Isokinetic strength test and functional outcomes in proximal humeral fractures treated with a locking plate.

BACKGROUND: Despite the use of many shoulder outcome scales in subjects with rotator cuff pathology or instability symptoms, it can be problematic to select an instrumental evaluation in the shoulder trauma population. In this study we evaluated patients with proximal humeral fractures treated with internal fixation with a locking plate, analyzing the recovery of strength with an isokinetic test and its correlation with clinical and functional outcomes. METHODS: We enrolled 46 individuals (17 men, 29 women). The evaluation included a structured interview, measurement of ROM, isokinetic strength test and Constant-Murley and QuickDASH scores. The isokinetic test was performed in flexion/extension and external/internal rotation of the operated shoulder in comparison with the contralateral side and concentric contractions in all movements. The parameter tested was peak torque. RESULTS: In the operated shoulder values we noticed a statistically significant correlation between the QuickDASH and Constant-Murley score. QuickDASH showed a significant correlation with flexion isokinetic strength, partial correlation with extension isokinetic values and no correlation with external/internal rotation values. In addition, we found a correlation between the Constant-Murley score and all the isokinetic strength parameters. Comparing the operated shoulder and the contralateral, in Neer type 2 fractures there was no significant difference in all the isokinetic peak torque values; in Neer type 3 and type 4, there was a significant statistical difference in both flexion peak torque values and no significant difference in the other movements. CONCLUSIONS: The isokinetic test can give objective data on strength recovery and could help the surgeon's clinical evaluation to assess the functional recovery of the operated shoulder over time. We believe that the isokinetic test and Constant-Murley score could act as a reference in the evaluation of post-surgical outcome of proximal humeral fractures. Furthermore, the type of fracture could be a post-surgical limb recovery predictor and the shoulder flexion force could be the best functionality recovery indicator.

Humeral shaft fractures treated with antegrade intramedullary nailing: what are the consequences for the rotator cuff?

PURPOSE: The purpose of this study was to investigate the clinical and sonographic impact on the rotator cuff (RC) of the use of the anterolateral approach for nailing. METHODS: A retrospective cohort of 48 patients treated for humeral diaphyseal fractures at the University Hospital of Parma between 2007 and 2011 was analysed. Inclusion criteria were (1) acute humeral shaft fractures treated with T2-proximal humeral nail (PHN) and (2) a minimum follow-up of one year. Exclusion criteria were (1) history of proximal and metaphyseal humeral fractures, (2) pathological fractures or open fractures of the humerus, and (3) RC lesions. Clinical assessment using the Constant score, simple shoulder test and through shoulder examination tests was carried out. The sonographic study investigated the integrity of the RC. RESULTS: Mean score on Constant's scale was 78.21 points, with most patients achieving a good result (79% obtained more than 65 points). One patient had a limited functional outcome (Constant's score of 49 points). The sonographic findings described for supraspinatus tendon were a partial ruptures of less than 30 mm in three patients and a complete tendon rupture in one case. CONCLUSIONS: The results of this study suggest that the use of the anterolateral approach for antegrade humeral nailing ensures a good functional result with no significant clinical-sonographic impact on the rotator cuff and a satisfactory long term clinical outcome.

Are percutaneous pinning the best treatment for gartland type iii supracondylar humeral fractures in children?

Background. Supracondylar humeral fractures are the most frequent fractures of the elbow in children. Gartland type III fractures require a surgical treatment. The preferred management is closed reduction and percutaneous pinning with K-wires. Methods. We have treated 15 patients (mean age 6,5 years) with Gartland type III fractures. In 14 patients the percutaneous reduction with K-wires was possible but in 1 case the open reduction was necessary due to the irreducibility of the fracture. In all cases a cycle of rehabilitation was performed. Results. All patients have been evaluated using Flynn's criteria with a mean follow-up of 24 months. All cases resulted excellent except the one that required open reduction, that resulted good. Conclusions. Percutaneous pinning is at our days the gold standard of treatment but open reduction must always be considered mandatory when an anatomical closed reduction is not possible. Rehabilitation is also fundamental though the young age of the patients.

Over the top or endobutton for ACL reconstruction?

