A Review of Current Approaches to Pain Management in Knee Osteoarthritis with a Focus on Italian Clinical Landscape.

The global cases of knee osteoarthritis (KOA) are projected to increase by 74.9% by 2050. Currently, over half of patients remain dissatisfied with their pain relief. This review addresses unmet needs for moderate-to-severe KOA pain; it offers evidence and insights for improved management. Italian experts from the fields of rheumatology, physical medicine and rehabilitation, orthopedics, primary care, and pain therapy have identified several key issues. They emphasized the need for standardized care protocols to address inconsistencies in patient management across different specialties. Early diagnosis is crucial, as cartilage responds better to early protective and structural therapies. Faster access to physiatrist evaluation and reimbursement for physical, rehabilitative, and pharmacological treatments, including intra-articular (IA) therapy, could reduce access disparities. Concerns surround the adverse effects of oral pharmacological treatments, highlighting the need for safer alternatives. Patient satisfaction with corticosteroids and hyaluronic acid-based IA therapies reduces over time and there is no consensus on the optimal IA therapy protocol. Surgery should be reserved for severe symptoms and radiographic KOA evidence, as chronic pain post-surgery poses significant societal and economic burdens. The experts advocate for a multidisciplinary approach, promoting interaction and collaboration between specialists and general practitioners, to enhance KOA care and treatment consistency in Italy.

Isolated greater trochanter fractures.

INTRODUCTION: Isolated fractures of the greater trochanter (GT) in adults are rare injuries and traditionally treated without surgery. The present systematic review was designed to examine the treatment protocol for isolated GT fractures and to discover if innovative surgical techniques, such as arthroscopy or suture anchors, can be used to improve outcomes in young active patients. METHODS: A systematic review was conducted including all full-text articles suited our inclusion criteria from January 2000 describing treatment protocols of isolated great trochanter fractures confirmed at MRI in adults. RESULTS: The searches identified a total of 247 patients from 20 studies with a mean age 56.1 years and mean follow-up 13,7 months. Only 4 case report treated 4 patients with not unique surgical strategy. The rest of the patients were treated conservatively. DISCUSSION: Most trochanteric fractures can heal without surgical intervention with good results However, the patient must not immediately bear full weight and the abductor's function could decrease. Displaced GT fragments more than 2 cm or athletes, young, demanding patients may benefit from surgical fixation to regain abductor function and strength. Evidence-based surgical strategies could be provided by arthroplasty and periprosthetic literature. CONCLUSION: The grade of fracture displacement and the physical demands of the athlete can be important factors in the decision process for or against surgery. By now, no evidence-based guideline exists for the ideal treatment method in demanding patients. It is necessary use a "patient-specific" treatment strategy.

The current treatment of hip arthroplasty revision: a systematic review of the literature.

INTRODUCTION: Acetabular revision surgery is the most challenging aspect in hip prosthetic. There is lack of consensus on the optimal method of reconstructing the acetabular defects. The aim of this systematic review is to take stock of the state of the art on the options available and highlight which type of construct is the most reliable in usual clinical practice. MATERIAL AND METHODS: The reporting of this systematic review was guided by the standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis 2020 Statement.Electronic search of MEDLINE was performed from 1991 up to April 2021 to identify relevant studies for this review.  Discussion: various surgical techniques have been adopted and proposed to treat acetabular bone defects: cemented cups, large-sized non-cemented acetabular cups, higher positioned cups, reinforcement rings, cage, oblong cups, custom triflange implants, high porous metal cups and augments. Bone defect defines the type of components to be implanted and among those, outcomes are various depending on the study taken into account, the component used and the degree of initial bone defect. CONCLUSIONS: In acetabular revision surgerythe use of TM cups and augment is a valid option in presence of major bone loss and pelvic discontinuities. In clinical practice the use of TM components replaced rings, while the cup-cage implant replaced conventional cages. TM augments and cups can be considered as the most promising technique in the reconstruction of wide acetabular defects, while the use of cages can be considered as a valid option in the elderly population.

The advantages of a single use retractor for soft tissue protection in direct anterior approach total hip arthroplasty: the preliminary experience.

