Clinical outcomes and complications of S53P4 bioactive glass in chronic osteomyelitis and septic non-unions: a retrospective single-center study.

INTRODUCTION: Dead space management following debridement surgery in chronic osteomyelitis or septic non-unions is one of the most crucial and discussed steps for the success of the surgical treatment of these conditions. In this retrospective clinical study, we described the efficacy and safety profile of surgical debridement and local application of S53P4 bioactive glass (S53P4 BAG) in the treatment of bone infections. METHODS: A consecutive single-center series of 38 patients with chronic osteomyelitis (24) and septic non-unions (14), treated with bioactive glass S53P4 as dead space management following surgical debridement between May 2015 and November 2020, were identified and evaluated retrospectively. RESULTS: Infection eradication was reached in 22 out of 24 patients (91.7%) with chronic osteomyelitis. Eleven out of 14 patients (78.6%) with septic non-union achieved both fracture healing and infection healing in 9.1 ± 4.9 months. Three patients (7.9%) developed prolonged serous discharge with wound dehiscence but healed within 2 months with no further surgical intervention. Average patient follow-up time was 19.8 months ± 7.6 months. CONCLUSION: S53P4 bioactive glass is an effective and safe therapeutic option in the treatment of chronic osteomyelitis and septic non-unions because of its unique antibacterial properties, but also for its ability to generate a growth response in the remaining healthy bone at the bone-glass interface.

Comparison of isometric strength in rotator cuff and scapulothoracic muscles between elite volleyball athletes versus non-athletes.

BACKGROUND: Volleyball is an exceptionally popular global sport that involves repetitive, rapid, powerful and wide overhead movements, which can seriously alter normal shoulder kinematics. A recognized hallmark of shoulder muscle balance is the ratio of shoulder external (ER) and internal (IR) rotators. By extension, objective measurement of shoulder muscles' strength could help identify at risk athletes and preempt those injuries by engaging in prescriptive strength training programs. METHODS: This cross-sectional study measured the isometric strengths of 1) shoulder internal and external rotator muscles, as well as the 2) supraspinatus, 3) rhomboid, and 4) middle and inferior trapezius muscles, in addition to calculation of ER:IR ratios, in professional volleyball players as well as in non-athletes. Measurements were made for dominant- and non-dominant upper limbs, in different position of the body (supine and orthostatic) and in different position of upper limb (adducted and abducted position). Our subject population included 11 male professional volleyball players as well as 14 healthy male orthopedic interns from Orthopedics and Trauma school of University of Milano Bicocca. Strengths were assessed by a handheld dynamometer. Each subject's isometric strength was assessed in triplicate in each limb position through a "make test" procedure; the greatest of each triplicate value was the accepted measure of isometric strength. RESULTS: We observed a gradient in muscle strength in the scapulothoracic complex in both groups; the rhomboid, middle trapezius, and lower trapezius ranked from greatest to least strength, respectively. The data suggest also that intrarotators are stronger in rotation adducted position than in rotation abducted position; however, extrarotators seem to be weaker in rotation adducted position than in rotation abducted position. There is also some indication that force development is enhanced in the supine position compared with the orthostatic position. CONCLUSIONS: Our findings indicate a scapulothoracic strength gradient with a rank order of strength of the rhomboid>middle trapezius>lower trapezius. The data further suggest that volleyball players have stronger intrarotation in rotation adducted position than in the rotation abducted position, while extra rotation shows the opposite trend. Finally, our data suggest that force development is greater in the supine position compared to the orthostatic position.

Prokineticin 2 and Cytokine Content in the Synovial Fluid of Knee Osteoarthritis and Traumatic Meniscal Tear Patients: Preliminary Results.

