Cannabidiol and positive effects on object recognition memory in an in vivo model of Fragile X Syndrome: Obligatory role of hippocampal GPR55 receptors.

Cannabidiol (CBD), a non-psychotomimetic constituent of Cannabis sativa, has been recently approved for epileptic syndromes often associated with Autism spectrum disorder (ASD). However, the putative efficacy and mechanism of action of CBD in patients suffering from ASD and related comorbidities remain debated, especially because of the complex pharmacology of CBD. We used pharmacological, immunohistochemical and biochemical approaches to investigate the effects and mechanisms of action of CBD in the recently validated Fmr1-Δexon 8 rat model of ASD, that is also a model of Fragile X Syndrome (FXS), the leading monogenic cause of autism. CBD rescued the cognitive deficits displayed by juvenile Fmr1-Δexon 8 animals, without inducing tolerance after repeated administration. Blockade of CA1 hippocampal GPR55 receptors prevented the beneficial effect of both CBD and the fatty acid amide hydrolase (FAAH) inhibitor URB597 in the short-term recognition memory deficits displayed by Fmr1-Δexon 8 rats. Thus, CBD may exert its beneficial effects through CA1 hippocampal GPR55 receptors. Docking analysis further confirmed that the mechanism of action of CBD might involve competition for brain fatty acid binding proteins (FABPs) that deliver anandamide and related bioactive lipids to their catabolic enzyme FAAH. These findings demonstrate that CBD reduced cognitive deficits in a rat model of FXS and provide initial mechanistic insights into its therapeutic potential in neurodevelopmental disorders.

Wheel Running Adversely Affects Disease Onset and Neuromuscular Interplay in Amyotrophic Lateral Sclerosis Slow Progression Mouse Model.

BACKGROUND: Physical activity in Amyotrophic Lateral Sclerosis (ALS) plays a controversial role. In some epidemiological studies, both recreational or professional sport exercise has been associated to an increased risk for ALS but the mechanisms underlying the effects of exercise have not been fully elucidated in either patients or animal models. METHODS: To better reproduce the influence of this environmental factor in the pathogenesis of ALS, we exposed SOD1G93A low-copy male mice to multiple exercise sessions at asymptomatic and pre-symptomatic disease stages in an automated home-cage running-wheel system for about 3 months. RESULTS: Repeated voluntary running negatively influenced disease progression by anticipating disease onset, impairing neuromuscular transmission, worsening neuromuscular decline, and exacerbating muscle atrophy. Muscle fibers and neuromuscular junctions (NMJ) as well as key molecular players of the nerve-muscle circuit were similarly affected. CONCLUSION: It thus appears that excessive physical activity can be detrimental in predisposed individuals and these findings could model the increased risk of developing ALS in predisposed and specific professional athletes.

Emerging Roles of Endocannabinoids as Key Lipid Mediators for a Successful Pregnancy.

In recent years, Cannabis use/misuse for treating pregnancy-related symptoms and other chronic conditions has increased among pregnant women, favored by decriminalization and/or legalization of its recreational uses in addition to its easy accessibility. However, there is evidence that prenatal Cannabis exposure might have adverse consequences on pregnancy progression and a deleterious impact on proper neurodevelopmental trajectories in the offspring. Maternal Cannabis use could interfere with the complex and finely controlled role performed by the endocannabinoid system in reproductive physiology, impairing multiple gestational processes from blastocyst implantation to parturition, with long-lasting intergenerational effects. In this review, we discuss current clinical and preclinical evidence regarding the role of endocannabinoids in development, function, and immunity of the maternal-fetal interface, focusing on the impact of Cannabis constituents on each of these gestational processes. We also discuss the intrinsic limitations of the available studies and the future perspectives in this challenging research field.

Maternal Immune Activation Induced by Prenatal Lipopolysaccharide Exposure Leads to Long-Lasting Autistic-like Social, Cognitive and Immune Alterations in Male Wistar Rats.

