxyapatite in combination with human amniotic fluid stem cells (AFSCs).

The present study was aimed at identifying a new scaffold/stem cell combination useful to treat large bone defects. Human amniotic fluid stem cells (AFSCs) were expanded in vitro, labeled with a fluorescent cell-permeable dye (PKH26) and transplanted in vivo in a femoral injured rat model. The femoral defect was left untreated (control rats) or filled with hydroxyapatite (HA; natural nanocrystalline carbonated hydroxyapatite-Orthoss®) scaffold alone or loaded with PKH26-labeled AFSCs. All animals were killed 3 weeks after implantation. Both gross anatomy and histological observations revealed a major bone regenerative response in rat specimens treated with HA scaffold, alone or supplemented with AFSCs. Samples injected with HA plus AFSCs displayed the presence of abundant fibrotic tissue, the formation of periosteal woven bone, and an increased presence of blood vessels in the bone marrow, with still fluorescent AFSCs in close proximity. These observations provide evidence that natural HA plus AFSCs represents a promising alternative therapeutic strategy to autologous bone grafting procedures.

Surgical treatment of displaced intraarticular calcaneal fractures by a minimally invasive technique using a locking nail: A preliminary study.

BACKGROUND: The aim of this retrospective study was to evaluate the outcome of patients with intra-articular calcaneal fractures treated using a minimally invasive locking nail (Calcanail®). METHODS: Between January 2016 and April 2017, 15 patients (9 men and 6 women) with a calcaneal fracture were consecutively treated with Calcanail®. The Böhler angle was recorded on standard X-rays pre- and post-operatively. The articular reduction of the posterior facet was evaluated with the Goldzak index in a CT scan 3 months post-operatively. The mean age of the patients was 53 years (range, 24-78). Mean final follow-up was 18 months (range, 12-24). RESULTS: Six fractures were classified as Sanders II, 7 as Sanders III and 2 as Sanders IV. In 13 out of the 15 patients treated, the post-operative Böhler angle was of more than 20°. Goldzak index was deemed as excellent in 73.5% of the cases (11 patients), good in 20% of cases (3 patients), and poor in 6.5% (1 patient). Post-operative mean AOFAS score was 85 (range, 60-96). CONCLUSIONS: The Calcanail® provides good restoration of the subtalar joint and the calcaneal angles with the advantages of a minimally invasive approach. It was effectively used in Sanders types II and III, even in the presence of poor cutaneous conditions.

Open and arthroscopic lateral ligament repair for treatment of chronic ankle instability: A systematic review.

BACKGROUND: Chronic ankle instability is defined by an instability lasting more than 6 months, in those cases where a comprehensive conservative treatment fails a surgical stabilization is required. Several surgical techniques have been proposed for the management of the chronic lateral instability of the ankle and even after 50 years, the Broström-Gould technique is still considered the gold standard for the treatment of this pathology. Recently, many authors have developed completely arthroscopic lateral ligament repair and the use of these procedures is rapidly increasing. The aim of this review is to provide an updated overview of open and new arthroscopic lateral ligament repair techniques in order to summarize and compare the effectiveness of these strategies. METHODS: A systematic literature review using PubMed/Medline databases was performed (July 1972-July 2015). Clinical results, satisfaction rate and complications of both patient populations were recorded and statistically analyzed. RESULTS: The total ankles treated with an open Broström ATFL repair in the 13 studies was 505 with a mean follow up of 73.4 months (range 9 months-27.9 years). Postoperative AOFAS score was reported in 11 studies, with a mean value of 90.1 (range, 60-100), patient's satisfaction rate was 91.7%. Surgery-related complications occurred in 40 (7.92%) out of 505 treated ankles. The total number of ankles treated within the 6 arthroscopic studies was 216 with a mean follow up of 37.2 months (range 6 months-14 years). Five studies reported a mean postoperative AOFAS score of 92.48 (range, 44-100) with a patient's satisfaction rate of 96.4%. Surgery-related complications were observed in 33 (15.27%) cases. CONCLUSIONS: The results of this review show the excellent efficacy of open and arthroscopic surgical procedures in the treatment of the chronic ankle instability. The higher complication rate of arthroscopic procedures respect to the open ones represents the major issue: however, this does not seem to affect the patient's satisfaction. Because of statistical heterogeneity observed no definitive conclusions can be statistically drawn. Finally, to definitively validate the effectiveness of arthroscopic procedures prospective and comparative studies are needed.

Identifying the learning curve for total ankle replacement using a mobile bearing prosthesis.