Knee osteoarthritis (OA) is a chronic degenerative inflammatory-based condition caused by a cascade of different intra-articular molecules including several cytokines. Among the cytokines, prokineticins (PKs) have recently been identified as important mediators of inflammation and pain. This observational study examined the potential involvement of PK2 in degenerative or traumatic knee disease. Fifteen patients presenting knee osteoarthritis (OA group) and 15 patients presenting a traumatic meniscal tear (TM group) were studied. Synovial fluid samples from affected knees were assessed for PK2, IL-10, and TNF-α using the ELISA method. At a long-term follow-up (minimum 5 years, mean = 6.1 years), patients in the TM group underwent clinical re-evaluation with PROMs (Tegner Activity Scale, IKDC, Lysholm, SKV); in addition, X-ray visualization was used to assess the presence of secondary OA. PK2 was detected in synovial fluids of both TM and OA patients and the levels were comparable between the two groups, while IL-10 levels were significantly greater in the OA group than those in TM patients. PK2 levels correlated with those of IL-10. PK2 levels were greater in blood effusions compared to clear samples, did not differ significantly between sexes, nor were they related to differences in weight, height, or injury (meniscal laterality, time since dosing). No correlation was found between PROMs and radiological classifications in patients in the TM group at final follow-up. These data are the first observations of PK2 in synovial fluid following traumatic meniscus injury. These findings suggest possible further prognostic indices and therapeutic targets to limit the development of secondary OA.

Long-term Outcomes of Tibial Spine Avulsion Fractures After Open Reduction With Osteosuturing Versus Arthroscopic Screw Fixation: A Multicenter Comparative Study.

Background: More information is needed regarding return to preinjury sport levels and patient-reported outcomes after tibial spine avulsion (TSA) fracture, which is most common in children aged 8 to 12 years. Purpose: To analyze return to play/sport (RTP), subjective knee-specific recovery, and quality of life in patients after TSA fracture treated with open reduction with osteosuturing versus arthroscopic reduction with internal screw fixation. Study Design: Cohort study; Level of evidence, 3. Methods: This study included 61 patients <16 years old with TSA fracture treated via open reduction with osteosuturing (n = 32) or arthroscopic reduction with screw fixation (n = 29) at 4 institutions between 2000 and 2018; all patients had at least 24 months of follow-up (mean ± SD, 87.0 ± 47.1 months; range, 24-189 months). The patients completed questionnaires regarding ability to return to preinjury-level sports, subjective knee-specific recovery, and health-related quality of life, and results were compared between treatment groups. Univariate and multivariate logistic regression analyses were conducted to determine variables associated with failure to return to preinjury level of sport. Results: The mean patient age was 11 years, with a slight male predominance (57%). Open reduction with osteosuturing was associated with a quicker RTP time than arthroscopy with screw implantation (median, 8.0 vs 21.0 weeks; P < .001). Open reduction with osteosuturing was also associated with a lower risk of failure to RTP at preinjury level (adjusted odds ratio, 6.4; 95% CI, 1.1-36.0; P = .035). Postoperative displacement >3 mm increased the risk of failure to RTP at preinjury level regardless of treatment group (adjusted odds ratio, 15.2; 95% CI, 1.2-194.9; P = .037). There was no difference in knee-specific recovery or quality of life between the treatment groups. Conclusion: Open surgery with osteosuturing was a more viable option for treating TSA fractures because it resulted in a quicker RTP time and a lower rate of failure to RTP as compared with arthroscopic screw fixation. Precise reduction contributed to improved RTP.

Meniscal Allograft Transplants in Skeletally Immature Patients: A Systematic Review of Indications and Outcomes.

Meniscal lesions in skeletally immature patients can lead to joint degradation and knee instability. Meniscal allograft transplant (MAT) surgery is a solution to maintain knee stability. There is a lack of consensus on MAT surgery outcomes in pediatric patients. A systematic review was conducted according to the PRISMA guidelines. PubMed, Scopus and EMBASE databases were searched from 1965 to June 2022. Studies were evaluated using the Newcastle-Ottawa Scale (NOS). Three studies were selected, and 58 patients were included (mean age 15.9 years) in total. The lateral meniscus was involved in 82.8% of all MAT surgeries. Post-meniscectomy syndrome and discoid meniscus were the main indications for MAT surgery. All studies reported improved subjective clinical scores and levels of sport after the surgery. The complication rate was 27.5%. Partial meniscectomy, meniscus knot removal, chondral defect treatment and lysis of adhesions were the most frequent procedures performed during reoperation. MAT surgery can improve clinical outcomes in pediatric patients with strictly selected indications. MAT surgery is safe when there are no limb asymmetries or malalignments, but it remains a challenging procedure with a high complication rate. Long-term follow-up is needed for definitive statements on the use of MAT in skeletally immature patients.