The anterior hip approach is a procedure with increasing popularity in hip replacement surgery due to its many benefits and the number of surgeons using it is steadily increasing around the world. Less pain, better results in the first few weeks, reduced dislocation rate are the prerogatives of this approach. We analyzed in a group of 26 patients the use of a soft tissue retractor, Alexis Orthopedic Protector, the CPK values in the first third and fifth postoperative day. The results obtained, normalized, demonstrate a slight reduction in tissue damage using the device compared to a control group. In addition to blood values, improved exposure, distribution of leverage, cleanliness of the field and a potential reduction in infectious risk are advantages for the use of an orthopedic surgery retractor. We believe that the adoption of the Alexis Orthopedic Protector provides numerous improvements during the hip arthroplasty surgical procedure, especially when adopting the direct anterior approach, because it distributes the traction forces around the surgical path resulting in greater visibility. However, the small number of patients is not sufficient to perform an accurate statistical analysis and further studies on larger samples will be required.

The experience of an indipendent center with the MINIHIP® femoral stem.

The implantation of short femoral stems has significantly increased over the past decade, thanks to their preservation of bone stock, allowing for easier potential revision of components and physiological joint reconstruction. Their main features are metaphyseal fixation and partial retention of the femoral neck which lead to biomechanical advantages and high stability. They also guarantee the preservation of bone stock and insertion through minimally invasive approaches. Fifty-one non-consecutive patients with osteoarthritis or avascular necrosis were treated by two senior surgeons with total hip arthroplasty (THA) with anterior or anterolateral approach between April 2013 and October 2016. Cementless short femoral stem monobloc (Minihip, Corin, Cirencester, UK) was implanted in all patients who were studied retrospectively. Radiographic outcome was analyzed and clinical outcomes were assessed with Harris Hip Score (HHS), Hip handicap and Osteaorthritis Outcome Score (HOOS) and Oxford Hip Score (OHS). Based on radiological results we did not find periprosthetic osteolysis while bone resorption was evaluated in 5 implants which were classified according to Gruen. The MiniHip stem demonstrates adequate metaphyseal grip, excellent implant stability to ensure implant survival.

Arthroscopic reduction and fixation of partial posterior wall acetabular fractures.

BACKGROUND AND AIM: Reduction and fixation of partial posterior wall fracture is usually performed with an open posterolateral approach. When the fragment may be fixed without a plate (with screws only), reduction and fixation may be also achieved via hip arthroscopy. To our knowledge no study described this technique. Aim of our study is to describe the surgical technique and to present the achieved outcomes and the occurred complications. METHODS: Six cases of arthroscopic fixation of partial posterior wall fracture have been reviewed for the purpose of this study. Patients were treated arthroscopically if the fragment was not bigger than 25% of the posterior wall. Patient demographic, injury, and surgical variables as well as complications were recorded and retrospectively evaluated. Radiographic outcome was scored according to Matta's criteria on postoperative radiographs and clinical outcomes were evaluated with the modified Harris hip score. RESULTS: Fracture reduction was classified as anatomic on post-operative x-rays in all patients. The mean clinical score was 98 points at one year follow-up. No patient developed symptomatic femoral head AVN, none had heterotopic ossification. In one patients a screw breakage occurred without clinical complications. CONCLUSIONS: Arthroscopic reduction and fixation of partial posterior wall fracture is an effective treatment and showed good outcomes if a careful patients' selection is done.

A vascular lesion in hip revision arthroplasty: a case report.

Vascular injuries during hip revision surgery can be life-threatening complications for patients. There are many aspects to consider when approaching this type of surgery for an optimal diagnostic and therapeutic strategy, as a careful planning with extensive preoperative investigations, a full attention during the surgical procedure and the use of suitable material for a proper treatment. This kind of surgery can require a dedicated and trained multidisciplinary team. We report a case of an acute intraoperative vascular lesion during an acetabular revision performed in a 55-years-old patient.

The "Ball in Basket" Technique for Tibiotalocalcaneal Fusion.

