Genome-wide assessment of diversity and differentiation between original and modern Brown cattle populations.

Identifying genomic regions involved in the differences between breeds can provide information on genes that are under the influence of both artificial and natural selection. The aim of this study was to assess the genetic diversity and differentiation among four different Brown cattle populations (two original vs. two modern populations) and to characterize the distribution of runs of homozygosity (ROH) islands using the Illumina Bovine SNP50 BeadChip genotyping data. After quality control, 34 735 SNPs and 106 animals were retained for the analyses. Larger heterogeneity was highlighted for the original populations. Patterns of genetic differentiation, multidimensional scaling, and the neighboring joining tree distinguished the modern from the original populations. The FST -outlier identified several genes putatively involved in the genetic differentiation between the two groups, such as stature and growth, behavior, and adaptability to local environments. The ROH islands within both the original and the modern populations overlapped with QTL associated with relevant traits. In modern Brown (Brown Swiss and Italian Brown), ROH islands harbored candidate genes associated with milk production traits, in evident agreement with the artificial selection conducted to improve this trait in these populations. In original Brown (Original Braunvieh and Braunvieh), we identified candidate genes related with fat deposition, confirming that breeding strategies for the original Brown populations aimed to produce dual-purpose animals. Our study highlighted the presence of several genomic regions that vary between Brown populations, in line with their different breeding histories.

Runs of homozygosity reveal genome-wide autozygosity in Italian sheep breeds.

The availability of dense single nucleotide polymorphism (SNP) assays allows for the determination of autozygous segments based on runs of consecutive homozygous genotypes (ROH). The aim of the present study was to investigate the occurrence and distribution of ROH in 21 Italian sheep breeds using medium-density SNP genotypes in order to characterize autozygosity and identify genomic regions that frequently appeared in ROH within individuals, namely ROH islands. After filtering, the final number of animals and SNPs retained for analyses were 502 and 46 277 respectively. A total of 12 302 ROH were identified. The mean number of ROH per breed ranged from 10.58 (Comisana) to 44.54 (Valle del Belice). The average length of ROH across breeds was 4.55 Mb and ranged from 3.85 Mb (Biellese) to 5.51 Mb (Leccese). Valle del Belice showed the highest value of inbreeding on the basis of ROH (FROH  = 0.099), whereas Comisana showed the lowest (FROH  = 0.016), and high standard deviation values revealed high variability in autozygosity levels within each breed. Differences also existed in the length of ROH. Analysis of the distribution of ROH according to their size showed that, for all breeds, the majority of the detected ROH were <10 Mb in length, with a few long ROH >25 Mb. The levels of ROH that we estimated here reflect the inbreeding history of the investigated sheep breeds. These results also highlight that ancient and recent inbreeding have had an impact on the genome of the Italian sheep breeds and suggest that several animals have experienced recent autozygosity events. Comisana and Bergamasca appeared as the less consanguineous breeds, whereas Barbaresca, Leccese and Valle del Belice showed ROH patterns typically produced by recent inbreeding. Moreover, within the genomic regions most commonly associated with ROH, several candidate genes were detected.

Genome-wide association study of milk fatty acid composition in Italian Simmental and Italian Holstein cows using single nucleotide polymorphism arrays.

Bovine milk is important for human nutrition, but its fat content is often criticized as a risk factor in cardiovascular disease. Selective breeding programs could be used to alter the fatty acid (FA) composition of bovine milk to improve the healthiness of dairy products for human consumption. Here, we performed a genome-wide association study (GWAS) on bovine milk to identify genomic regions or specific genes associated with FA profile and to investigate genetic differences between the Italian Simmental (IS) and Italian Holstein (IH) breeds. To achieve this, we first characterized milk samples from 416 IS cows and 436 IH cows for their fat profile by gas chromatography. Subjects were genotyped with single nucleotide polymorphism array and a single-marker regression model for GWAS was performed. Our findings confirm previously reported quantitative trait loci strongly associated with bovine milk fat composition. More specifically, our GWAS results revealed significant signals on chromosomes Bos taurus autosome 19 and 26 for milk FA. Further analysis using a gene-centric approach and pathway meta-analysis identified not only some well-known genes underlying quantitative trait loci for milk FA components, such as FASN, SCD, and DGAT1, but also other significant candidate genes, including some with functional roles in pathways related to "Lipid metabolism." Highlighted genes related to FA profile include ECI2, PCYT2, DCXR, G6PC3, PYCR1, and ALG12 in IS, and CYP17A1, ACO2, PI4K2A, GOT1, GPT, NT5C2, PDE6G, POLR3H, and COX15 in IH. Overall, the breed-specific association outcomes reflect differences in the genetic backgrounds of the IS and IH breeds and their selective breeding histories.