Several studies have supported the association between maternal immune activation (MIA) caused by exposure to pathogens or inflammation during critical periods of gestation and an increased susceptibility to the development of various psychiatric and neurological disorders, including autism and other neurodevelopmental disorders (NDDs), in the offspring. In the present work, we aimed to provide extensive characterization of the short- and long-term consequences of MIA in the offspring, both at the behavioral and immunological level. To this end, we exposed Wistar rat dams to Lipopolysaccharide and tested the infant, adolescent and adult offspring across several behavioral domains relevant to human psychopathological traits. Furthermore, we also measured plasmatic inflammatory markers both at adolescence and adulthood. Our results support the hypothesis of a deleterious impact of MIA on the neurobehavioral development of the offspring: we found deficits in the communicative, social and cognitive domains, together with stereotypic-like behaviors and an altered inflammatory profile at the systemic level. Although the precise mechanisms underlying the role of neuroinflammatory states in neurodevelopment need to be clarified, this study contributes to a better understanding of the impact of MIA on the risk of developing behavioral deficits and psychiatric illness in the offspring.

Candida periprosthetic infection of the knee: a systematic review of surgical treatments and clinical outcomes.

BACKGROUND: Candida periprosthetic joint infections (PJIs) are a rare cause of prosthesis revision with severe consequences and challenging treatment. This study aims to produce a systematic analysis of types of treatment and outcome of knee Candida PJIs and their correlation with specific pathogen species. METHODS: During April 2021, a literature search was performed according to PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) guideline. Reviewers used the Oxford Level of Evidence (LoE) and Methodological index for non-randomized studies (MINORS) score. Modal value of surgical, pharmacological treatment and outcome along with the correlation between types of treatment and outcome was calculated through Chi-square or Fisher exact test. RESULTS: In total, 115 cases were collected through 51 articles, identifying 116 pathogens. Candida albicans was the most frequent pathogen. Analysis of LoE reveals 40 LoE 5 and 11 LoE 4. Thirteen patients underwent one-stage revision, 46 patients two-stage revision, 6 patients resection arthroplasty and arthrodesis, 4 patients long-term antifungal therapy, and 3 patients debridement with prosthesis retention. Global rate of success was 85.14%. Modal distribution revealed a preference for two-stage revision and Fluconazole in medical therapy. No difference in terms of fungal eradication was found among Candida species (p = 0.503) and for treatments except for two-stage revision and resection arthroplasty (p = 0.0125) or debridement with implant retention (p = 0.0498), and the rest of procedures and resection arthroplasty (0.0192). MINORS score was poor. CONCLUSIONS: Analysis of the literature did not highlight any difference between types of surgical treatment and pathogens in terms of relapse or infection eradication. However, two-stage replacement may be preferred, allowing healing of infection in most cases.

Anandamide and 2-arachidonoylglycerol differentially modulate autistic-like traits in a genetic model of autism based on FMR1 deletion in rats.

Autism spectrum disorder (ASD) has a multifactorial etiology. Major efforts are underway to understand the neurobiological bases of ASD and to develop efficacious treatment strategies. Recently, the use of cannabinoid compounds in children with neurodevelopmental disorders including ASD has received increasing attention. Beyond anecdotal reports of efficacy, however, there is limited current evidence supporting such an intervention and the clinical studies currently available have intrinsic limitations that make the interpretation of the findings challenging. Furthermore, as the mechanisms underlying the beneficial effects of cannabinoid compounds in neurodevelopmental disorders are still largely unknown, the use of drugs targeting the endocannabinoid system remains controversial. Here, we studied the role of endocannabinoid neurotransmission in the autistic-like traits displayed by the recently validated Fmr1-Δexon 8 rat model of autism. Fmr1-Δexon 8 rats showed reduced anandamide levels in the hippocampus and increased 2-arachidonoylglycerol (2-AG) content in the amygdala. Systemic and intra-hippocampal potentiation of anandamide tone through administration of the anandamide hydrolysis inhibitor URB597 ameliorated the cognitive deficits displayed by Fmr1-Δexon 8 rats along development, as assessed through the novel object and social discrimination tasks. Moreover, blockade of amygdalar 2-AG signaling through intra-amygdala administration of the CB1 receptor antagonist SR141716A prevented the altered sociability displayed by Fmr1-Δexon 8 rats. These findings demonstrate that anandamide and 2-AG differentially modulate specific autistic-like traits in Fmr1-Δexon 8 rats in a brain region-specific manner, suggesting that fine changes in endocannabinoid mechanisms contribute to ASD-related behavioral phenotypes.