There are an estimated 80-100,000 ACL repairs in the US each year: most ACL tears occurs from noncontact injuries. The 3.9% of the knee ligament injuries undergoes surgery: in the 80% of these patients, this means ACL reconstruction. The purpose of this study is to compare two surgical techniques normally used for acl recustruction; the first one is the intra- extra articular technique with single bundle fixed with staples and the second one is the intra-articular technique with double bundle and endobutton post-fixation. We evaluate the clinical outcome of our patients at the time of 4 years follow up. From January 2006 to April 2009 40 patients underwent to ACL reconstruction, all operated by using hamstring tendons: 20 patients with an average age of 28,75 years (12 men and 8 women) underwent surgery using the intra-extra articular technique, whereas the remaining 20 patients with an average age of 34,5 years (11 men and 9 women) benefited the intra-articular technique with double bundle ligament and endobutton post-fixation. Our study shows no substancial difference between these'two technique, but clinical outcome measures (I.K.D.C., Lysholm and Tegner) estimated better results for the double bundle technique with Endobutton post-fixation. (www.actabiomedica.it).

Surgical treatment of displaced acetabular fractures: report of 13 clinical cases.

BACKGROUND AND AIM OF THE WORK: Displaced acetabular fractures are complex lesions which may cause severe consequences if not appropriately treated. The results are linked to the quality of the articular reduction. Anatomical reduction, through surgical treatment with rigid internal fixation, should be considered to obtain an early mobilization, reduce long term osteoarthritis evolution and make the acetabular cavity suitable to eventually recive a total hip prosthesis. The aim of this study is to evaluate functional and radiographic outcome of patients with displaced acetabular fractures surgically treated. METHODS: Between 2005 and 2011, 29 displaced acetabular fracures were treated with open reduction and internal fixation. This study highlight our results in 13 patients with a mean follow-up of 29,5 months (range 5,5-66,3). Clinical evaluation was done according to the Harris hip score, while the radiological criteria were those of Kellgren-Lawrence. The associated injuries and complications were evaluated. RESULTS: At the latest follow-up the radiological results, based on the Kellgren-Lawrence grading scale, showed 3 patients with a I grade of osteoarthritis, 5 with a II grade, 3 with a III grade and 2 with a IV grade. The average Harris hip score was 77 (range 37-100). Postoperative complications included avascular necrosis of the femoral head in 3 patients and heterotopic ossification in 2 patients. CONCLUSIONS: This study confirm that open reduction and internal fixation in displaced acetabular fractures represents the best treatment able to lead to a satisfactory functional outcome. Moreover, it posticipates long-term arthrosis and eventually makes easier the implant of total hip prosthesis. (www.actabiomedica.it).

Prevalence of shoulder discomfort in paraplegic subjects.

INTRODUCTION: The annual incidence of acute spinal cord injury, as reported in the National Spinal Cord Injury Statistical Center, was estimated to be approximately 40 cases per million, or approximately 11.000 new cases in the United States each year (1). In subjects with spinal cord injury, overstress of the upper extremities occurs not only during daily life activities, but also utilizing wheelchair. The aim of this study is to determine the prevalence of shoulder discomfort in subjects affected by paraplegia living in our country area and evaluate the associated risk factors negatively affecting the shoulder function. MATERIAL AND METHOD: A computerized database search for paraplegic patients was performed at the Department of Orthopedic Surgery, Trauma Surgery and Rehabilitation Medicine. Among the 54 selected paraplegic patients, 47 accepted to participate at the study. Once the patients were contacted, the medical records were reviewed to obtain information regarding shoulder, elbow and spine region pain and discomfort. RESULTS: The 60% of all the patients who answered to the questionnaire complain shoulder pain, 90% bilaterally, and the 30% referred elbow pain, 20% bilaterally. 77% complains back pain, involving particularly lumbar region. Only 2% of this population undergoes a shoulder surgery treatment for cuff tear and shoulder disability. DISCUSSION AND CONCLUSION: The present study is the first in our country that gives an overview of prevalence of upper limb discomfort in paraplegic patients. We have shown the interplay between shoulder elbow and spine with pain, age of patients and type of wheel chair utilized. The previous factors can be corrected and upper limb discomfort relieved.

Combined arthroscopic and radioscopic management of tibial plateau fractures: report of 18 clinical cases.