Comparison of all-suture anchors with metallic anchors in arthroscopic cuff repair: Structural and functional properties and clinical suitability.

Purpose: This study examined and compared all-suture anchors with metallic anchors in the arthroscopic repair of small to medium supraspinatus tears; a multi-dimensional evaluation protocol assessed (i) clinical, (ii) ultrasonographical, and (iii) functional criteria at mid-term. Materials and methods: A sample of 40 patients, prescreened from a larger group who had undergone arthroscopic rotator cuff repair, were resolved into two groups of 20, based on the type of anchor used in their surgery (all-suture or metallic) and were evaluated postoperatively (mean = 44.3 months, SEM = 22.4 months, minimum period = 10.3 months). Clinical assessments included (i) objective and subjective scores (Constant, DASH, SPADI, SST), (ii) ultrasonographical examination, as well as (iii) isometric and isokinetic strength testing. Raw data from the operated side was compared with those from the contralateral side within each group. Raw data for the PROMs and for the US evaluation were compared between groups. Strength data, as well as the Constant score values, were further analyzed based on (i) the difference between operated and intact sides, as well as (ii) the strength ratio between operated and intact sides; the transformed data were then compared between the two groups. Results: We found no statistically significant differences in any of the parameters considered between shoulders operated using ASAs or MAs, nor between operated and non-operated sides in each group. Conclusion: Our findings indicate that the reliability and performance characteristics of all-suture anchors and metallic anchors are practically indistinguishable for arthroscopic treatment of small to medium lesions of the supraspinatus tendon.

Osteochondritis dissecans of the knee: Epidemiology, etiology, and natural history.

Osteochondritis dissecans of the knee is a disease that typically affects skeletally immature patients. Clinically manifested with knee pain, limping, and joint disfunction, this condition has remained misunderstood and undervalued for a long period. Although being a rare condition, its awareness is of utmost clinical interest because of the possible severe consequences it can bring when misrecognized or inadequately treated. Its etiology remains unclear and is still debated. Many theories have been proposed, including inflammation, local ischemia, subchondral ossification abnormalities, genetic factors, and repetitive mechanical microtrauma, with a likely interplay of the same. This review article aims to deliver and discuss current and up-to-date concepts on epidemiology, etiology, and natural history of this pediatric condition. Level of evidence: level V.

Surgical techniques in the management of pediatric anterior cruciate ligament tears: Current concepts.

Background: Anterior cruciate ligament injury in the child and adolescent patient remains a controversial topic when considering management, especially regarding surgical choices. Treatment variations are seen not just when comparing different countries but also within nations. This arises partly as contemporary treatment is mostly inferred from the adult population who physiologically and in terms of outcomes differ significantly from children. There is an increasing body of evidence for this cohort of patients who have specific challenges and difficulties when determining the optimum treatment. Methods: Within this article, we will summarize the current evidence for surgical management of anterior cruciate ligament injury for the pediatric patient. Results and Conclusions: There remain many controversies and gaps inthe treatment of Paediatric Anterior cruciate ligament reconstruction and this high risk cohort continues to cause difficulty in identifying the best mode of surgical management. Level of evidence: level IV.

FIFA 11+ Kids: Challenges in implementing a prevention program.

Purpose: Soccer is a popular sport among children and adolescents that exposes to a high risk of injury. Several prevention programs, including the FIFA 11+ Kids program have been developed to decrease this injury rate. The aim of the study was to investigate the knowledge and use of the FIFA 11+ Kids program among soccer coaches of skeletally immature soccer players in a Swiss canton and analyze difficulties of implementing such a prevention program. Materials & methods: First, an online survey was sent to all soccer coaches involved in Swiss training programs for male players from 7 to 13 years of age. Coaches were identified through existing Swiss coaching networks. A total of 237 coaches completed the survey. Second, the FIFA 11+ Kids program was implemented in three soccer teams (players from 7 to 13 years of age) during 6 months in the same canton. Utilization of FIFA 11+ Kids program and compliance of coaches were recorded by the research staff. Results: Around 84% of the included coaches in the survey were certified. Of those, 59% had been taught injury prevention during their course(s). Only 14% of the included coaches knew one of the FIFA programs (11, 11+, 11+ Kids), of those, about one-third (10 out of 237) used the FIFA 11+ Kids program. After 6 months, none of the soccer coaches applied the entire FIFA 11+ Kids program twice a week. One coach had completely abandoned the program. The main reasons for their disapproval were the time and surveillance needed and the players' lack of motivation. They stated, however, that the exercises were good if used occasionally. Conclusion: Injury prevention should be integrated in every soccer coach education courses. An adaptation of the FIFA 11+ Kids program should be considered, especially for the youngest players.