Conservative treatment of spinal tuberculosis in a retrospective cohort study over 20-year period: high eradication rate and successful health status can be expected.

Background: Tuberculosis (TB) which mainly cause lung primarily TB, can also affect the musculoskeletal system. Spine involvement occurs in 50% of the cases and neurologic deficit and kyphotic deformity may occur. The choice of conservative or surgical management of spinal TB in the absence of neurologic deficits remains controversial. The aim of the present study was to investigate the outcome and the success rate of conservative treatment and to provide evidence for the timing of treatment for spinal TB in adult patients. Methods: Consecutive enrolled adult patients were conservatively treated from January 2000 to January 2020 for spinal TB in a tertiary care Orthopedic and Trauma Center-Spine Surgery Unit in Turin. Patients were conservatively treated with antibiotics and orthoses and followed up for at least 12 months. Clinical, radiological, laboratory and microbiological tests were performed for all the patients and demographic data, risk factors, comorbidity, clinical symptoms such as peripheral neurological deficit, and vertebral level involved were recorded. Treatment success was considered as no disease recurrence after 1 year of follow-up. Patients underwent successful conservative treatment were also evaluated with the self-perceived quality of life [36-Item Short Form (SF-36)] survey. Results: A total of 132 patients (59 women and 73 men) suffering from spinal TB with a mean age at presentation of 49 years (range, 32-68 years) were treated. The mean follow-up was 43 months (range, 12-82 months). In 80 cases, there was a single vertebra involvement while multiple levels were involved in 52 cases. Sixty-nine (52%) patients presented spondylitis without involvement of the disk and 63 (48%) patients presented a spondylitis with disk involvement. Conservative treatment was effective in 113 patients (86%) which showed inter-somatic fusion with stability of the spine. The mean period of antibiotic therapy was 12 months (range, 8-15 months). Patients wear spinal orthosis for at least 12 weeks. The physical component summary (PCS)-36 (48.9±10.0) and mental component summary (MCS) (46.5±7.0) summary scores at follow-up were comparable to the normative values (P=0.652 and P=0.862, respectively). Painful deformity occurred in 25 patients (19%). Conclusions: Conservative treatment is effective treatment for spinal TB and may avoid surgical intervention in the absence of neurologic deficits.

FMR1 deletion in rats induces hyperactivity with no changes in striatal dopamine transporter availability.

Autism Spectrum Disorder (ASD) is a pervasive neurodevelopmental disorder emerging in early life characterized by impairments in social interaction, poor verbal and non-verbal communication, and repetitive patterns of behaviors. Among the best-known genetic risk factors for ASD, there are mutations causing the loss of the Fragile X Messenger Ribonucleoprotein 1 (FMRP) leading to Fragile X syndrome (FXS), a common form of inherited intellectual disability and the leading monogenic cause of ASD. Being a pivotal regulator of motor activity, motivation, attention, and reward processing, dopaminergic neurotransmission has a key role in several neuropsychiatric disorders, including ASD. Fmr1 Δexon 8 rats have been validated as a genetic model of ASD based on FMR1 deletion, and they are also a rat model of FXS. Here, we performed behavioral, biochemical and in vivo SPECT neuroimaging experiments to investigate whether Fmr1 Δexon 8 rats display ASD-like repetitive behaviors associated with changes in striatal dopamine transporter (DAT) availability assessed through in vivo SPECT neuroimaging. At the behavioral level, Fmr1 Δexon 8 rats displayed hyperactivity in the open field test in the absence of repetitive behaviors in the hole board test. However, these behavioral alterations were not associated with changes in striatal DAT availability as assessed by non-invasive in vivo SPECT and Western blot analyses.