Tibiotalocalcaneal arthrodesis (TTCA) in severe bone deficit represents a complex challenge for expert orthopedic surgeons also. This study aims to illustrate a surgical technique, defined as "ball in basket", that facilitates the fitting of the structural bone graft (femoral head from bone bank) and its placement, in order to fill the bone gap during instrumented arthrodesis. The proposed technique includes the preparation of the recipient bone surfaces with acetabular convex reamers and of concave reamers to shape the bone graft from bone bank. This preparation guarantees a maximum congruence of the bone surfaces and a greater stability of the bone graft during the placement of the fixation devices to optimize the bone fusion and to provide a good patient clinical outcome. The preliminary results obtained for two patients, initially presenting with severe anatomical deformity associated with severe bone gap, are described. Patients underwent clinical and radiographic follow-up evaluations (respectively at 4 and 30 months of follow-up) showing radiographic healing and good functional recovery. The results are encouraging, although long-term studies and a wider cohort of patients are necessary to consider this technique a reliable aid in case of severe bone deficit. (www.actabiomedica.it).

Bio-inductive implant for rotator cuff repair: our experience and technical notes.

The treatment of chonic large and partial rotator cuff tears represents a common challenge for orthopedic surgeons. Numerous treatments were suggested but the best is still controversial. Into this field the use of an augment for rotator cuff repair aims to protect the tension of the suture in the postoperative phase and to facilitate the biological healing process. In our institution we treated 4 patients (3 males and 1 female) with rotator cuff tear with bio-inductive implant. All patients presented with a postero-superior rotator cuff tear: 3 patients with a type C-III tear according to Snyder classification and 1 patient with partial articular tear with significant degeneration and poor tendon quality (type A-III tear according to Snyder classification). The final outcome is highly satisfying intraoperatively and the postoperative protocol reflects our normal postoperative protocol following to rotator cuff repair. No complications occurred at 6 months follow-up. The use of the bio-inductive implant in the arthroscopic rotator cuff repair resulted easy, rapid and reproducible. Although no current scientific evidences regarding such implants exist, in selected cases and with the correct indications, the use of bio-inductive implant could represent an effective aid and an option in case of complex rotator cuff tears.

Early experience with the ATTUNE Total Knee Replacement System.

BACKGROUND: Modern TKA implants promise to improve functional outcomes, stability, patient satisfaction and operating room efficiency. The purpose of this retrospective study is to evaluate our short-term clinical and radiological results and survival using the ATTUNE Total Knee Replacement System. METHODS: The authors reviewed 228 primary cemented TKAs using ATTUNE Total Knee Replacement System which were implanted between 2014 and 2018 concerning short-term clinical and radiographical outcomes and survival. Clinical evaluation was performed using the Knee injury Osteoarthritis Outcome Score (KOOS), the Oxford Score and a Numeric Rating Scale (NRS) for pain. Radiographic analysis was performed using the Modern Knee Society Score Evaluation System. RESULTS: The means of the clinical results as measured with KOOS score were Pain 82,7, Symptoms 79, ADL 78,3, Sport and recreation 51,8 and QOL 78,6. The mean Oxford score was 35 and NRS 2. The mean ROM was 113,4 (SD 9,4 range 90-130). Radiographically mean mechanical axis was 1,97° of Varus and radiolucent lines were detected in 43 knees (22,4%). The survival rate is 98.4% at 2 years and 97.4% at 5 years. CONCLUSION: At short-term follow-up the ATTUNE Knee Replacement System provide excellent clinical and radiographical outcomes and good results regarding revision rate. Due to high incidence of radiolucent lines, those patients should be closely monitored even though they show no clinical evidence for loosening.

Two cases of neglected posterior fracture-dislocation of the shoulder with ipsilateral humeral shaft fracture.

Posterior shoulder fracture-dislocations are rare. A combination of this injury with ipsilateral humeral shaft fracture is an extremely rare event. We report two cases of posterior shoulder fracture-dislocation with ipsilateral fracture shaft of humerus treated in our department. We highlight the rarity of the condition and the potential risk of recognize only the shaft fracture. We emphasize the importance of complete physical and radiological examination (x-rays and CT scan) in such cases to ensure early detection and its subsequent surgical treatment.

