Interobserver Reliability of Pirani and Dimeglio Scores in the Clinical Evaluation of Idiopathic Congenital Clubfoot.

BACKGROUND: Dimeglio (DimS) and Pirani (PirS) scores are the most common scores used in congenital talipes equinovarus (CTEV) clinical practice. The aim of this study was to evaluate the interobserver reliability of these scores and how clinical practice can influence the clinical outcome of clubfoot through the DimS and Pirs. METHODS: Fifty-four feet were assessed by six trained independent observers through the DimS and PirS: three consultants (OS), and three residents (RS) divided into three pediatric orthopaedic surgeons (PeO) and three non-pediatric orthopaedic surgeons (NPeO). RESULTS: The PirS and DimS Scores were strongly correlated. In the same way, OS and RS, PirS, and DimS scores were strongly correlated, and the interobserver reliability ranked "good" in the comparison between PeO and NPeO. In fully trained paediatric orthopaedic surgeons, an "excellent" interobserver reliability was found but was only "good" in the NPeO cohort. CONCLUSIONS: In conclusion, after careful preparation, at least six months of observation of children with CTEV, PirS and DimS proved to be valid in terms of clinical evaluation. However, more experience with CTEV leads to a better clinical evaluation.

Functional Outcome at Short and Middle Term of the Extracorporeal Shockwave Therapy Treatment in Lateral Epicondylitis: A Case-Series Study.

Lateral epicondylitis (LE) of the humerus is a chronic degeneration of wrist extensor tendons at their attachments to the lateral epicondyle of the humerus. There is not a common consensus on a specific therapeutic algorithm, but Extracorporeal Shockwave Therapy (ESWT) is widely used. The purpose of this study is to evaluate the clinical benefits of low dose ESWT in LE-affected patients in short and medium follow-up. Between January 2015 and December 2017, 60 patients (38 male, mean age 52.2 ± 10.1 years, the duration of the disease was 3.6 ± 1.3 months) were clinically evaluated using visual analog scale (VAS) and Patient Rated Tennis Elbow Evaluation Test (PRTEE-I) scores before treatment, at one, three, six and 12 months after treatment. According to the VAS and PRTEE-I scoring systems, all patients achieved an improvement of pain and functional outcome comparing the baseline results with one, six and 12 months values. Low dose ESWT is a safe and effective treatment of LE in the short and middle term. In elderly subjects, patients with a long disease history, or those with occupational and sportive risk factors, a longer persistence of the symptomatology could be observed.

Extracorporeal Shockwave Therapy Treatment in Upper Limb Diseases: A Systematic Review.

Background: Rotator cuff tendinopathy (RCT), subacromial impingement (SAIS), and medial (MEP) and lateral (LEP) epicondylitis are the most common causes of upper limb pain caused by microtrauma and degeneration. There are several therapeutic choices to manage these disorders: extracorporeal shockwave therapy (ESWT) has become a valuable option. METHODS: A systematic review of two electronic medical databases was performed by two independent authors, using the following inclusion criteria: RCT, SAIS, MEP, and LEP, ESWT therapy without surgical treatment, with symptoms duration more than 2 months, and at least 6 months of follow-up. Studies of any level of evidence, reporting clinical results, and dealing with ESWT therapy and RCT, SAIS, MEP, and LEP were included. RESULTS: A total of 822 articles were found. At the end of the first screening, following the previously described selection criteria, we selected 186 articles eligible for full-text reading. Ultimately, after full-text reading, and reference list check, we selected 26 articles following previously written criteria. CONCLUSIONS: ESWT is a safe and effective treatment of soft tissue diseases of the upper limbs. Even in the minority cases when unsatisfied results were recorded, high energy shockwaves were nevertheless suggested in prevision of surgical treatment.

Periprosthetic femoral fractures after total hip arthroplasty: An algorithm of treatment.