The appearance of phagocytic microglia in the postnatal brain of Niemann Pick type C mice is developmentally regulated and underscores shortfalls in fine odor discrimination.

The loss of NPC1 or NPC2 function results in cholesterol and sphingolipid dyshomeostasis that impairs developmental trajectories, predisposing the postnatal brain to the appearance of pathological signs, including progressive and stereotyped Purkinje cell loss and microgliosis. Despite increasing evidence reporting the activation of pro-inflammatory microglia as a cardinal event of NPC1 disease progression at symptomatic stages both in patients and preclinical models, how microglia cells respond to altered neurodevelopmental dynamics remains not completely understood. To gain an insight on this issue, we have characterized patterns of microglia activation in the early postnatal cerebellum and young adult olfactory bulb of the hypomorphic Npc1nmf164 mouse model. Previous evidence has shown that both these areas display a number of anomalies affecting neuron and glial cell proliferation and differentiation, which largely anticipate cellular changes and clinical signs, raising our interest on how microglia interplay to these changes. Even so, to separate the contribution of cues provided by the dysfunctional microenvironment we have also studied microglia isolated from mice of increasing ages and cultured in vitro for 1 week. Our findings show that microglia of both cerebellum and olfactory bulb of Npc1nmf164 mice adopt an activated phenotype, characterized by increased cell proliferation, enlarged soma size and de-ramified processes, as well as a robust phagocytic activity, in a time- and space-specific manner. Enhanced phagocytosis associates with a profound remodeling of gene expression signatures towards gene products involved in chemotaxis, cell recognition and engulfment, including Cd68 and Trem2. These early changes in microglia morphology and activities are induced by region-specific developmental anomalies that likely anticipate alterations in neuronal connectivity. As a proof of concept, we show that microglia activation within the granule cell layer and glomerular layer of the olfactory bulb of Npc1nmf164 mice is associated with shortfalls in fine odor discrimination.

Is vertebral stenting kyphoplasty a good choice in the treatment of osteoporotic vertebral fracture? A series of 47 patients (v2).

Background: The incidence of vertebral fragility fracture is increasing over last three decades with an essential impact on quality of life. Some devices were proposed to improve conventional kyphoplasty in the last five years, known as vertebral stenting kyphoplasty (VSK). Materials and Methods: All osteoporotic vertebral fractures (OVF) treated with VSK, single-level fracture without neurological impairment, and with more than 24 months of follow-up were included in the study. We recorded fracture types according to DGOU classification, fracture level, regional kyphosis angle (RKA), Oswestry disability index (ODI), and complications. Results: Forty-seven consecutive patients were included. RKA significantly improved from pre to postoperative values (p<0.000001) and to follow-up values (p<0.00001). A significant difference was found between preoperative RKA of (OF2+OF3) and OF4 (p<0.00001), confirmed immediately after surgery (p= 0.005425) and at last follow up (p= 0.000947). A significant difference was found in correction of RKA between (OF2+OF3) and OF4 at injury time and after treatment (p<0.00001), and it was confirmed at the last follow-up (p=0.000026). ODI showed a significant difference between (OF2+OF3) and OF4 type of fractures (p=0.038216). We recorded five complications: 2 cases of leakage without neurological impairment, two progressions of kyphosis, and one implant migration. Conclusions: VSK is an excellent and reliable option in the treatment of OVF, with good clinical results and preservation of obtained RKA at the time of treatment. However, in case of vertebral collapse with the involvement of both vertebral plates, surgeons must be aware of possible implant failure or migration. Level of Evidence: 4.

