Inter-rater reliability of classification systems of scapular dyskinesis.

Prevalence of scapular dyskinesis varies across records, with overhead athletes being more frequently affected than non-overhead athletes A number of methods have been described to evaluate scapular kinematics and scapular dyskinesis. The "yes/no" and the "4-type" classification systems are widely accepted and diffusely used among orthopaedics and physical therapists. The inter-rater reliability for both the "yes/no" and the "4-type" classification systems may be different. Moreover, differences between physical therapists and orthopaedic surgeons may exist. Seven examiners (2 orthopaedic surgeons and 5 physical therapists) were asked to evaluate a mixed sequence of video recordings of healthy subjects and patients affected by shoulder, scapular or clavicular disorders and to assess scapular dyskinesis using the "yes/no" and the "4-type" classification systems. Cohen's kappa coefficient (κ) and weighted kappa were used to measure inter-rater reliability. Twenty-four subjects were enrolled. In general, the "4- type" system has higher κ values than ''yes/no'' classification system and orthopaedic surgeons achieve higher reliability than physical therapists for both systems. The clinical evaluation of active shoulder movements permits reproducible assessment and classification of scapular dyskinesis, in particular for the "4-type" classification system. The "4-type" classification system can be used to assess and classify scapular dyskinesis, especially among orthopaedic surgeons.

Radiological pleuroparenchymal fibroelastosis associated to limited cutaneous systemic sclerosis: a case report.

BACKGROUND: Pleuroparenchymal fibroelastosis (PPFE) is a very rare interstitial lung disease (ILD) characterized by progressive fibrotic lesions of the visceral pleura and the sub-pleural parenchyma, affecting predominantly the upper lobes. PPFE may occur in different contextes like bone marrow or lung transplantations, but also in the context of telomeropathy with mutations of telomerase reverse transcriptase (TERT), telomerase RNA component (TERC) or regulator of telomere elongation helicase 1 (RTEL1) genes. PPFE-like lesions have recently been described in patients with connective tissue disease (CTD)-related ILD. We report here the first detailed case of PPFE associated to systemic sclerosis (SSc) in a woman free of telomeropathy mutations. CASE PRESENTATION: A caucasian 46 year old woman was followed for SSc in a limited form with anti-centromere Ab since 1998, and seen in 2008 for a routine visit. Her SSc was stable, and she had no respiratory signs. Pulmonary function tests showed an isolated decreased cTLCO at 55.9% (of predicted value). Cardiac ultrasonography was normal. Thoracic CT-scan showed upper lobes predominant mild and focal pleural and subpleural thickenings, suggestive of PPFE, with a slight worsening at 8 years of follow-up. She remained clinically stable. Biology only found a moderate and stable peripheral thrombocytopenia, and sequencing analysis did not find any mutations in TERT and TERC genes. CONCLUSIONS: ILD is frequent in SSc but isolated PPFE has never been described so far. In our case, PPFE is not related to telomeropathy, has indolent outcome and seems to have good prognosis. PPFE might be an extremely rare form of SSc-related ILD, although a fortuitous association remains possible.

Current practice in shoulder pathology: results of a web-based survey among a community of 1,084 orthopedic surgeons.

PURPOSE: The aim of this study was to report orthopedic surgeons' management of choice for difficult clinical scenarios of shoulder pathologies. METHODS: A web questionnaire was developed including four clinical scenarios of shoulder pathologies. Subsequently, opinions were solicited from more than 1,000 members of an international association of surgeons specialized in sports traumatology and knee surgery (ESSKA). RESULTS: The response rate was 40% (412 questionnaires). For scenario 1, first anterior dislocation of the shoulder, the most indicated treatment for 71% of respondents was an arthroscopic Bankart repair (P < 0.001). For scenario 2, shoulder arthritis with concentric erosion and cuff tear, 38% chose a shoulder replacement, while 37% preferred a supraspinatus tendon repair in combination with long head of biceps (LHB) tenodesis or tenotomy. For scenario 3, large tendon tears with 70% fatty infiltration of the infraspinatus tendon and lateral LHB instability, 70% of surgeons considered that, among conservative treatments, hyaluronic acid injection was not an appropriate management. Arthroscopic rotator cuff repair, arthroscopic acromioplasty, and LHB tenotomy gained larger consensus (81, 80, and 79% of respondents, respectively). A double-row technique for rotator cuff repair was preferred to a single-row technique (P = 0.02). Scenario 4, adhesive capsulitis, split the respondents equally, with 51% in favor of a surgical approach and 49% in favor of a conservative approach (N.S.). CONCLUSIONS: On-line questionnaires have the potential to improve knowledge about current trends in clinical practice and can help orthopedic surgeons to develop guidelines. LEVEL OF EVIDENCE: Cross-sectional; Level V (expert opinion).