How to prevent dislocation after revision total hip arthroplasty: a systematic review of the risk factors and a focus on treatment options.

BACKGROUND: Dislocation represents the most common complication after revision total hip arthroplasty (rTHA). Understanding risk factors for dislocation has a great clinical relevance for every hip surgeon in order to consider all surgical options for effective planning. The aim of this systematic review was to answer two main questions-(1) what are the risk factors for instability after rTHA? and (2) what are the best preoperative assessments and surgical options to avoid dislocation after rTHA? MATERIALS AND METHODS: Scientific databases were accessed to identify papers dealing with prevention and treatment of dislocation after rTHA. We performed a search using the keywords 'revision hip arthroplasty' and 'dislocation', 'instability', 'outcome', 'failure', 'treatment'. After removal of duplicates and exclusion of works published in different languages, 33 articles were reviewed completely. RESULTS: Risk factors were analysed in order to establish the most relevant and evidence-based treatments available in the current literature. CONCLUSIONS: The risk of dislocation after rTHA can be reduced using some precautions inferred from the literature. The use of a larger femoral and acetabular component, elevated rim liner and dual mobility implants can significantly reduce the risk of dislocation after rTHA. However, care must be taken regarding patient-related risk factors since these cannot be addressed and modified. Hence, a complete evaluation of risk factors should be performed for each patient and procedure before starting rTHA.

Modified minimally invasive direct anterior approach through a bikini incision for total hip arthroplasty: technique and results in young female patients.

Direct anterior approach for THA has gained popularity over the last years. However, concerns have been raised regarding the cosmetic, related to the incision that does not respect the Langer's skin tension line and may produce hypertrophic scars. The aim of this study was to analyze the preliminary results in 22 young female patients undergoing THA through a minimally invasive direct anterior approach using a modified oblique bikini incision. Clinical evaluations showed an improvement of WOMAC, UCLA and Harris Hip Score at 5-month follow-up. The technique ensured proper implant positioning and showed advantages in terms of complications, transfusion rates, hospital length of stay and functional recovery. From the aesthetic point of view, the expected cosmetic results were obtained. Minimally invasive direct anterior approach using a modified oblique bikini incision represent a viable option for THA, combining both the advantages of a minimal invasive procedure with a better aesthetic appearance.

Saphenous nerve injury during hamstring tendons harvest: Does the incision matter? A systematic review.

PURPOSE: Infrapatellar branch of saphenous nerve injury is a common complication following hamstring graft harvest during anterior cruciate ligament reconstruction. The direction of skin incision performed at proximal tibial metaphysis may affect the rate of iatrogenic nerve damage. Aim of the present systematic review was to evaluate evidence that would substantiate the adoption of one incision over another for hamstring graft harvesting. METHODS: The available literature was systematically screened searching studies dealing with iatrogenic injury to the saphenous nerve after anterior cruciate ligament reconstruction using hamstring tendons. A search was performed using the keywords "Saphenous" and "Infrapatellar branch" in combination with "Anterior cruciate ligament", "arthroscopy" and "hamstrings", supplying no limits regard the publication year. Coleman methodological score was performed in all the retained articles. RESULTS: Five articles matched the inclusion criteria. There were two randomized controlled trials, one prospective comparative study and two retrospective comparative series. Poor methodological quality was found overall. A vertical incision was found to significantly affect the presence of hypoesthesia and the extent of the area of sensory loss in three articles; no difference was registered in one, and a trend towards a lower rate of iatrogenic nerve damage using an oblique incision was found in the remaining one, without any statistical significance. CONCLUSION: Although the low methodological quality of the analysed studies does not permit to draw definitive conclusions, the anatomical course of the nerve along with the results obtained in the available studies seems to suggest lower rate of neurological impairment adopting an oblique incision. This kind of incision may therefore be preferred in the routine clinical practice. LEVEL OF EVIDENCE: Systematic review, Level II.

Isolate acetabular cup revision through the direct anterior hip approach: surgical technique, early experience and review of the literature.