BACKGROUND: Total ankle arthroplasty remains a technically demanding surgery highly influenced by the operator experience. However, no consensus exists regarding the ideal number of cases that need to be performed before a surgeon is considered proficient. The aim of this study was to identify the learning curve of a specific replacement system with regards to intraoperative and postoperative outcomes. METHODS: The first 31 patients undergoing total ankle arthroplasty were examined. No additional procedures were performed at the time of the TAA. Intraoperative characteristics, postoperative complications, as well as clinical and radiologic outcomes were assessed with 24-month follow-up. Learning curves, examining the relationship between surgeon experience and patient outcomes, were determined using the Moving Average Method. RESULTS: The operatory time, and the risk of intraoperative fractures decreased with increasing surgeon experience with the learning curve stabilizing after the 14th and 24th patient, respectively. Furthermore, there appeared to be a learning curve associated with most of the important clinical and radiological outcomes. The number of patients required to stabilize the learning curve for the VAS, ROM, and AOFAS was 11, 14 and 28, respectively. Radiographically, there appeared to be a learning curve of 22 patients required to stabilize the tibio-talar ratio. There was no learning curve associated with the SF-12 PCS and MCS as well as the α-, ß-, and γ-angle. CONCLUSION: This study demonstrates that a surgical learning curve does indeed exist when performing TAA. Most of the operative variables as well as clinical and radiological outcomes stabilize after a surgeon has performed 28 cases.

Intraforaminal ozone therapy and particular side effects: preliminary results and early warning.

BACKGROUND: The term "low back pain syndrome" represents a complex nosological entity. The therapeutic approach is often only symptomatic and not etiologic. METHODS: Since 2013, 186 patients (97 males and 89 females, mean age 59.8 years) have undergone microsurgery for lumbar disc hernia or lumbar segmental stenosis. Among these patients, 23 had been previously treated with ozone therapy by the intraforaminal approach and 28 by intraforaminal steroid injections in other hospitals between 12 and 24 months before our clinical evaluation. These patients received 16 applications in an 8-week period (standard therapy). RESULTS: During the surgery, many hard adhesions between the soft tissues and bony structures were unexpectedly discovered. In particular, it was noted that the root contracted and had firm adhesions to the dural sac and/or fragmented disc, which were difficult to resolve. These specific pathological patterns were observed only in the patients who received ozone injections by the intraforaminal approach. We did not find any pathological abnormalities in the patients who did not receive any injections or who received intraforaminal steroid injections. Thus, we could exclude that the tissue damage was due to the mechanical action of the needle. CONCLUSION: It is important to assert that ozone therapy procedures can be associated with several major complications. Therefore, performing a revision of the guidelines and protocols for ozone therapy application is indispensable.

Amniotic Fluid Stem Cells: A Novel Source for Modeling of Human Genetic Diseases.

In recent years, great interest has been devoted to the use of Induced Pluripotent Stem cells (iPS) for modeling of human genetic diseases, due to the possibility of reprogramming somatic cells of affected patients into pluripotent cells, enabling differentiation into several cell types, and allowing investigations into the molecular mechanisms of the disease. However, the protocol of iPS generation still suffers from technical limitations, showing low efficiency, being expensive and time consuming. Amniotic Fluid Stem cells (AFS) represent a potential alternative novel source of stem cells for modeling of human genetic diseases. In fact, by means of prenatal diagnosis, a number of fetuses affected by chromosomal or Mendelian diseases can be identified, and the amniotic fluid collected for genetic testing can be used, after diagnosis, for the isolation, culture and differentiation of AFS cells. This can provide a useful stem cell model for the investigation of the molecular basis of the diagnosed disease without the necessity of producing iPS, since AFS cells show some features of pluripotency and are able to differentiate in cells derived from all three germ layers "in vitro". In this article, we describe the potential benefits provided by using AFS cells in the modeling of human genetic diseases.

Long-term beneficial effects of platelet-rich plasma for non-insertional Achilles tendinopathy.