Tibial plateau fractures are complex lesions capable of causing severe consequences if not appropriately treated. They are often the result of a high-energy trauma and, not rarely, are associated with significant soft-tissue and intra-articular injuries. Different therapeutic options can be managed in the treatment of these lesions. Minimally invasive surgery offers several advantages compared to other surgical techniques and allows, with less additional soft tissue damages, good reduction and stable fixation of the fracture. In this study we assessed the results of the combined arthroscopic and radioscopic assisted reduction and internal fixation of tibial plateau fractures in 18 patients affected by Schatzker type I, II, III, IV fractures. According to Hohl's and Rasmussen's grading system, 16 out of 18 patients scored a satisfactory result. We experienced no complications due to arthroscopy.

Arthroscopic absorbable suture fixation for tibial spine fractures.

The purpose of this technical note and accompanying video is to describe a modified arthroscopic suture fixation technique to treat tibial spine avulsion fractures. Twenty-one patients underwent arthroscopic treatment for tibial spine avulsion with our technique; they were clinically and biomechanically evaluated at 2 years' follow-up and showed optimal clinical and radiographic outcomes. Repair with this arthroscopic technique provides a significant advantage in the treatment of type III and IV fractures of the tibial eminence by obtaining arthroscopic fixation within the substance of the anterior cruciate ligament: suture methods based on the avulsed bone fragment are technically impossible, but sutures through the base of the ligament itself provide secure fixation, reducing the risks of comminution of the fracture fragment and eliminating the time for hardware removal. This arthroscopic technique restores the length and the integrity of the anterior cruciate ligament and provides a simplified, reproducible method of treating patients, including young patients, with low hardware costs in comparison to sutures using anchors or other hardware.

Quadriceps tendon tear rupture in healthy patients treated with patellar drilling holes: clinical and ultrasonographic analysis after 36 months of follow-up.

BACKGROUND: quadriceps tendon subcutaneous rupture is an uncommon injury affecting predominantly middle-aged men as a result of direct or indirect trauma; aim of this work is to evaluate clinical outcome and tendon morphology in patients treated surgically with transpatellar drilling suture. METHODS: 20 patients (20 male) with an average age of 54 (42-59) were evaluated with a mean follow-up of 36 months. Measurements of range of motion (ROM) and of tight circumference were collected. Lysholm and Rougraff Score were also performed. All the patients underwent a US evaluation the morphologic changes of the repaired tendon. RESULTS: mean active ROM was 1°-117°; average difference in the circumference of the quadriceps was 2.6% 10 C and 3.3% 15 C. The mean Lysholm Score calculated was 88/100; the mean Rougraff Score 17/25. At ultrasonographic evaluation all tendons were continuous; heterotopic ossification was present in 18 quadriceps tendons. Thickness was augmented in 18 quadriceps tendons and in 5 patellar tendons. Vascularization was always conserved. Lateral subluxation of patella was reported in 1 case. CONCLUSIONS: patellar drilling holes repair is a non-demanding procedure, inexpensive and technically uncomplicated. US evaluation confirms tendon healing; tendon remodeling does not affect patient's clinical outcome and quality of life. LEVEL OF INCIDENCE: IV.

Isolated fractures of the greater tuberosity in proximal humerus: does the direction of displacement influence functional outcome? An analysis of displacement in greater tuberosity fractures.

BACKGROUND AND AIM OF THE WORK: The treatment of isolated fractures of the greater tuberosity of the proximal humerus is still debated, especially in the case of minimally dispaced fractures. Differently from other proximal humerus fractures this kind of injury frequently affects young patients with high functional request. The aim of this study is to assess the outcome of patients treated conservatively for greater tubero-sity isolated fractures, comparing the clinical results in patients with different direction of fracture displacement. METHODS: 38 patients with isolated fracture of greater tuberosity participated to the study and were evaluated at 17 months (10-26) of follow up using Constant Murley Score and DASH Score. Patients were divided in groups with different direction of displacement (10 no displacement, 13 postero-superior, 6 antero-superior and 9 antero-inferior displacement). RESULTS: Patients with no displaced fractures had a mean Constant Murley Score of 82 and a mean DASH Score of 15; those with postero-superior displacement had a mean a Constant Murley Score of 61 and a mean DASH Score of 43; for antero-superior displacement the mean Constant Murley Score was 76 and the mean DASH Score of 18; for the antero-inferiorly displaced the mean Constant Murley Score was 83 and the DASH Score 16. CONCLUSION: Data suggest that postero-superior displacement leads to poorer outcomes than undisplaced or displaced in other directions fractures treated conservatively.