Spondylodiscitis After Endovascular Aortic Repair Due to Noninvasive Listeriosis: A Case Report.

CASE: An 83-year-old man suffered progressive lower back pain 4 weeks after an endovascular aortic repair (EVAR) procedure. Computed tomography showed L4 vertebral body collapse and abnormal soft tissue-like density swelling with increased uptake on 18F-fluoro-D-glucose (FDG) positron emission tomography (PET)/CT. Listeria monocytogenes was identified from ultrasound-guided fine-needle aspiration. Ultrasound-guided drainage of the retroperitoneal abscess and intravenous antibiotic therapy with ampicillin and gentamicin resulted in the rapid relief of symptoms. CONCLUSION: Spondylodiscitis after EVAR requires a timely diagnosis. Uncommon organisms such as L. monocytogenes must be suspected, even in focal infections without signs of listeriosis. Conservative treatment with preservation of the graft should be considered as long as close follow-up evaluations are performed.

May footwear be a predisposing factor for the development of hallux rigidus? A review of recent findings.

Hallux rigidus (HR) is the clinical manifestation of osteoarthritis of the first metatarsophalangeal (MTP1) joint and affects about 2.5% of people older than 50 years. The condition may significantly impact patients' quality of life, leading to debilitating pain and limited range of motion (ROM). Numerous hypotheses have been postulated about contributing factors to the development of the disease, but with poor proven association. Some types of footwear over others may transmit altered pressure and stress toward the forefoot and this can significantly contribute to development of the condition. The purpose of this review is therefore to analyze the importance of correct footwear and if an incorrect shoe can influence the development and/or worsening of symptoms in patients affected by HR. From the results of the studies, it appears that symptoms improve with rigid-soled low-heeled shoes such as boots and worsen with flat flexible-soled shoes such as sandals and tennis shoes, which should therefore be avoided. Despite this, although incorrect footwear increases symptoms, a direct correlation with the development of the condition has not been detected but rather an improvement in comfort in some types of shoes than in others. In predisposed patients, incorrect footwear is more a way to increase symptoms than a real risk factor for the development of the disease, remaining in a very low risk percentage to be considered indicative.

Effectiveness and reliability of cannulated fenestrated screws augmented with polymethylmethacrylate cement in the surgical treatment of osteoporotic vertebral fractures.

BACKGROUND: Implants' stability, especially in osteoporosis patients, is a challenging matter. Nowadays, the adoption of cannulated fenestrated screws augmented with polymethylmethacrylate cement (PMMA CSF) is described by some authors. This single-center, retrospective observational study aims to evaluate the long-term effectiveness, reliability, and mechanical performances of this type of screws in osteoporotic fractures. MATERIALS AND METHODS: All the patients surgically treated from January 2009 to December 2019 with PMMA CSF were evaluated and submitted to the inclusion and exclusion criteria. Clinical and radiological evaluations were performed at pre- and post-surgery time and at the follow-up (FU). Loss of correction in the sagittal plane (bisegmental Cobb angle), kyphosis angle of the fracture (fractured vertebral angle), loosening of pedicle screws (screw's apex vertebral body's anterior cortex mean gap called SAAC gap and screw's apex vertebral body's superior endplate mean gap called SASE gap), visual analog scale, and Oswestry disability index scores were evaluated. RESULTS: One hundred and sixty-three patients (58 males and 105 females) aged over 65 years affected by vertebral osteoporotic fractures were included in the study. At FU, we do not found significant differences in radiological items in respect to the postoperative period. Only one case of loosening and 18 cases of cement leaking (without neurological impairments) were found. Clinical scores improvement was significant in the interval between preoperative and FU. CONCLUSIONS: PMMA CSF seems to can guarantee good efficacy and effectiveness in the surgical treatment of vertebral fractures in osteoporosis.