BACKGROUND: The aim of this retrospective study is evaluating the long-term clinical outcome in patients affected by mid-portion Chronic Recalcitrant Achilles Tendinopathies (CRAT) treated with administration of single platelet-rich plasma (PRP). METHODS: A total of 83 tendons (73 patients, 59 males and 14 females; age 43±17.5 years) affected by non-insertional CRAT were treated with single PRP injection. These were evaluated with the Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire, Blazina score and satisfaction index at baseline at intervals of 3 weeks, 3 months, 6 months. Final follow-up was carried out at a mean of 50.1 months (range, 24-96). RESULTS: Baseline VISA-A was 45±15. Results relative to the final follow-up improved significantly to a mean of 88±8 (p<00.1). Blazina was used for patients practicing sports (54 tendons out of 46 different patients): 37 tendons were grade IIIa, 11 II, and 6 IIIbis. Final follow-up Blazina scores improved for 45 grade 0, 5 I, 4 II (p<00.5). Seventy-six tendons (91.6%) were rated as satisfactory and patients would repeat the treatment. Seven tendons (8.4%) were classified as unsatisfactory at the 6 months follow-up and underwent a second PRP injection. In addition to this, patients reported no Achilles tendon rupture. CONCLUSIONS: The study shows beneficial effects and low complication rate following of single PRP injections on a large cohort of patients with mid-long-term follow-up. No cases reported Achilles tendon rupture, in contrast to literature, which described CRAT as one of the most common risk factors. The use of a single PRP injection can therefore be a safe and attractive alternative in the treatment of non-insertional CRATs.

Arthrodesis of proximal inter-phalangeal joint for hammertoe: intramedullary device options.

BACKGROUND: Proximal inter-phalangeal (PIP) joint arthrodesis today represents the standard treatment for structured hammertoes; however, recently, a lot of new intramedullary devices for the fixation of this arthrodesis have been introduced. The purpose of this work is to look at the currently available devices and to perform a review of the present literature. MATERIALS AND METHODS: A literature search of PubMed/Medline and Google Scholar databases, considering works published up until September 2014 and using the keywords: hammertoe, arthrodesis, PIP joint, fusion, intramedullary devices, and K-wire, was performed. The published papers were included in the present study only if they met the following inclusion criteria: English articles, arthrodesis of PIP joints for hammertoes with new generation intramedullary devices, series with n > 10. Studies using absorbable pins or screws that are considered as another kind of fixation that involved more than one articulation, as well as comments, letters to the editor, or newsletters were excluded. RESULTS: Nine publications were included. Of the patients' reports, 93-100 % were good or excellent concerning satisfaction. Radiological arthrodesis was achieved in 60.5-100 % of cases. Three of the publications compared the new devices with the K-wire. Of these three articles, two employed the traditional technique and one the buried technique. The AOFAS score, evaluated in three publications, showed a delta of 19, 45 and 58 points. Major complications, which required a secondary surgical revision, were between 0 and 8.6 %. The complications of the K-wire and the new devices were similar; also the reoperation rate was close to equal (maximal difference 2 %). On the other hand, these kinds of devices definitely have a higher price, compared to the K-wire. CONCLUSION: The use of these new devices provides good results; however, their high price is currently a problem. For this reason, cost-benefit studies seem to be necessary to justify their use as standard treatment.

Femoroacetabular impingement: is hyaluronic acid effective?

PURPOSE: Femoroacetabular impingement may predispose to the development of hip osteoarthritis. Conservative treatments are effective in the short term, but surgery is often required. Aim of this paper was to report the short-term results on hip pain and function after ultrasound-guided injections of hyaluronic acid. METHODS: In this open prospective trial, twenty patients suffering from mild femoroacetabular impingement were enrolled. Each patient received a 2-ml intra-articular ultrasound-guided injection of hyaluronic acid at baseline and after 40 days; the same dosing schedule was repeated after 6 months. The clinical evaluation was performed at baseline and after 6 and 12 months of follow-up. Pain score, Lequesne Index, Harris Hip Score and anti-inflammatory medication consumption were measured. Adverse events were also registered. RESULTS: Twenty-three hips (3 bilateral cases) were treated. Pain decreased from 6.7 ± 1.3 to 3.7 ± 1.8 and to 1.7 ± 1.8 after 6 and 12 months, respectively; Lequesne Index was reduced and the mean Harris Hip Score improved from 83.3 ± 6 before treatment to 88.2 ± 4.7 at 12 months. Consumption of anti-inflammatory drugs was also reduced, from 14 to 4 subjects and from 3.6 ± 2.2 to 1.3 ± 1.3 tablets/week. Local side effects after injection were observed only in 2 cases. CONCLUSIONS: Hyaluronic acid is safe and effective in the treatment of mild femoroacetabular impingement, with significant pain reduction and function improvement.

Bilateral traumatic rupture of Achilles tendons in absence of risk factors treated with percutaneous technique and platelet-rich plasma: a case report.