Osteochondritis dissecans of the knee: Imaging, instability concept, and criteria.

Osteochondritis dissecans of the knee is an idiopathic, focal, subchondral-bone abnormality that can cause instability or detachment of a bone fragment and overlying articular cartilage, with subsequent progression to osteoarthritis. The degree of lesion instability is best assessed by magnetic resonance imaging. Unstable lesions require operative management with fragment fixation. Level of evidence: V.

Non-Union Scoring System (NUSS): Is It Enough in Clinical Practice?

Introduction: Bone consolidation defects represent a real orthopedic challenge because of the absence of validated treatment guidelines that can assist the surgeon in his choices. The aim of this study is to evaluate the appropriateness of the Non-Union Scoring System NUSS treatment protocol in the management of long bone non-unions by comparing it to the experience-based therapeutic approach carried out in our facility. Materials and Methods: We conducted a comparative outcome study of a retrospective series of 89 patients surgically treated for long bone non-union in our facility vs. clinical results reported by Calori et al. obtained following the NUSS treatment protocol. Results: Radiographic healing was reached in 13/13 non-unions (100%) in group NUSS 1, in 58/62 (93.5%) in group NUSS 2, and in 13/14 (92.9%) in group NUSS 3. The mean time to radiographic healing was 5.69 ± 2.09 months in group 1, 7.38 ± 3.81 months in group 2 and 9.23 ± 2.31 months in group 3. 91% of patients in group I, 69% in group II and 48% in group III received what would be considered by the NUSS treatment protocol an "overtreatment", especially from a biological stand point. The comparative outcome analysis shows that our case series achieved significantly higher global healing rates (p value = 0.017) and shorter radiological healing times in groups NUSS 1 and 2 (p value < 0.001). Conclusion: From the results obtained, we can assume that the NUSS treatment protocol might underestimate the necessary therapies, particularly from a biological point of view.

Isolated MPFL reconstruction with soft tissue femoral fixation technique in 54 skeletally immature patients: Clinical outcomes at 2 years follow-up. A French multicenter retrospective study.

BACKGROUND: Medial patello-femoral ligament (MPFL) reconstruction is one of the therapeutic options to treat patellofemoral instability. Classically, a à la carte treatment of skeletal and ligament abnormalities is described. This option is difficult to achieve in children because bony procedures can damage the femoral and/or tibial growth plate. The objective was to evaluate a strategy for isolated reconstruction of the MPFL in the treatment of objective patellar instabilities in children, in a large cohort. The return to sport, knee function and pain or discomfort were studied as secondary endpoints. METHODS: This French multicenter retrospective study included 54 pediatric patients with objective patellofemoral instability. Patients were included if they had presented at least 2 episodes of objective patella dislocation. A Deie-like technique with gracilis tendon graft, soft tissue femoral fixation and patellar bone tunnels for patellar fixation was used. Recurrence of dislocation was studied as the primary endpoint, and the recurrence rate was compared with the literature. A comparison of functional scores (Kujala, Lille femoro-patellar instability score or LFPI Score and Tegner activity score) and NRS between pre- and postoperative was studied as a secondary objective. RESULTS: A recurrence of femoro-patellar instability was observed for five patients within 2 years follow up (9%). A significant improvement of the Kujala, LFPI score, Tegner and NRS scores was observed (p<0.001). CONCLUSION: Isolated reconstruction of the MPFL presents a risk of recurrence of 9% at 2years follow-up. This technique significantly improves the functional scores of the knee. This modified Deie technique provides good clinical and functional results, allowing return to sports with an acceptable risk of recurrence of patellar dislocation, similar to those observed in the literature. Isolated MPFL reconstruction as a first-line treatment appears to be a reliable and effective technique in terms of recurrence of dislocation and functional scores. It allows early recovery and rehabilitation and has lower morbidity than procedures requiring bone gestures. LEVEL OF EVIDENCE: III, retrospective comparative study.