[Enamel laser conditioning before sealant application].

The purpose of this study was to investigate the advantages offered by enamel laser conditioning before sealants application. 150 teeth of 50 patients were subdivided randomly into three groups. In each patient one tooth was etched with 37% orthophosphoric acid for 30 seconds, a second one with Er:YAG laser and orthophosphoric acid for 30 seconds and a third one exclusively with laser beam. Checks of the integrity of sealants applied were made at 3, 6, 12 months. The group treated with laser and orthophosphoric acid showed the best retention scores after 3, 6, 12 months. Enamel laser conditioning before sealants application reduced sealants fractures and loss during the observation time span.

Reliability of anterior medial collateral ligament plication of the elbow.

PURPOSE: The aim of this study is to describe a new surgical procedure to plicate the anterior bundle medial collateral ligament (aMCL) into its humeral footprint using a suture anchor, and to present the results of a preliminary clinical series. METHODS: Eight patients with posttraumatic medial elbow pain and signs of medial elbow instability underwent aMCL plication with suture anchors and decompression of ulnar nerve. Arthroscopic evaluation permitted to define signs of minor medial elbow instability; 70°-scope was used to document from an intra-articular point of view of the aMCL status. The patients were then retrospectively evaluated with the Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPI) and single-assessment numeric evaluation (SANE) by an independent examiner. RESULTS: In all cases, the 70°-scope allowed direct visualization of the aMCL. Lateral subluxation of the coronoid process into the trochlea was observed in all patients. Postoperative median SANE was 50 [35-74.5] points; postoperative median OES was 17 [15.5-31.5] points; postoperative median MEPI was 65 [57.5-72.5] points. None of the patients reported further episodes of medial elbow instability or pain and all patients returned to normal daily activities. CONCLUSIONS: The 70°-scope arthroscopic evaluation of the joint allows a direct evaluation of the inner aMCL status. Lateral subluxation of the coronoid process into the trochlea was observed and can be considered a sign of minor medial elbow instability. Mini-open suture anchor aMCL plication is an original technique that enables an anatomic and minimally invasive ligament retension. CLINICAL RELEVANCE: The authors introduce a valid and safe treatment of posttraumatic medial elbow laxity.

It's time to change perspective! New diagnostic tools for lateral elbow pain.

PURPOSE: The presence of intra-articular findings that may complement the extra-articular pathology in lateral epicondilytis has been suggested, and a role for minor instability of the elbow as part of the causative process of this disease has been postulated. This study was designed to describe two new clinical tests, aimed at detecting intra-articular pathology in patients affected by recalcitrant lateral epicondylitis and investigate their diagnostic performance. METHODS: Ten patients suffering of atraumatic lateral elbow pain unresponsive to conservative treatment were considered in this study. Two clinical tests were developed and administrated prior to arthroscopy: Supination and Antero-Lateral pain Test (SALT); Posterior Elbow Pain by Palpation-Extension of the Radiocapitellar joint (PEPPER). Sensitivity, specificity, predictive values and accuracy of SALT and PEPPER as diagnostic tests for seven intra-articular findings were calculated. RESULTS: In 90% of the patients, at least one test was positive. All patients with signs of lateral ligamentous patholaxity or intra-articular abnormal findings had a positive response to at least one of the two tests. SALT proved to have a high sensitivity but a low specificity and is accurate in detecting the presence of intra-articular abnormal findings, especially synovitis. PEPPER test was sensible, specific and accurate in the detection of radial head chondropathy. CONCLUSIONS: Two new diagnostic tests (SALT and PEPPER) were specifically designed to evoke pain from intra-articular structures. These tests could be a valid support in the diagnostic algorithm of recalcitrant lateral elbow pain. Positive findings may be indicative of a minor instability of the lateral elbow condition. LEVEL OF EVIDENCE: Diagnostic study, development of diagnostic criteria on basis of consecutive patients, level II.