We present a clinical case of a 52-year-old man with bilateral traumatic rupture of the Achilles tendon (AT) in absence of risk factors. In medical history, the patient does not report pre-existing tendon diseases. AT ruptures occurred following a skiing injury in which the forward fall caused a severe stress and elongation of the AT. Associated with tendon injury there was a fracture of the right humeral greater tuberosity. The patient was subjected to percutaneous tenorraphy according to Maffulli's technique and subsequently topical injection of autologous platelet-rich plasma (PRP) 7 days after the injury. After surgery, the patient followed an accelerated rehabilitation protocol, allowing the weight bearing with guards (Rom-Walker) and crutches to four weeks then freely to 8 weeks. We performed a clinical (AOFAS ankle-hindfoot score) and ultrasonography follow-up at month 1, 3, 6 and 12, with excellent results in the end. To the best of our knowledge bilateral cases like this have not been described in the literature.

Management and Rehabilitative Treatment in Osteoarthritis with a Novel Physical Therapy Approach: A Randomized Control Study.

Knee osteoarthritis (KOA) is a chronic degenerative disease characterized by progressive joint damage leading to significant disability. Although rehabilitative treatment methods for KOA have been widely implemented, the optimal integrated instrumental physical therapy approach remains unclear. Therefore, this study aimed to analyze the effect of Quantum Molecular Resonance (QMR) on pain reduction as the primary outcome and the functional improvement in activity daily living (ADL) as a secondary outcome. The study was designed as a double-blind, randomized, controlled trial in an outpatient setting. Fifty-four (N = 54) patients were enrolled and then randomized into three groups according to a simple randomization list: Group 1 (intensive protocol, N = 22), Group 2 (extensive protocol, N = 21), and a Sham group (N = 11). Patients were evaluated over time with scales assessing pain and function. Treatment was performed with the QMR model electro-medical device, which generates alternating electric currents characterized by high frequency (4-64 MHz). The results showed that QMR had a positive effect with respect to the Sham group in terms of pain and function (p < 0.01), and intensive treatment was more effective than the extensive treatment in terms of "speed of response" to the treatment (p < 0.05). In conclusion, QMR in KOA could be effective in slowing the progression of clinical symptoms and improving patients' pain and functionality and thus quality of life. Future studies will be necessary to investigate further treatment algorithms and therapeutic associations with rehabilitative exercise.

Quantum Molecular Resonance Inhibits NLRP3 Inflammasome/Nitrosative Stress and Promotes M1 to M2 Macrophage Polarization: Potential Therapeutic Effect in Osteoarthritis Model In Vitro.

This study aimed to investigate the anti-inflammatory effects of Quantum Molecular Resonance (QMR) technology in an in vitro model of osteoarthritis-related inflammation. The study used THP-1-derived macrophages stimulated with lipopolysaccharide and hyaluronic acid fragments to induce the expression of inflammatory cytokines and nitrosative stress. QMR treatment inhibited COX-2 and iNOS protein expression and activity and reduced NF-κB activity. Furthermore, QMR treatment led to a significant reduction in peroxynitrite levels, reactive nitrogen species that can form during inflammatory conditions, and restored tyrosine nitration values to those similar to sham-exposed control cells. We also investigated the effect of QMR treatment on inflammasome activation and macrophage polarization in THP-1-derived macrophages. Results showed that QMR treatment significantly decreased NLRP3 and activated caspase-1 protein expression levels and downregulated IL-18 and IL-1ß protein expression and secretion. Finally, our findings indicate that QMR treatment induces a switch in macrophage polarization from the M1 phenotype to the M2 phenotype.

The Role of Platelet-Rich Plasma on the Chondrogenic and Osteogenic Differentiation of Human Amniotic-Fluid-Derived Stem Cells.

Amniotic fluid represents a new and promising source of engraftable stem cells. The purpose of this study was to investigate the in vitro effects of platelet-rich plasma (PRP) on amniotic-fluid-derived stem cells (AFSCs) on chondrogenic or osteogenic differentiation potential. Amniotic fluid samples were obtained from women undergoing amniocentesis for prenatal diagnosis at 16-18 weeks of pregnancy. Undifferentiated human AFSCs were cocultured with PRP for 14 days. The study includes two protocols investigating the effects of activated PRP using two different methods: via freeze-thaw cycles and via the addition of calcium gluconate. On the 14th day of culturing, the differentiation potential of the cocultured AFSCs was then compared with undifferentiated AFSCs. Staining with alcian blue solution (ABS) and alizarine red solution (ARS) was performed, and chondrogenic- and osteogenic-associated genes markers were investigated. ABS demonstrated enhanced glycosaminoglycan expression. Cocultured cells expressed chondrocyte-associated genes, determined by real-time polymerase chain reaction (RT-PCR), including type I collagen, type II collagen, COMP, and aggrecan. In regard to the osteogenic markers, osteopontin and bone sialoprotein, there were no changes. In particular, the activation of PRP using the freeze-thaw cycle protocol showed a higher expression of the chondrogenic markers. Our preliminary in vitro results showed that PRP has good potential in the chondrogenic differentiation of AFSCs.