Has the COVID-19 Pandemic Changed the Daily Practices and Psychological State of Orthopaedic Residents?

BACKGROUND: The coronavirus-19 (COVID-19) pandemic has been an unprecedented time for healthcare and has substantially changed resource availability in surgeons' work practices and routines. Many orthopaedic departments suspended elective surgery, and some re-deployed orthopaedic residents to stressful nonorthopaedic tasks; long hours were commonplace. Stress-reaction symptoms such as anxiety and depression have been reported in about 10% of healthcare workers during previous infectious-diseases outbreaks (including the Ebola virus), but little is known about the psychological needs of residents faced with this global disaster. QUESTIONS/PURPOSES: (1) Have anxiety and depression symptoms among orthopaedic residents worsened from the period before to the period after the lockdown in Italy? (2) Are there differences in anxiety and depression symptoms between residents who worked in a COVID-19 department and those who did not? METHODS: The Italian Association of Orthopaedic and Traumatology Residents is comprised of 365 members who were recruited through the organization's mailing list; they were asked to respond to a survey about their health and well-being at the beginning and end of the first COVID-19 Italian lockdown (March 9, 2020 to May 3, 2020). For the survey's development, 10 orthopaedic surgery residents at the Magna Graecia University of Catanzaro were preliminarily asked to answer the surveys, and both face validity and content validity were tested. The test-retest reliability was 0.9. Impact on and future concerns about family life and daily work practice, as well as sleep disorders, were investigated. Anxiety and depression were assessed with the Hospital Anxiety and Depression Scale (HADS), which includes 14 questions (seven for anxiety, HADS-A; and seven for depression, HADS-D) on a Likert scale (0-3); thus, a patient can have a score between 0 and 21 for either the HADS-A or HADS-D, with higher scores indicating a greater likelihood of anxiety or depression. Previously reported minimum clinically important differences ranged from 1.5 to 1.7. For each scale, total scores of ≤ 7 , 8 to 10, and ≥ 11 were taken to represent normal, borderline, or abnormal level of anxiety or depression, respectively. Overall, 75% (272 of 365) of residents completed the survey at both the beginning and end of the lockdown; 72% (196 of 272) were men, the mean ± SD age was 30 ± 3 years, 72% (197 of 272) worked in a hospital setting with patients who were COVID-19-positive, 20% (55 of 272) served in a COVID-19 department, and 5% (7 of 139) tested positive for COVID-19 by nasal-pharyngeal swab. Overall, 9% (24 of 272) of residents had family members who contracted COVID-19, and 3% (8 of 272) had a relative who died. Because of the risk of possible COVID-19 exposure, 18% (48 of 272) of residents needed to temporarily change their household given that social distancing was considered the best way to slow the spread of COVID-19. RESULTS: At the end of the lockdown, orthopaedic residents exhibited signs of worsening anxiety and depression as measured by the overall HADS score (median 9 [IQR 5 to 14] versus median 11 [IQR 6 to 17.8], respectively; median difference -1 [95% CI -1.5 to -0.5]; effect size [r] = -0.24; p < 0.001) as well as in the depression subscale (median 4 [IQR 2 to 7] versus median 5.5 [IQR 3 to 8], respectively; median difference -1 [95% CI -1.5 to -0.5]; r = -0.36; p < 0.001). We found no difference in the development of anxiety or depression between residents who worked in a COVID-19 department and those who did not, as demonstrated by comparing the change in HADS scores between these groups (median 1 [IQR -3 to 4] versus median 1 [IQR -2 to 4] in HADS change score over time; median difference 0 [95% CI -1 to 2]; r = -0.03; p = 0.61). CONCLUSION: The COVID-19 pandemic has affected the daily practice of orthopaedic residents and has had important, far-reaching consequences on their health and well-being, including social implications. Residents showed higher anxiety and depression symptoms at the end of the lockdown. No differences were found in changes of anxiety and depression, over time, for residents who worked in a COVID-19 department compared with those who did not. The evaluation of anxiety and depression through standardized questionnaires could help to identify residents at risk of higher psychological distress who could be referred to regular psychological counseling as a possible prevention strategy during stressful times. Future studies should confirm the long-term effects of these findings. LEVEL OF EVIDENCE: Level II, prognostic study.

