I.S.Mu.L.T - Rotator Cuff Tears Guidelines.

Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.

Stress fractures in the elderly: different pathogenetic features compared with young patients.

Stress fractures mainly occur in the lower limb as a result of cyclic submaximal stresses. Most commonly affected by this specific type of fractures are young athletes, military or elderly subjects with metabolic bone diseases like osteoporosis. In consideration of the heterogeneity of affected patients is presumable that there are different pathogenic mechanisms. In young person bone tissue, although metabolically intact, is not able to withstand the stresses to which it is chronically subjected, also because of muscle fatigue. This leads to a macrostructural failure and to the development of "fatigue" fractures. Instead, in elderly patients, there are numerous physiological conditions that determine a bone metabolism alteration. This is the main reason for the structural changes in trabecular and cortical bone, which is reflected in reduced biomechanical strength. In addition, muscular situation, such as muscle fiber atrophy, is unable to correctly support bone tissue, leading to the development of insufficiency fractures.

Bone mineral density evaluation in osteoporosis: why yes and why not?

Osteoporosis is a diffuse skeletal disease in which a decrease in bone strength leads to an increased risk of fractures. A wide variety of types of bone densitometry measurements are available, including quantitative computed tomography measurements of the spine, quantitative ultrasound devices for measurements of the heel and other peripheral sites and dual-energy X-ray absorptiometry (DXA) for measurement of bone mineral density (BMD) at the lumbar spine, proximal femur, forearm and total body scans. Compared with alternative bone densitometry techniques, hip and spine DXA examinations have a number of advantages that include a consensus that BMD results can be interpreted using the World Health Organization T score definition of osteoporosis, a proven ability to predict fracture risk, proven effectiveness at targeting anti-fracture therapies, and the ability to monitor response to treatment. However, in recent years, the authors have raised some important questions about the objective limits of this method that have led to doubts about its effectiveness in terms of clinical outcome.

Fragility fractures: the clinical pathway.

The clinical management of fragility fracture is simple but complex at the same time. Patients are different from one another, and advancing age increases the prevalence of comorbidities and conditions that can impair bone quality and healing, while increasing the risk of falls and fractures. Keeping in mind some principles and key points can help identify patients at risk, thus following an ideal path for the identification, treatment and prevention of fragility fractures.

Fracture healing in elderly patients: new challenges for antiosteoporotic drugs.

Osteoporosis is a major public health concern, characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fracture. Fracture repair progresses through different pathways, striking a balance between bone formation and bone remodeling mechanisms. Conventionally, fracture repair is divided into defined stages, each characterized by a specific set of cellular and molecular events. In postmenopausal women and elderly patients, bone healing rates are conditioned by cellular and molecular alterations to bone tissue that result in a progressive deterioration of fracture healing ability. In addition, in elderly patients, comorbidities and drugs therapies may also affect fracture healing. For this reason, pharmacological research is now focused on the possible use of antiosteoporotic drugs to promote bone healing in frail patients.

Bone healing and osteoporosis.

A correct fracture healing depends on the synergy between biomechanical, molecular and cellular factors. Focusing on different stages, fracture hematoma represents the starting point of the inflammatory process, with a critical role in triggering the process of fracture healing. The essential factors for bone repair are the activation of mesenchymal stem cells and the release of growth and regulatory factors. Moreover, the efficacy of fracture healing is determined by three ideal conditions: adequate blood supply, good contact between bone fragments and good stability. It is remarkable how the implant choice influences fracture healing after surgical treatment. In osteoporosis, bone quality adversely affects the tissue structural competence, increasing the risk of a complicated fracture healing. The qualitative and quantitative alterations established at the cellular level during osteoporosis explain the progressive deterioration of bone tissue healing ability.

The incidence of hip, forearm, humeral, ankle, and vertebral fragility fractures in Italy: results from a 3-year multicenter study.

INTRODUCTION: We aimed to assess the incidence and hospitalization rate of hip and "minor" fragility fractures in the Italian population. METHODS: We carried out a 3-year survey at 10 major Italian emergency departments to evaluate the hospitalization rate of hip, forearm, humeral, ankle, and vertebral fragility fractures in people 45 years or older between 2004 and 2006, both men and women. These data were compared with those recorded in the national hospitalizations database (SDO) to assess the overall incidence of fragility fractures occurring at hip and other sites, including also those events not resulting in hospital admissions. RESULTS: We observed 29,017 fractures across 3 years, with hospitalization rates of 93.0% for hip fractures, 36.3% for humeral fractures, 31.3% for ankle fractures, 22.6% for forearm/wrist fractures, and 27.6% for clinical vertebral fractures. According to the analyses performed with the Italian hospitalization database in year 2006, we estimated an annual incidence of 87,000 hip, 48,000 humeral, 36,000 ankle, 85,000 wrist, and 155,000 vertebral fragility fractures in people aged 45 years or older (thus resulting in almost 410,000 new fractures per year). Clinical vertebral fractures were recorded in 47,000 events per year. CONCLUSIONS: The burden of fragility fractures in the Italian population is very high and calls for effective preventive strategies.

Pharmacological agents and bone healing.

Osteoporosis is the most common alteration of bone metabolism. It derives from an increase in bone resorption with respect to bone formation and is characterized by microarchitectural alterations, decreased bone mass and increased risk of fracture. The coupling between bone formation and resorption is a fundamental concept in skeletal metabolism, and it explains how a certain amount of removed tissue can be replaced by the same amount of new bone. Various substances used to treat osteoporosis may also be used for orthopaedic conditions such as fracture healing, implant fixation, bone grafts and osteonecrosis. Fracture healing consists in the replacement of the lost bone by a tissue that has the same biomechanical properties as those preceding the fracture. The repair process is triggered by the local response to the tissue injury that damaged the continuity of bone. The duration of each phase of the healing process can vary significantly, depending on the site and characteristics of the fracture, on patient related factors and on the treatment choice. While most of the fractures heal with conventional treatment, they can also cause permanent damage and complications, especially in a certain kind of patients. Osteoporosis and old age may contribute in delaying or impairing the reparative process. In animal models the healing process is slower in older and/or ovariectomized animals. Biomechanical tests have also shown that bone strength is compromised in human osteoporotic cadaver bone. The same problems were highlighted in the surgical treatment of fractures in osteoporotic patients. Mainly in the treatment of hip fractures there is an increased risk of cut-out, re-fractures and implant failure in patients with osteoporosis. Preclinical studies have shown that certain pharmacological agents (bisphosphonates, strontium ranelate, teriparatide) may enhance osseointegration and stimulate reparative processes. They may be administered systemically and/or used locally at the fracture site on the implant surface. The aim of fracture treatment is to restore bone biomechanical properties and to allow restoring normal function at the affected site. If the new pharmacological approaches could be translated into clinical benefit and offered to patients with osteoporosis or other factors that put at risk the process of healing (subjects with severe loss of substance or fractures at high risk of complications), they could represent a valuable aid in the treatment of fractures.