Use of platelet-rich plasma in the care of sports injuries: our experience with ultrasound-guided injection.

BACKGROUND: Platelet-rich plasma is being used more frequently to promote healing of muscle injuries. The growth factors contained in platelet-rich plasma accelerate physiological healing processes and the use of these factors is simple and minimally invasive. The aim of this study was to demonstrate the efficacy of ultrasound-guided injection of platelet-rich plasma in muscle strains and the absence of side effects. MATERIALS AND METHODS: Fifty-three recreational athletes were enrolled in the study. The patients were recruited from the Emergency Room in the University Hospital at Parma according to a pre-defined protocol. Every patient was assessed by ultrasound imaging to evaluate the extent and degree of muscle injuries. Only grade II lesions were treated with three ultrasound-guided injections of autologous platelet-rich plasma every 7 days. Platelet concentrate was produced according to standard methods, with a 10% variability in platelet count. The platelet gel for clinical use was obtained by adding thrombin to the concentrates under standardised conditions. Outcomes assessed were: pain reduction, muscle function recovery and return to sports activity, ultrasound-imaging tissue healing, relapses, local infections, and any side effect during the treatment. RESULTS: In all cases muscle lesions healed fully on ultrasound-imaging, the pain disappeared, and muscle function recovery was documented with a return to sports activity. A single patient had a relapse 1 year after treatment. DISCUSSION: Platelet-rich plasma injected into the injury site is one of the most important factors rendering the treatment effective. To maximise its efficacy the preliminary ultrasound must be done accurately to localise the lesion and guide the needle into the corresponding lesion. According to the current results, which document full muscle recovery and no relapse except for one case, platelet-rich plasma ultrasound-guided injection represents a valid mini-invasive treatment for muscle injuries.

Arthroscopic treatment for cuff tear: strength recovery at 12 months of follow-up.

The rotator cuff tear is one of the most frequent musculoskeletal disorders, but the real incidence is not clearly known because it's usually asymptomatic, even if it's more common in patients with shoulder pain (36%). The prevalence of the complete tear among general population is estimated approximately around 20.7% and it is more usual with the increasing of the age. The aim of this study is to evaluate a group of patients with any size of full-thickness cuff tear treated by arthroscopic technique, comparing the clinical and functional recovery (isokinetic, isotonic and isometric strength) with the un-operated side. Between October 2009 and June 2011, 74 patients, mean age 59 (20-72) years old, underwent arthroscopic treatment for rotator cuff tear. Forty-two patients were finally included in the study, 20 men and 22 women, mean age of 55 (20-68) years old. The mean follow-up was 12 months (6-23 months). The strength of each patient's shoulder, both operated and un-operated, was evaluated using isokinetic, isotonic and isometric tests (BIODEX Medical System). The functional outcome showed no significant differences between operated and un-operated shoulder, confirmed by Constant-Murley score and DASH score. The isokinetic, isotonic and isometric tests are valid support to clinical evaluation in order to obtain an objective data on shoulder recovery.

Salter-Harris type II proximal humerus injuries: state-of-the-art treatment.

Proximal epiphyseal injuries of the humerus represent a very low percentage of traumatic growth pathologies, 5 % of all fractures during childhood. In the literature, there have been only a limited number of clinical studies investigating these injuries, basically from an epidemiological point of view, focusing on the incidence of the different types of fractures. We report our experience of 6 young patients with Salter-Harris type II proximal humerus epiphyseal injuries adopting a minimally invasive surgical technique consisting of closed reduction and percutaneous fixation with Kirschner wires. At 2 years of follow-up, the results consisting in constant; disabilities of the arm, shoulder, and hand; simple shoulder test; and Visual Analogue Scale scores obtained have been excellent and all the patients come back to a normal life with sports practice and normal daily activities. The range of motion was completely restored without any deficit in abduction-adduction, flection-extension, or intra-extra rotation. No differences in anthropometric parameters were found with no case of malangulation, vascular, or neurological complications. Our data support with evidence how the close reduction internal fixation with K-wires treatment can give to the surgeons and the patients a better security about the correct fracture healing. Furthermore, with this article, we will provide a detailed review of the literature in order to define the state-of-the-art treatment to better face such a challenging skeletal injury.