Radiographic presentation of musculoskeletal involvement in Werner syndrome (adult progeria).

Werner syndrome (i.e., adult progeria) is a rare autosomal recessive disorder caused by mutations of the WRN gene, which is characterized by the premature appearance of features associated with normal aging and cancer predisposition. Patients with Werner syndrome can present with musculoskeletal complaints, associated with suggestive radiographic features with a potential prognostic or therapeutic impact. This review illustrates the main radiographic features of Werner syndrome, focusing on the musculoskeletal system, such as soft-tissue calcification, muscular atrophy, osteoporosis, foot deformities, osteitis and osteomyelitis, and bone or soft-tissues malignancies. The identification of these features by radiologists can therefore be useful in the clinical screening of Werner syndrome.

[Respiratory functional decline after 5 years in patients with silicosis and asbestosis]. / Declino funzionale respiratorio a 5 anni nei soggetti affetti da silicosi e asbestosi.

A retrospective study of 561 patients with silicosis and 234 with asbestosis was performed to assess whether lung function decline in five years is related to the type (restrictive or obstructive) and/or to the degree of initial damage. Based on lung function tests, three groups of patients were identified: NC with normal lung function tests, CR with restrictive impairment and CO with airway obstruction. The degree of impairment was classified as mild, moderate and severe. Patients were considered worse if five years later they presented a higher degree of impairment. The prevalence of CR was significantly higher in asbestosis, that of NC and CO in silicosis (p less than 0.01). Among subjects with normal starting lung function, 9% only developed CR or CO 5 years later. The prevalence of subjects with worsened lung function in the CR groups was significantly higher (p less than 0.001) in asbestotics (36%) than in silicotics (14%) and was closely related to starting functional impairment. In the CO group the prevalence of worsened subjects was significantly higher than in CR (p less than 0.001), similar in the two diseases and independent of starting lung impairment.

Acute dystonia in labour: side-effect of concealed self-medication attributed to epidural analgesia.

Any convulsion during labour requires immediate action, but before this can occur a correct diagnosis must be made. Here we describe a case where a 'fit' was wrongly attributed to epidural analgesia. This was in fact a dystonic reaction secondary to undeclared self-medication with metoclopramide. It is therefore important to ensure that a full drug history is obtained from all patients to exclude a drug interaction or side-effect when faced with unusual and potentially serious complications of drug therapy.

Optimal glenoid component inclination in reverse shoulder arthroplasty. How to improve implant stability.

PURPOSE: The purpose of this study is to demonstrate that inferior inclination of the glenosphere is a protecting factor from joint dislocation in reverse total shoulder replacement. The hypothesis is that an average of 10° of inferior inclination of the glenoid component would determine a significant inferior rate of dislocation as compared to neutral inclination. METHODS: A retrospective case (dislocation)-control (stability of the implant) study was performed. Inclusion criteria were the homogeneity of the prosthetic model and availability of pre- and postoperative imaging of the shoulder, including antero-posterior and axillary X-ray views. Glenoid and glenosphere inclination were calculated according to standardized methods. Difference in between the angles determined the inferior tilt. RESULTS: Thirty-three cases fit the inclusion criteria. Glenoid and glenosphere inclination measured, respectively, 74.1° and 83.5°. The average tilt of the glenosphere measured 9.4°. The average tilt in stable patients was 10.2°. Tilt in patients with atraumatic dislocation measured, respectively, -6.9° (superior tilt) and 2.4°, while it was 8.3° for the patient with traumatic instability. The association between the tilt of glenosphere and atraumatic dislocation was significant. CONCLUSIONS: A 10° inferior tilt of the glenoid component in reverse shoulder arthroplasty is associated with a reduced risk of dislocation when compared to neutral tilt.