Diagnosis and management of periprosthetic femoral fractures after hip arthroplasty.

INTRODUCTION: Periprosthetic femoral fracture represent a severe complication, at present the third cause of revision surgery, with an estimated incidence from 0,1 to 2,1%. The number of these fracture can be expect to increase in line with the aging of population and amount of THA implants also in younger high demanding patients. MATERIALS AND METHODS: The aim of this study is analyze the diagnostic and therapeutic decision making processes performed in 64 patients with periprosthetic fractures treated surgically from January 2012 and October 2016 in our center. We analysed instrumental exams and surgical reports focusing on type of procedure, surgical access, operative time and type of fixation. RESULTS: Average age was 809 years and a mean follow-up 231 months. According to Vancouver system and after X-rays, CT scan and intraoperative evaluation, 26 fractures were classified as type B1, 31 as type B2, 3 type B3 and 4 type C. Follow up results were divided on the basis of the surgical treatment: in ORIF group (23 type B1 fractures and 4 type C fracture) fracture union was obtained in 16 cases (593%) and the final HHS mean value was 6161; in Revision group (3 type B1, 31 type B2 and 3 type B3) bone healing was reported in 26 cases (703%) with mean HHS score of 7194. CONCLUSIONS: In this surgery the objectives are provide an adequate bone healing and return to previous functional status as soon as possible. Many reasons make these goals challenging, in particular advanced age, osteoporosis, co-morbidity and weakness that lead to low energy trauma, the most frequent cause of these injuries. In our opinion a crucial aspect is the evaluation of stem stability, considering an implant mobilized until the opposite is clearly evident. Reduction of surgical time and early mobilization are goals of this surgery, often associated with several complications and high mortality rate.

Cementless metaphyseal reverse shoulder arthroplasty: our preliminary experience.

Reverse shoulder arthroplasty (rTSA) is a largely used procedure with a wide variety of indications. The incidence of this surgery is increased in recent years and the literature expects similar trend for them future. Metaphyseal stem rTSA seems to be a promising solution considering major objectives the preservation of humeral bone stock and ease of revision. In our study we analyzed 19 patients treated with cementless metaphyseal stem rTSA for osteoarthritis (group A) and acute fractures (group B). In group A (7 patients) the average Constant score improved from 21,57 (16-29) to 56,85 (38-72), the average SST improved from 2,29 (1-4) to 9,43 (8-12) and the mean VAS score improved from 14,29 to 4,86. In group B (12 patients) the mean Constant-Murlay score at last follow up was 42,17; the average SST was 7 and average pain score was 8,92. Overall active range-of-motion (ROM) improved significantly. Surgical considerations, clinical (analyzing Constant score and Simple Shoulder Test) and radiological short-term outcomes are encouraging, with low rate of complications. Long term follow-up studies are necessary to confirm our findings and the potential benefits related to these implants.

Asymmetric bilateral hip dislocation in young man: a case report.

Bilateral hip dislocation is a rare event, asymmetric dislocation is even rarer. Due to the intrinsic stability of the hip joint this lesions usually follow a high energy trauma. Because of the common associated lesions, the initial clinical assessment should be performed thoroughly. CT scan rather than x-rays offers a complete survey of these possible associated injuries such as thoracic or abdominal bleedings, neurologic lesions or fractures directly associated with the hips dislocations. The first goal should be reduction of the dislocation to prevent avascular necrosis (AVN) of the femoral head and arthritis. We report a case of a young man with right anterior hip dislocation and left posterior hip dislocation with associated fracture of the posterior wall.

Extensor mechanism realignment procedures in the treatment of patellofemoral instability.

Patellar instability is one of the most common conditions treated in the field of orthopedics. A diagnosis based on clinical and instrumental tests allows proper treatment planning. The techniques at the disposal of the surgeon - arthroscopic, arthroscopically-assisted and open - are numerous, and extensor mechanism realignment procedures are among the ones most frequently used. The choice of the most appropriate technique must be made case by case, considering the peculiarities of the individual patient.