Isolation of osteogenic progenitors from human amniotic fluid using a single step culture protocol.

BACKGROUND: Stem cells isolated from amniotic fluid are known to be able to differentiate into different cells types, being thus considered as a potential tool for cellular therapy of different human diseases. In the present study, we report a novel single step protocol for the osteoblastic differentiation of human amniotic fluid cells. RESULTS: The described protocol is able to provide osteoblastic cells producing nodules of calcium mineralization within 18 days from withdrawal of amniotic fluid samples. These cells display a complete expression of osteogenic markers (COL1, ONC, OPN, OCN, OPG, BSP, Runx2) within 30 days from withdrawal. In order to test the ability of these cells to proliferate on surfaces commonly used in oral osteointegrated implantology, we carried out cultures onto different test disks, namely smooth copper, machined titanium and Sandblasted and Acid Etching titanium (SLA titanium). Electron microscopy analysis evidenced the best cell growth on this latter surface. CONCLUSION: The described protocol provides an efficient and time-saving tool for the production of osteogenic cells from amniotic fluid that in the future could be used in oral osteointegrated implantology.

Italian consensus statement (2020) on return to play after lower limb muscle injury in football (soccer).

Return to play (RTP) decisions in football are currently based on expert opinion. No consensus guideline has been published to demonstrate an evidence-based decision-making process in football (soccer). Our aim was to provide a framework for evidence-based decision-making in RTP following lower limb muscle injuries sustained in football. A 1-day consensus meeting was held in Milan, on 31 August 2018, involving 66 national and international experts from various academic backgrounds. A narrative review of the current evidence for RTP decision-making in football was provided to delegates. Assembled experts came to a consensus on the best practice for managing RTP following lower limb muscle injuries via the Delphi process. Consensus was reached on (1) the definitions of 'return to training' and 'return to play' in football. We agreed on 'return to training' and RTP in football, the appropriate use of clinical and imaging assessments, and laboratory and field tests for return to training following lower limb muscle injury, and identified objective criteria for RTP based on global positioning system technology. Level of evidence IV, grade of recommendation D.

Intercalary allograft reconstruction in a patient with large tibial defect: Case report.

A fit 26 year-old-man presented to our Department with an open fracture of the left tibial shaft (AO 42-C3). The fracture was initially treated with an External Fixator, which was replaced by an intramedullary Grosse Kempf nail after 4 months. In the following year he developed an atrophic non-union and we witnessed the increasing bone resorption at the fracture site which led to the nail breakage. An accurate CT pre-operative planning was made and a revision surgery was successfully performed: the broken nail was removed and intercalary allograft reconstruction was made, using a compressible intramedullary nail. Whereas in literature it is well described how intercalary allografts can be used to fill the massive diaphyseal defects after tumor resections, we assumed it could also be an adequate technique to treat a large bone defect at a non-union site.

Italian consensus conference on guidelines for conservative treatment on lower limb muscle injuries in athlete.

Provide the state of the art concerning (1) biology and aetiology, (2) classification, (3) clinical assessment and (4) conservative treatment of lower limb muscle injuries (MI) in athletes. Seventy international experts with different medical backgrounds participated in the consensus conference. They discussed and approved a consensus composed of four sections which are presented in these documents. This paper represents a synthesis of the consensus conference, the following four sections are discussed: (i) The biology and aetiology of MIs. A definition of MI was formulated and some key points concerning physiology and pathogenesis of MIs were discussed. (ii) The MI classification. A classification of MIs was proposed. (iii) The MI clinical assessment, in which were discussed anamnesis, inspection and clinical examination and are provided the relative guidelines. (iv) The MI conservative treatment, in which are provided the guidelines for conservative treatment based on the severity of the lesion. Furthermore, instrumental therapy and pharmacological treatment were discussed. Knowledge of the aetiology and biology of MIs is an essential prerequisite in order to plan and conduct a rehabilitation plan. Another important aspect is the use of a rational MI classification on prognostic values. We propose a classification based on radiological investigations performed by ultrasonography and MRI strongly linked to prognostic factors. Furthermore, the consensus conference results will able to provide fundamental guidelines for diagnostic and rehabilitation practice, also considering instrumental therapy and pharmacological treatment of MI. Expert opinion, level IV.