Effectiveness of corticosteroid injections in Civinini-Morton's Syndrome: A systematic review.

BACKGROUND: The aim of this paper is to analyze the effectiveness of corticosteroid injections (CI), in combination with or without a local anaesthetic, for Civinini-Morton's Syndrome to determine which protocol could be the most appropriate among conservative treatments. METHODS: All selected articles were screened using a thorough database search of PubMed, EMBASE and SCOPUS to assess their suitability to the research focus. RESULTS: Selection produced 10 articles as full-text, for a total of 590 patients, with a mean follow-up of 14 ± 14.2 (range 3-48) months. Johnson satisfaction scale, resulting from 6 studies, scored 25.6% (range 5-38) and 39.4% (range 15-51.8), respectively completely satisfied and satisfied with minor reservations. Mean VAS, declared in 5 studies, decreased from 70.7 ± 16.5 (range 67-89) to 33.4 ± 7.6 (26-42.5) points (p < 0.01). Most common complication was skin depigmentation in 7 (2.6%) cases. CONCLUSIONS: CI appear to be a safe treatment allowing good results with a very low complications rate. A neuroma of 6.3 mm seems to be the cut-off size; below which CI could have best indications and be considered as an intermediate treatment between shoe modifications and more invasive procedures such as percutaneous alcoholization or surgery. LEVEL OF EVIDENCE: Level II, systematic review.

Surgical treatment of scoliosis in neurofibromatosis type I: A retrospective study on posterior-only correction with third-generation instrumentation.

BACKGROUND: Scoliosis is the most common orthopedic complication of neurofibromatosis type I. Scoliosis can be occurred with two patterns: dystrophic or idiopathic-like. In adolescence, in consideration of bone dystrophy, osteopenia, and often associated hyperkyphosis, most of the authors recommend an anterior-posterior approach. According to other authors, modern instrumentations could be sufficient to sustain a solid posterior arthrodesis. MATERIALS AND METHODS: Ten patients were diagnosed with scoliosis in neurofibromatosis type I aged between 8 and 25 years, Cobb angle of the thoracic curve >45°, and minimum follow-up (FU) of 1 year and treated with posterior-only approach with third-generation high-density instrumentations. Radiographic measurements were performed on the coronal and sagittal planes. Nonparametric tests (Friedman test and Wilcoxon test) were applied to evaluate the reducibility of the preoperative curve (T0), the postoperative surgical correction (T1), and its maintenance on FU. RESULTS: Statistics showed results compared to those evaluated in the literature with a combined approach regarding surgical correction and its maintenance on FU. On T1, a median correction of 53.5% of the scoliotic curve and of 33.7% of the thoracic hyperkyphosis was observed. On FU, the correction was maintained. A global improvement in balance was appreciated. The curves, despite rigid, showed a relative reducibility to bending tests and traction. No significant complications occurred. CONCLUSIONS: The posterior-only approach produces a satisfactory correction of the dystrophic neurofibromatosis scoliosis if associated with the use of high-density third-generation instrumentations. We are confident in recommending posterior-only approach in dystrophic neurofibromatosis scoliosis with coronal curves till 110° and coexisting thoracic kyphosis till 80°.

Sublaminar fixation versus hooks and pedicle screws in scoliosis surgery for Marfan syndrome.