Clinical outcomes and complications after anterior cruciate ligament reconstruction with bone-patellar tendon-bone in patient Tanner 3 and 4: a systematic review.

BACKGROUND: Clinical outcomes and potential complications associated with Bone-Patellar Tendon-Bone (BPTB) graft in skeletally immature ACL reconstruction (ACLR) are poorly defined. Considering that in Tanner 1-2 patients this kind of graft is not recommended, we focused our systematic review on the evaluation of all the studies in the literature that reported clinical outcomes and rate of complications of the ACLR using BPTB graft in Tanner 3-4 patients. METHODS: This review was conducted in accordance with the PRISMA statement. PubMed, Cochrane Library, EMBASE and Scopus were examined from 1965 to 2020 using different combinations of the following keywords: "ACL reconstruction", "skeletally immature", "young", "patellar tendon" and "BPTB". The database search yielded 742 studies, on which we performed a primary evaluation. After carrying out a full-text evaluation for the inclusion criteria, 4 studies were included in the final review and assessed using the Newcastle-Ottawa scale. Ninety-six cases with mean age of 14.2 years were reported. RESULTS: Good stability and functional outcomes were reported with a mean follow-up of 49.5 months. Return to sport rate ranged from 91.7% to 100%. A KT-1000 side-to-side difference higher than 5 mm was observed in five patients (5.2%). No lower limb length discrepancy and angulation were reported. Graft rupture rate was 5.2%. CONCLUSION: According to these results, BTPB graft could be a good choice in Tanner 3-4 patients who want to achieve their preinjury sport level with a low risk of growth disturbances and graft failure. Further investigations in a wider population are needed.

Management of anterior cruciate ligament tears in Tanner stage 1 and 2 children: a narrative review and treatment algorithm guided by ACL tear location.

The incidence of anterior cruciate ligament (ACL) tears in skeletally immature patients has acutely increased over the last 20 years, yet there is no consensus on a single "best treatment." Selection of an optimal treatment is critical and based on individual circumstances; consequently, we propose a treatment-selection algorithm based on skeletal development, ACL tear location, type, and quality, as well as parental perspective in order to facilitate the decision-making process. We combined our surgical group's extensive case histories of ACL tear management in Tanner Stage 1 and 2 patients with those in the literature to form a consolidated data base. For each case the diagnostic phase, communication with patient and parents, treatment choice(s), selected surgical techniques and rehabilitation schedule were critically analyzed and compared for patient outcomes. MRI-imaging and intraoperative tissue quality assessment were preeminent in importance for selection of the optimal treatment strategy. Considerations for selecting an optimal treatment included: associated lesions, the child/patient and parent(s)' well-informed and counseled consent, biological potential, and the potential for successful ACL preservative surgery. Complete ACL tears were evaluated according to tear-location. In type I and II ACL tears with remaining good tissue quality, we propose primary ACL repair. In type III and IV ACL tears we propose physeal-sparing reconstruction with an iliotibial band graft. Finally, in the case of a type V ACL tear, we propose that the best treatment be based on the Meyers-McKeever classification. We present a facile decision-making algorithm for ACL management in pediatric patients based on specific elements of tissue damage and status.

Characterization of microRNA Levels in Synovial Fluid from Knee Osteoarthritis and Anterior Cruciate Ligament Tears.

This study investigated modifications of microRNA expression profiles in knee synovial fluid of patients with osteoarthritis (OA) and rupture of the anterior cruciate ligament (ACL). Twelve microRNAs (26a-5p, 27a-3p, let7a-5p, 140-5p, 146-5p, 155-5p, 16-5p,186-5p, 199a-3p, 210-3p, 205-5p, and 30b-5p) were measured by real-time quantitative polymerase chain reaction (RT-qPCR) in synovial fluids obtained from 30 patients with ACL tear and 18 patients with knee OA. These 12 miRNAs were chosen on the basis of their involvement in pathological processes of bone and cartilage. Our results show that miR-26a-5p, miR-186-5p, and miR-30b-5p were expressed in the majority of OA and ACL tear samples, whereas miR-199a-3p, miR-210-3p, and miR-205-5p were detectable only in a few samples. Interestingly, miR-140-5p was expressed in only one sample of thirty in the ACL tear group. miR-140-5p has been proposed to modulate two genes (BGN and COL5A1100) that are involved in ligamentous homeostasis; their altered expression could be linked with ACL rupture susceptibility. The expression of miR-30b-5p was higher in OA and chronic ACL groups compared to acute ACL samples. We provide evidence that specific miRNAs could be detected not only in synovial fluid of patients with OA, but also in post-traumatic ACL tears.