Direct anterior approach to the hip allows perfect exposure of the acetabulum and an easy proximal and medial extension that makes it eligible for isolate acetabular cup revision although it is seldom used and there are only few published studies. On 23 consecutive acetabular revision (16 cases Paprosky grade 1 or 2, 5 cases 3A, 1 case 3B and 1 case 4) at an average 28-month follow up, we did not record failures or major complications. Early complications included prolonged wound healing in 4 cases and transient femoral cutaneous nerve palsy in 2 cases, the mean postoperative Harris Hip Score was 82.2 with 82.5% of excellent and good results. Our results are consistent with those reported in the literature with similar techniques. The direct anterior approach has shown excellent results for isolated cup revision, though is probably better suited for surgeons that have some experience with the same approach for primary cases.

Is a minimally invasive anterior approach effective in old patients? A pilot study.

Minimally invasive approach to the hip is a blood preserving surgery, with rapid rehabilitation, and low dislocation rate. Intuitively, these characteristics render this approach extremely suitable in the elderly patient. The aim of this study was to analyze the early clinical and radiographic results in the first 30 consecutive patients above 70 years of age undergoing THR through a minimally invasive anterior approach. Clinical evaluations showed an improvement of the Harris Hip Score and WOMAC score after surgery. Radiographic assessment showed cup orientation averaging 47° (range 40°–59°) and no valgus stem aligned. Allogeneic blood transfusion was required in only 6 patients (19.8%). One patient experienced an intraoperative fracture of the greater trochanter. No early implant dislocation was observed in the study population. In conclusion we advise a minimally invasive anterior approach for THR in older patients when a careful patient selection has been done.

Genome-wide analysis of Italian sheep diversity reveals a strong geographic pattern and cryptic relationships between breeds.

Italy counts several sheep breeds, arisen over centuries as a consequence of ancient and recent genetic and demographic events. To finely reconstruct genetic structure and relationships between Italian sheep, 496 subjects from 19 breeds were typed at 50K single nucleotide polymorphism loci. A subset of foreign breeds from the Sheep HapMap dataset was also included in the analyses. Genetic distances (as visualized either in a network or in a multidimensional scaling analysis of identical by state distances) closely reflected geographic proximity between breeds, with a clear north-south gradient, likely because of high levels of past gene flow and admixture all along the peninsula. Sardinian breeds diverged more from other breeds, a probable consequence of the combined effect of ancient sporadic introgression of feral mouflon and long-lasting genetic isolation from continental sheep populations. The study allowed the detection of previously undocumented episodes of recent introgression (Delle Langhe into the endangered Altamurana breed) as well as signatures of known, or claimed, historical introgression (Merino into Sopravissana and Gentile di Puglia; Bergamasca into Fabrianese, Appenninica and, to a lesser extent, Leccese). Arguments that would question, from a genomic point of view, the current breed classification of Bergamasca and Biellese into two separate breeds are presented. Finally, a role for traditional transhumance practices in shaping the genetic makeup of Alpine sheep breeds is proposed. The study represents the first exhaustive analysis of Italian sheep diversity in an European context, and it bridges the gap in the previous HapMap panel between Western Mediterranean and Swiss breeds.

Technical note: Advantages and limitations of authenticating Palmera goat dairy products by pyrosequencing the melanocortin 1 receptor (MC1R) gene.

Inferring the breed of origin of dairy products can be achieved through molecular analysis of genetic markers with a population-specific pattern of segregation. The goal of the current work was to generate such markers in goats by resequencing several pigmentation genes [melanocortin 1 receptor (MC1R), v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog (KIT), tyrosinase (TYR), and tyrosinase-related protein 2 (TYRP2)]. This experiment revealed 10 single nucleotide polymorphisms (SNP), including 5 missense mutations and 1 nonsense mutation. These markers were genotyped in 560 goats from 18 breeds originally from Italy, the Iberian Peninsula, the Canary Islands, and North Africa. Although the majority of SNP segregated at moderate frequencies in all populations (including 2 additional markers that were used as a source of information), we identified a c.764G>A SNP in MC1R that displayed highly divergent allelic frequencies in the Palmera breed compared with the Majorera and Tinerfeña breeds from the Canary Islands. Thus, we optimized a pyrosequencing-based technique that allowed us to estimate, very accurately, the allele frequencies of this marker in complex DNA mixtures from different individuals. Once validated, we applied this method to generating breed-specific DNA profiles that made it possible to detect fraudulent cheeses in which Palmero cheese was manufactured with milk from Majorera goats. One limitation of this approach, however, is that it cannot be used to detect illegal manufacturing where Palmero dairy products are produced by mixing milk from Palmera and Majorera goats, because the c.764G>A SNP segregates in both breeds.