BACKGROUND: Periprosthetic femoral fractures (PFFs) following total hip arthroplasty are becoming more prevalent and management of these fractures is often demanding. The surgeon has to assess in detail implant loosening, bone loss and type of fracture. The aim of the study is to identify the suitability of a treatment algorithm, based on the Vancouver classification that takes into account the activity and comorbidity of each patient. PATIENTS AND METHODS: This study retrospectively assessed 38 patients who were surgically treated for a PFF around total hip arthroplasty between 2010 and 2014. All fractures were classified according to the Vancouver classification. There were 14 type B1, 8 type B2, 10 type B3 and 6 type C fractures. The data examined were age, sex, mechanism of injury, type of fracture, ASA score, type of surgery and complications. Radiographic evaluations were performed at 1, 3, 6 months and every 12 months thereafter. Clinical results were measured using the Merle-d'Aubigné-Postel score. Treatment options included an ORIF in 22 patients and a stem revision in 16 patients, with or without plates or supplemental cortical strut grafting when required. RESULTS: The mean duration of follow-up was 3.1 years, mean age was 71.2 years and six patients (15.7%) died. Union was obtained in all patients in a mean of 16 weeks. Three patients required a surgical revision: one for stem loosening and two for re-fracture after a new fall. One patient had varus malunion of the femur. The mean postoperative Merle-d'Aubigné-Postel score was 13.2. Thirteen patients showed excellent results, 14 had a good result, three had a fair outcome and two had a poor result. Twenty patients returned to their baseline mobility status, while 12 patients had either a decline in their ambulatory status or a need for additional assistive devices. CONCLUSIONS: PFF remains a serious complication of hip arthroplasty that is accompanied by high morbidity and mortality rates. This study shows how patients' comorbidities and functional demand can direct the proper treatment. This is a suitable algorithm for the treatment of PFF, which can provide satisfactory results in terms of pain and function.

Bone mineral density as a marker of hip implant longevity: a prospective assessment of a cementless stem with dual-energy X-ray absorptiometry at twenty years.

PURPOSE: Bone remodeling around the femoral component after total hip arthroplasty (THA) is considered to be an important factor in long-term stability and seems to be strictly related to the stem design, coating, and fixation. Stress shielding, micro-movement, and high intra-articular fluid pressure might activate macrophages and osteoclasts, causing progressive bone density decreases. Here we analyze the bone mineral density (BMD) around a cementless femoral stem during a 20-year period to better understand the adaptive bone changes around such implants during long-term follow-up. METHODS: In this retrospective study, 14 patients treated by THA were reviewed from a cohort of 84. Clinical evaluation with Harris Hip Score and radiographic assessment were performed throughout a 20-year follow-up. To evaluate the bone remodeling around the stem, we monitored the femoral BMD in four regions of interest with a dual-energy X-ray absorptiometry (DEXA) post-operatively and at one, two, three, five and 20 years of follow-up. RESULTS: The main BMD changes between the post-operative examination and the 20-year follow-up varied between + 11.19% and + 24.30%. Patients with signs of loosening, low Harris Hip Scores, and pain showed decreasing BMD values. CONCLUSIONS: The correlation between the clinical result and BMD values could suggest DEXA results as a predictor of implant loosening or longevity.

Can Clinical and Surgical Parameters Be Combined to Predict How Long It Will Take a Tibia Fracture to Heal? A Prospective Multicentre Observational Study: The FRACTING Study.

BACKGROUND: Healing of tibia fractures occurs over a wide time range of months, with a number of risk factors contributing to prolonged healing. In this prospective, multicentre, observational study, we investigated the capability of FRACTING (tibia FRACTure prediction healING days) score, calculated soon after tibia fracture treatment, to predict healing time. METHODS: The study included 363 patients. Information on patient health, fracture morphology, and surgical treatment adopted were combined to calculate the FRACTING score. Fractures were considered healed when the patient was able to fully weight-bear without pain. RESULTS: 319 fractures (88%) healed within 12 months from treatment. Forty-four fractures healed after 12 months or underwent a second surgery. FRACTING score positively correlated with days to healing: r = 0.63 (p < 0.0001). Average score value was 7.3 ± 2.5; ROC analysis showed strong reliability of the score in separating patients healing before versus after 6 months: AUC = 0.823. CONCLUSIONS: This study shows that the FRACTING score can be employed both to predict months needed for fracture healing and to identify immediately after treatment patients at risk of prolonged healing. In patients with high score values, new pharmacological and nonpharmacological treatments to enhance osteogenesis could be tested selectively, which may finally result in reduced disability time and health cost savings.

Potential presence of metals in patients treated with metal-metal coupling prostheses for hip arthroplasty at 7 and 10 years of follow-up.