Acute Ankle Sprain Management: An Umbrella Review of Systematic Reviews.

Even though ankle sprains are among the most frequent musculoskeletal injuries seen in emergency departments, management of these injuries continues to lack standardization. Our objective was to carry out an umbrella review of systematic reviews to collect the most effective evidence-based treatments and to point out the state-of-the-art management for this injury. PubMed, Scopus, Web of Science, and the Cochrane library were searched from January 2000 to September 2020. After removing duplicates and applying the eligibility criteria, based on titles and abstracts, 32 studies were screened. At the end of the process, 24 articles were included in this umbrella review with a mean score of 7.7/11 on the AMSTAR quality assessment tool. We found evidence supporting the effectiveness of non-surgical treatment in managing acute ankle sprain; moreover, functional treatment seems to be preferable to immobilization. We also found evidence supporting the use of paracetamol or opioids as effective alternatives to non-steroidal anti-inflammatory drugs to reduce pain. Furthermore, we found evidence supporting the effectiveness of manipulative and supervised exercise therapy to prevent re-injury and restore ankle dorsiflexion.

Comparison of two arthroscopic repair techniques for small-medium supraspinatus tendon tear: 1 triple-loaded vs 2 double-loaded metallic sutures anchors.

Introduction: Surgical repair of the rotator cuff is based on the use of anchors whose ideal numbers and configurations continue to be controversial. We compared the clinical-functional results arising from the arthroscopic repair of shoulders, with small-medium lesions of the supraspinatus tendon, among patients using one anchor with three sutures, or two anchors with two sutures. Methods: In this retrospective study patient were resolved into 2 groups. Clinical and functional results were assessed based on Constant Score and instrumental isometric examination. Results: Patients in Group 1 experienced shoulder repair using a single anchor with three sutures (n = 21, mean age = 56 years, range = 51-65). In Group 2, patients received two anchors with two sutures each (n = 24, mean age = 59 years, range = 24-75). The mean follow-up time was 15 months. The mean values of the operated shoulders' Constant Score were 88.05 and 88.25 respectively. Examination of isometric test results in operated shoulders, healthy shoulders and the two different rotator cuff repair techniques did not reveal any statistically significant differences. Conclusion: In the arthroscopic repair of small-medium supraspinatus tendon tears, the short to mid-term clinical and functional outcomes arising from use of 1 triple-loaded or 2 double-loaded metallic sutures anchors are comparable.

Jump performance during a season in elite volleyball players.

BACKGROUND: The aim of this study was to measure and compare jump load and dynamic performance in elite volleyball athletes under varied conditions over an entire season of practices and games. Jump load and dynamic performance were compared among best jump height, mean jump height, as well as according to the number of jumps per game or practice session and the proportion of jumps higher than 50 cm relative to the total number of jumps in a practice or game. METHODS: Every jump performed by each of 12 players, in all practices and regular games (813 player-sessions in total), was measured by a particle accelerometer in accordance with a validated protocol (Vert, Fort Lauderdale, FL, USA). Data were collected and analyzed using STATA (SataCorp, College Station, TX, USA); the significance level for definition of confidence intervals was set to 95%, unless otherwise specified. Statistical analysis and comparison of means and proportions between groups was based on standard t-tests. RESULTS: Among player positions, the middle blocker consistently presented the greatest jump loads during the season; by comparison, the smallest jump loads were observed in the setter. CONCLUSIONS: Monitoring players' jump loads and performance using a simple accelerometer provides evidence which can be used to plan individual player activity, roster composition, the season calendar and furthermore increase knowledge to reduce over-training and recurrence of injuries.