Under 2$ hand anesthesia? Our first 800 cases with Wide-Awake Local Anesthesia No Tourniquet (WALANT) in hand surgery.

INTRODUCTION: The Wide-Awake-Local-Anesthesia-No-Tourniquet (WALANT) technique is being used progressively more and more in hand surgery as it avoids tourniquet-related complications and saves money. MATERIALS AND METHODS: In the present study, we analyzed our cases of carpal tunnel syndrome or trigger finger operated upon with this technique from January 1, 2018 to December 31, 2022. RESULTS: We obtained 822 cases (426 carpal tunnel syndrome, 396 trigger finger) with an overall anesthesiologic efficacy (no need of additional anesthetic) of 97.8%. Patients were satisfied or very satisfied with the anesthetic choice in 99.8% of cases. CONCLUSIONS: We believe WALANT to be a safe and effective technique that every hand surgeon should have in his/her repertoire.

How to perform correct templating in total hip replacement.

Templating plays a key role in surgery that is often underestimated. There is a difference between planning and templating: in the first not only the hip is considered but involves the evaluation of the patient in its entirety. Templating instead consists of calculating the position of the implant in order to place it in the best possible position. Fundamental is a correct X-ray of the pelvis, which must follow certain standards. For traditional templating, drawings on appropriately enlarged transparent implants were provided by the prosthesis manufacturer. The implementation of digital software into clinical practice has improved the accuracy and reproducibility of templating, which in most surgical units is performed by standard 2D radiographic images. Thanks to digital preoperative templating in a digital radiology environment, the hip reconstructive surgeon can perform preoperative planning and implant sizing quickly, consistently, and affordably. Currently, 3D templating can also be performed by software used initially to create personalized stems for THA. Aim of the current review is to outline the essentials of correct templating in THA performance, and to report the updates since the introduction of digital and 3D technologies in this setting.

The use of resurfacing capitate pyrocarbon implants (RCPI) in chronic diseases of the wrist: outcomes of more than 100 cases.

INTRODUCTION: In advanced chronic post-traumatic wrist pathology, the goal of surgery has always been to reduce pain while trying to preserve the function of the wrist itself as much as possible; numerous interventions have been developed to achieve these goals (partial arthrodesis, 4-angle arthrodesis, the use of prosthetic implants…). PURPOSES: The purpose of the study is to evaluate outcomes and complications rate of proximal row carpectomy associated with the resurfacing capitate pyrocarbon implant (RCPI) for chronic diseases of the wrist. MATERIALS AND METHODS: A retrospective analysis of the patients operated on between June 2004 and March 2021 was performed. Pain, wrist range of motion in flexion, extension, radial and ulnar deviation and grip strength were compared preoperatively and at 1, 6, 12 and 24 months. Complications and additional procedures were recorded. RESULTS: A total of 112 patients underwent surgery for proximal row carpectomy and placement of RCPI with a mean follow-up of 6.6 years. Between the preoperative and the 2-year follow-up, a reduction in pain (VAS from 7.3 to 0.5), an increase in grip strength (from 8 to 17 kg) and an increase in ROM in all planes (flexion from 19° to 44°, extension from 20° to 46°, radial deviation from 7° to 14° and ulnar deviation from 13° to 28°) were recorded. Ten (8.9%) patients required additional surgery, with only 2 (1.8%) patients requiring revision of the implant. CONCLUSIONS: Proximal row carpectomy associated with RCPI is an excellent surgical strategy to relieve pain and to improve wrist range of motion and grip strength in patients with chronic diseases of the wrist.

Muscle transcriptome profiling in divergent phenotype swine breeds during growth using microarray and RT-PCR tools.

Using an array consisting of 10 665 70-mer oligonucleotide probes, the longissimus dorsi muscle tissue expression during growth in nine pigs belonging to Casertana (CT), an autochthonous breed characterized by slow growth and a massive accumulation of backfat, was compared with that of two cosmopolitan breeds, Large White (LW) and a crossbreed (CB; Duroc × Landrace × Large White). The results were validated by real-time PCR. All animals were of the same age and were raised under the same environmental conditions. Muscle tissues were collected at 3, 6, 9 and 11 months of age, and a total of 173 genes showed significant differential expression between CT and the cosmopolitan genetic types at 3 months of age. Time series cluster analysis indicated that the CT breed had a different pattern of gene expression compared with that of the LW and the CB. Four of the eight clusters highlighted the gene differences between CT and the other two breeds, which were further supported by statistical analyses: clusters 4 and 5 contained a total of 71 genes that were underexpressed at 3 months of age, and cluster 3 and cluster 7 included 28 and 42 genes respectively that were overexpressed at 3 months of age. As expected, differentially expressed genes belonged to the category of genes coding for contractile fibres and transcription factors involved in muscle development and differentiation. These findings highlight muscle expression genes during pig growth and are useful to understand the genetic meaning of the different developmental rates.