BACKGROUND: Beginning in 2008, metal-on-metal prostheses have been in the spotlight owing to much higher revision rates than expected. Adverse local tissue reactions have been well described in the literature as potential complications. METHODS: Between 2012 and 2013, 13 patients with metal-on-metal total hip replacements were evaluated clinically and radiologically and with laboratory samples. The same tests were repeated between 2015 and 2016 on eight patients to assess any changes. In the laboratory assessment, we searched for chromium, cobalt, molybdenum, and nickel in blood and urine samples over 24 h. RESULTS: Clinical assessment has shown good score in all patients except one. On a second examination, between 2015 and 2016, all patients obtained results similar to those obtained in the first assessment, except a patient, who reported a recent fall. In the radiological assessment between 2012 and 2013, results were optimal, apart from a case of aseptic mobilization. The patients reassessed 3 years after the first examination showed radiological results similar to those previously obtained, apart from a patient, who showed signals of mobilization. Metal levels found in their blood decreased in most cases after 3 years. Urine levels of nickel increased in five subjects, and chromium levels increased in four, but levels of cobalt and molybdenum decreased in four patients. CONCLUSION: It could be hypothesized that the decreasing trend of metal ion levels is associated with a stable wear status. On the contrary, a progressive increase in metal ion levels must be considered as early proof of implant loosening.

Acetabular revisions using porous tantalum components: A retrospective study with 5-10 years follow-up.

AIM: To evaluate the clinical and X-ray results of acetabular components and tantalum augments in prosthetic hip revisions. METHODS: Fifty-eight hip prostheses with primary failure of the acetabular component were reviewed with tantalum implants. The clinical records and X-rays of these cases were retrospectively reviewed. Bone defect evaluations were based on preoperative CT scans and classified according to Paprosky criteria of Radiolucent lines and periprosthetic gaps; implant mobilization and osteolysis were evaluated by X-ray. An ad hoc database was created and statistical analyses were performed with SPSS software (IBM SPSS Statistics for Windows, version 23.0). Statistical analyses were carried out using the Student's t test for independent and paired samples. A P value of < 0.05 was considered statistically significant and cumulative survival was calculated by the Kaplan-Meier method. RESULTS: The mean follow-up was 87.6 ± 25.6 mo (range 3-120 mo). 25 cases (43.1%) were classified as minor defects, and 33 cases (56.9%) as major defects. The preoperative HHS rating improved significantly from a mean of 40.7 ± 6.1 (range: 29-53) before revision, to a mean of 85.8 ± 6.1 (range: 70-94) at the end of the follow-up (Student's t test for paired samples: P < 0.001). Considering HHS only at the end of follow-up, no statistically significant difference was observed between patients with a major or minor defect (Student's t test for independent samples: P > 0.05). Radiolucent lines were found in 4 implants (6.9%). Postoperative acetabular gaps were observed in 5 hips (8.6%). No signs of implant mobilization or areas of periprosthetic osteolysis were found in the x-rays at the final follow-up. Only 3 implants failed: 1 case of infection and 2 cases of instability. Defined as the end-point, cumulative survival at 10 years was 95% (for all reasons) and 100% for aseptic loosening of the acetabular component. CONCLUSION: The medium-term use of prosthetic tantalum components in prosthetic hip revisions is safe and effective in a wide variety of acetabular bone defects.

Biomarkers of Osteosarcoma, Chondrosarcoma, and Ewing Sarcoma.

Osteosarcoma is the most frequent malignant bone neoplasm, followed by chondrosarcoma and Ewing sarcoma. The diagnosis of bone neoplasms is generally made through histological evaluation of a biopsy. Clinical and radiological features are also important in aiding diagnosis and to complete the staging of bone cancer. In addition to these, there are several non-specific serological or specific molecular markers for bone neoplasms. In bone tumors, molecular markers increase the accuracy of the diagnosis and assist in subtyping bone tumors. Here, we review these markers and discuss their role in the diagnosis and prognosis of the three most frequent malignant bone neoplasms, namely osteosarcoma, chondrosarcoma, and Ewing sarcoma.

Low-Energy Extracorporeal Shock-Wave Therapy in the Treatment of Chronic Insertional Achilles Tendinopathy: A Case Series.

Introduction. We report the results of a series of 40 patients with chronic insertional Achilles tendinopathy treated with low-energy ESWT after the failure of a 3-month program of eccentric exercises alone. Methods and Materials. 40 patients, 28 (70%) males and 12 (30%) females, were treated between January and December 2014. All patients were previously treated with only eccentric exercises for a 3-month period. The treatment protocol included 4 sessions of ESWT with a 2-week interval, from 800 shots in each one (4 Hz, 14 KeV), together with eccentric exercises. Visual Analogue Scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot score were recorded. Results. At the 12-month follow-up, 26 (65.0%) patients did not complain about pain (VAS < 2), 11 (27.5%) patients got back to normal activities despite residual pain (VAS 2-4), and 3 (7.5%) of the patients still complained about pain (VAS > 4). There was no significative improvement in both scores after eccentric exercises alone. Mean VAS improvement was 5.8 ± 1.3 SD points (P < 0.001). Mean AOFAS Hindfoot score improvement was 19.8 ± 5.0 SD points (P < 0.001). Conclusions. ESWT is recommended, in combination with an eccentric exercise program, in patients with chronic Achilles tendinopathy being both insertional and not.