BACKGROUND: In patients with Marfan syndrome (MFS), surgical correction of spinal deformities with hooks and/or pedicle screws involves a higher rate of complications than in patients with adolescent idiopathic scoliosis. Therefore, sublaminar instrumentation is often a last resort option. This study wants to assess the ability of sublaminar fixation to achieve three-dimensional scoliosis correction and spine stabilization compared with hook and/or pedicle screw systems. METHODS: Twenty-one MFS patients who underwent posterior spinal fusion at a highly specialized medical center in 1995-2017 were divided into two different groups retrospectively evaluated at a minimum follow-up of 2 years. Group 1 (8 patients) was composed by hooks and screws instrumentation, while Group 2 (13 patients) was composed by hook or pedicle screw system associated to sublaminar wires/bands. Radiological (correction and long-term stability) and general endpoints (mean blood loss, surgery time, and complications) were compared between the groups. RESULTS: The degree of correction compared with the preoperative status was satisfactory with both approaches, although the difference between them was not significant. No significant differences were found for general endpoints between groups. CONCLUSION: Our data suggest that scoliosis correction with sublaminar fixation is not inferior to treatment with hooks and/or pedicle screws. LEVEL OF EVIDENCE: III.

The effectiveness of shoe modifications and orthotics in the conservative treatment of Civinini-Morton syndrome: state of art.

Civinini Morton's Syndrome (CMS), better known as Morton's Neuroma, is a benign enlargement that typically affects the third common digital branch of the plantar nerve. It is a common cause of metatarsalgia leading to debilitating pain. It prefers the female gender, with a female to male ratio of 5:1 and an average age of 50 years at time of surgery. Precise aetiology remains under debate, with four etiopathogenetic theories often cited in the literature. Clinical symptoms, physical exam and instrumental evidence are important in assessing and grading the disease. Biomechanics seem to play an important role, especially regarding the usefulness of correct footwear. The first approach in the early stages of this condition usually begins with shoe modifications and orthotics, designed to limit the nerve compression. In order to prevent or delay the development of CMS, shoes should be sufficiently long, comfortable, broad toe-boxed, should bear a flat heel and a sufficiently thick external sole which should not be excessively flexible. Most authors suggested that an insole with medial arch support and a retrocapital bar or pad, just proximal to the metatarsal heads, displaces the pressure sites and can be beneficial to relieve the pain from the pinched nerve. A threshold period of 4.5 months appears to emerge from the results of the analysed studies, indicating that, beyond this period and in neuromas larger than 5-6 mm, orthotics and/or shoes modifications do not seem to give convincing results, proving to be more a palliation for the clinical condition to allow an acceptable life with pain rather than a real treatment.

The efficacy of shoe modifications and foot orthoses in treating patients with hallux rigidus: a comprehensive review of literature.

Hallux rigidus (HR) is a degenerative disease of the first metatarsophalangeal (MTP1) joint and affects about 2.5% of people older than 50 years. The real etiology of this condition remains under debate. Clinical symptoms, physical exam, and instrumental evidence are important in assessing and grading the disease. The anatomy of the first metatarsal is unique and its configuration may play a significant role in the HR development. The first approach usually begins with shoe modifications and foot orthoses, designed to limit irritation from the dorsal osteophytes, reducing motion and the mechanical stresses on the joint. To prevent or delay the development of HR, shoes should be sufficiently long, comfortable, with high toe box and broad toe-boxed, and should bear an allowed space for the orthotic device. The ideal orthotic appears to require a 3-mm thickness with a correct stiffness, and also increasing and extending the medial metatarsal arch just proximal to the metatarsal head, raising the first metatarsal and allowing the proximal phalanx to rest in a more plantarflexed position, decompressing the dorsal aspect of the joint. The increased foot pronation moment with medial column overload should be corrected. In addition, the maximum follow-up found by the analyzed studies was of 14.4 years, so the Authors cannot conclude how long conservative care can keep a patient free from pain and able to perform normal daily activities. However, the use of shoe modifications and foot orthoses may be considered a safe treatment and then should be always offered to patients.