Polymorphism of the goat agouti signaling protein gene and its relationship with coat color in Italian and Spanish breeds.

Agouti signaling protein (ASIP) is one of the key players in the modulation of hair pigmentation in mammals. Binding to the melanocortin 1 receptor, ASIP induces the synthesis of phaeomelanin, associated with reddish brown, red, tan, and yellow coats. We have sequenced 2.8 kb of the goat ASIP gene in 48 individuals and identified two missense (Cys126Gly and Val128Gly) and two intronic polymorphisms. In silico analysis revealed that the Cys126Gly substitution may cause a structural change by disrupting a highly conserved disulfide bond. We studied its segregation in 12 Spanish and Italian goat breeds (N = 360) with different pigmentation patterns and found striking differences in the frequency of the putative loss-of-function Gly(126) allele (Italian 0.43, Spanish Peninsular 0.08), but we did not observe a clear association with coat color. This suggests that the frequency of this putative loss-of-function allele has evolved under the influence of demographic rather than selection factors in goats from these two geographical areas.

Scaphoid fractures with scapholunate ligament involvement: Instability or ligamentous laxity? Role of arthroscopy and pinning.

PURPOSE: Percutaneous fixation of scaphoid fractures often does not allow the evaluation of potential ligamentous lesions. Arthroscopy is an useful tool in the management of scaphoid fractures to visualize potentially associated lesions. With arthroscopic assistance, we often found scapholunate ligament lesions. Our study's aim was to evaluate the role of arthroscopy in the treatment of scaphoid fracture and in particular if the alteration found was a real lesion causing instability or just a paraphysiologic laxity. Furthermore, we evaluated whether the scapholunate joint pinning alters the outcome. METHODS: We performed a retrospective study on 39 patients (33 males and 6 females), with an average age at trauma of 31.2 years (range 15-67), who underwent surgery for scaphoid fractures between 2010 and 2016 in our Center of Hand Surgery. Patients were divided into four groups based on surgical technique and finding of scapholunate lesions. RESULTS: Differences between the four groups analyzed, both in terms of clinical scores and ROM, were not statistically significant. This corroborates the hypothesis that all four treatments are equivalent. CONCLUSIONS: Based on our experience and the literature available, we believe the systematic use of arthroscopy to be useful in patients needing surgical treatment for scaphoid fractures. This is because arthroscopy allows the control of the fracture reduction, screw protrusion evaluation and ligamentous lesions assessment. In cases of partial scapholunate ligament alteration in which no sign of acute lesion is present (hemorrhage and clear rupture), pinning is not necessary since it might just be a paraphysiologic laxity. LEVEL OF EVIDENCE: IV.

Trends in surgical management of the infected total ankle arthroplasty.

OBJECTIVE: We performed a systematic review of surgical treatment of the infected total ankle arthroplasty. The purpose of this investigation was to describe the current trends and to perform a critical analysis of the evidence reported in the existing literature. MATERIALS AND METHODS: A comprehensive search for all relevant articles published in English was conducted. Scientific databases were accessed to identify papers dealing with the management of the infected total ankle arthroplasty. We identified and collected every patient that underwent a surgical management of infected ankle arthroplasty. Data extracted were summarized and reported. A descriptive analysis was performed; when possible, a statistical analysis was accomplished. RESULTS: Thirty-two papers (152 infected ankle arthroplasty) published in the last 20 years were identified. Twenty-seven patients (17.76%) were treated with irrigation and debridement, revision total ankle arthroplasty was performed in 72 cases (47.37%), arthrodesis was performed as a primary treatment in 30 patients (19.74%), 12 patients (7.89%) underwent a spacer arthroplasty while amputation was performed as a primary treatment in 9 patients (5.92%). CONCLUSIONS: Our study reveals the improvement of the surgical management of the infected total ankle arthroplasty through the last 20 years. Irrigation and debridement and two-stage revision represent the most viable treatment in acute postoperative and late chronic infections respectively. We noted a trend towards maintaining articularity through a two-stage revision. The quality of evidence is weak with biases both in reporting and selection process. High quality randomized controlled trials are required to compare different treatments in order to introduce an evidence-based treatment protocol.