Calcaneo-stop procedure in the treatment of the juvenile symptomatic flatfoot.

Flexible flatfoot is the most prevalent condition seen in pediatric orthopedic clinics. It is characterized by an absence of the medial arch and a valgus position of the calcaneus. The purpose of the present study was to report on the results obtained in children treated using the calcaneo-stop procedure. A total of 410 flatfeet in 242 consecutive patients were treated using the calcaneo-stop procedure from January 1999 to March 2010 (10 years, 3 months) and were followed up to February 2012. The mean age at surgery was 11 (range 7 to 14) years, and the mean follow-up duration was 88 (range 14 to 157) months. A clinical evaluation, podoscopic examination, and radiologic assessment were performed in the participating patients preoperatively and at 6 months postoperatively. Of the 242 patients, 168 (69.42%) underwent bilateral foot surgery and 74 (30.58%) unilateral intervention, involving 33 right (44.6%) and 41 left (55.4%) feet. At follow-up, the outcome was satisfactory in 397 feet (96.83%); heel valgus was observed in only 12 feet (2.92%), and the footprint was normalized in 328 feet (80%). The calcaneo-stop procedure is a simple, reliable, and minimally invasive procedure for the treatment of pediatric flexible flatfoot. It allows alignment of the talus and calcaneus, restoring a proper foot arch.

Osteosynthesis systems in fragility fracture.

Atraumatic fractures, more commonly known as "fragility fractures", have as their basis the decreased bone strength due to osteoporosis. The major technical problem is the difficulty in obtaining secure fixation in osteoporotic bone, because the pull-out strength of implant is significantly reduced. The high rate of complications has encouraged extensive research into the development of implant which can improve the bone-implant interface by preventing high stress and distributing the forces transmitted to bone in a load-sharing, rather than load-bearing way.

Growing pains: a study of 30 cases and a review of the literature.

BACKGROUND: Data from the literature regarding the clinical profile of growing pains are limited. The purpose of this study was to define the clinical features, familial history, laboratory findings, and therapeutic outcome of growing pains in children. METHODS: Thirty children (18 male and 12 female; 3 to 14 y of age) who presented with growing pains between January 2006 and December 2007 were enrolled and prospectively followed up for 1 year. The inclusion criterion was lower extremity pain, which was recurrent and lasted for >3 months. The exclusion criteria were any abnormal systemic or local symptoms and signs, joint involvement, and limp or limitation of activity. Laboratory tests, including complete blood count, erythrocyte sedimentation rate, and serum calcium and phosphorus levels, were performed in all children. RESULTS: The study group had pain during the night and afternoon in 43.3% and 56.7% of cases, respectively. Both lower limbs were involved in 80% of cases, causing awakening and crying episodes in 40% and 37% of cases, respectively. The frequency of pain was as follows: daily, 5%; weekly, 45%; monthly, 35%; and every 3 months, 15%. The pains were relieved by massaging the affected site in 95% of cases and by analgesics in 5% of children. A family history of growing pains was positive in 20% of patients. All patients had laboratory tests within normal values. CONCLUSION: Growing pain is a frequent noninflammatory syndrome consisting of intermittent, often annoying, pains that affect the lower extremities of children. Clinical diagnosis is easy if precise inclusion and exclusion criteria in the history and physical examinations are strictly followed. Patients and family reassurance is mandatory. LEVEL OF EVIDENCE: This is a Level I prospective study.

Bilateral total hip arthroplasty in subjects with multiple epiphyseal dysplasia.

Multiple epiphyseal dysplasia (MED) is a rare autosomal dominant skeletal dysplasia caused by abnormalities in the gene(s) coding for type IX collagen and cartilage oligomeric matrix protein. Clinically, the disease is characterized by abnormalities in the epiphyseal cartilage of multiple joints. Orthopedic manifestations include pain and restricted mobility. The disorder, which has a predilection for the femoral head and acetabulum, usually presents from the third to the fourth decade with secondary hip osteoarthritis. We report on 7 subjects affected by multiple epiphyseal dysplasia, which presented hip osteoarthritis in their third decade of life and underwent staged bilateral total hip arthroplasty. All patients experienced pain relief and improved quality of life after surgical treatment.