Lipid composition of meat and backfat from Casertana purebred and crossbred pigs reared outdoors.

The study aimed to evaluate, with regard to the human nutrition, the lipid profile of meat and backfat from gilts and barrows of the Italian autochthonous genotype Casertana and its crossbreed (Casertana×Large White) slaughtered at two different live weights. Meat from the Casertana cross was nutritionally comparable to that from the purebreed and both would be considered healthy, irrespective of sex and weight, due to the relatively low levels of intramuscular lipids and cholesterol. Muscle cholesterol was considerably lower in the heavy pigs than in the light ones and, as weight increased, cholesterol decreased but only in gilts. Females supply meat with higher polyunsaturated fatty acids (PUFA) and slightly lower saturated fatty acids (SFA) respect to barrows and, thus, higher PUFA/SFA ratio. Casertana crossbreds can represent a good alternative to pure Casertana, mainly in the production of Colonnata lard, due to the better fatty acid profile of the subcutaneous adipose tissue. From the nutritional point of view, the optimal slaughtering weight was about 150kg for both genotypes. Heavy pigs, compared to the light ones, produced loin with lower atherogenic and thrombogenic indexes, lower SFA/unsaturated fatty acids ratio, and higher PUFA/SFA ratio.

A new sign allowing diagnosis in the pathologies of the extensor tendons of the hand.

INTRODUCTION: The thorough knowledge of the anatomy of the extensor tendon system of the hand is crucial for clinical examination and detection of tendon injuries. The Juncturae between the EDCII and other extensor tendons presents different incidences, shapes ("r" or "y") and morphologies (Type I, II, III). The EIP does not receive connection. These characteristics may result in variable effects on extensor tendons during active finger movements. The purpose of this study is to investigate and describe a new sign helping diagnosis for injuries or pathologies of EIP and EDC index finger (EDC II), based on a cadaveric dissection and clinical observation. MATERIALS AND METHODS: The authors performed a clinical observational study in 520 patients in order to distinctly evaluate by means of inspection and palpation the EIP and EDC II tendons and an anatomical analysis of extensor tendon apparatus of long fingers was then performed in 89 cadaver hands focusing the investigation on the juncturae system. RESULTS: The observational studies showed that during the flexion of the III, IV and V fingers, associated to the active extension of the I and II fingers, the EDC of the III, IV and V fingers moved the EDC II in ulnar direction by means of juncturae action. The EIP remained in its position becoming visible and isolated from the migrated EDC II. CONCLUSIONS: This feature allows the distinct clinical evaluation by observation and palpation of both EDC II and EIP tendons and may be helpful in clinical conditions such as diagnosis of tendon lesions, pre-operative planning of EIP transfer and extensor tendon tenolysis associated to soft tissue scar at the second MPj.

The carpal tunnel syndrome in children.

INTRODUCTION: Carpal tunnel syndrome (CTS) in children represents a complex challenge for the hand surgeon because of its rarity, poor patient cooperation, frequently associated malformation syndromes and mental retard, atypical symptoms and nuanced and poor sensitivity of instrumental tests. The most frequently associated causes with the CTS in children are rare congenital malformations and diseases, requiring an overall assessment of the young patient and a high degree of suspicion for the potentially associated canalicular syndrome. On the other hand, the associated syndromes may be the main ally for a diagnosis that starts from the knowledge of the literature and the surgeon's suspicion by observing the child wailing. Early diagnosis and decompression treatment is mandatory. MATERIALS AND METHODS: The authors report a case series of 26 children and analyze the etiology and diagnostic algorithms. Patient assessment was based on complete clinical examination and medical history collection of these young patients with the involvement of the family and educators. RESULTS: In all 26 patients treated, along an average period of 23 months (minimum 12, maximum 30), no signs of recurrence or persistence of median nerve disturbances were recorded. CONCLUSIONS: In conclusion, we believe that anamnesis, a careful physical examination and analysis of instrumental examinations, should be accompanied by a thorough knowledge of rare diseases in the context of congenital malformations. The carpal tunnel syndrome, while well known and treated by each orthopedic surgeon, reveals a mysterious aspect in the context of the "fabulous" world of childhood illnesses, even more difficult than rare congenital diseases.