Functional repair in massive immobile rotator cuff tears leads to satisfactory quality of living: results at 3-year follow-up.

PURPOSE: The aim of this retrospective study was to report clinical results of a selective population undergone to arthroscopic functional repair of massive, contracted, immobile rotator cuff tears. METHODS: From 2005 to 2009, 311 patients with rotator cuff tears were treated at our institution. Of them, 26 shoulders in 25 patients with a mean age of 64 years that presented a massive, contracted immobile tear repaired using an interval slide technique, were included in this study. RESULTS: The mean postoperative follow-up period was 39 months (range 19-70 months). The mean postoperative disabilities of the arm, shoulder and hand (DASH) score and simple shoulder test (SST) score were, respectively, 20.91 and 8.8 (range DASH: 0.83-59.1; range SST: 2-12). Based on single assessment numeric evaluation score, the outcome of surgery was satisfactory with a mean of 76 % (range 0-100 %). The residual level of pain was low, as reported by a final mean visual analog scale score of 1.8 (range 0-8). The mean postoperative range of motion was 157.5° in forward elevation (range 90°-180°) and 55.3° in extra rotation (range 0°-90°). Eleven patients reached mid-back, in 7, the lower back and in 8 cases, upper back. CONCLUSION: Arthroscopic functional repair could be considered an appropriate treatment option in case of massive, contracted and immobile cuff tears. This treatment can provide improvement in pain and function that positively affects patients' quality of life without precluding other, more invasive, eventually consequent solutions.

Complications associated with arthroscopic rotator cuff repair: a literature review.

The aim of this literature review was to report complications associated with arthroscopic rotator cuff repair (RCR). A computerized search of articles published between 200 and 2009 was performed using MEDLINE and PubMed. We included clinical studies (Level 1-4): (a) investigating patients with rotator cuff tears, managed by a completely arthroscopic RCR technique; (b) reported data about complications. Data about arthroscopic-assisted techniques were excluded. Articles that meet criteria inclusion were analytically examined. Complications were classified into general complications and specific complications related to arthroscopic RCR. We found 414 complications in 2,890 patients; most of them were specific complications related to arthroscopic RCR. Re-rupture was the most frequently encountered complication: re-tear rate ranged between 11.4 and 94%. Stiffness and hardware-related complications were observed in 74 and 12 patients, respectively. Eleven less common complications were also reported: 5 neurovascular, 3 septic, 2 thromboembolic events, and 1 anesthesiological complication. This review stated that arthroscopic RCR is a low-risk surgical procedure. Anatomical failure of the repair is the most common complication encountered in the literature.

Advantages of 70° arthroscope in management of ECRB tendinopathy.

Lateral epicondylitis requires a challenging therapeutic management even for expert surgeons. With the failure of conservative treatment, the physician should consider a surgical choice. The purpose of the surgical procedure is to excise the degenerated tissue of extensor carpi radialis brevis tendon. This article describes the arthroscopic release, performed under direct visualization with a 70° scope; the aim is to encourage the use of this type of lens, versus the traditional 30° one. The patient is positioned in a modified lateral decubitus. After joint distension, a diagnostic arthroscopy of the posterior compartment is performed as first step. Then, an anterior compartment arthroscopic evaluation, a subsequent antero-lateral capsulectomy, and extensor carpi radialis brevis tendon exposition are performed with a 30° view. At this point, the 70° lens is switched and the tendon release is performed under direct control. The 70° lens allows a safer procedure, but requires a dedicated learning curve.

[Urachal remnant infection: keep it in mind during atypical abdominal pain in children]. / Infection d'un résidu ouraquien: cause de douleur abdominale atypique.

Etiological diagnosis of abdominal pain is delicate due to its many possible causes. Those that are less frequent are consequently less known and can lead to a trickier diagnosis. We report on a rare case of a 2.5-year-old female patient presenting with abdominal pain in association with secondary dysuria due to an urachal remnant infection. Knowledge of the anatomical pathway of the urachal channel can discriminate its role during an atypical clinical case. The diagnosis is then based on ultrasound scans, which localize and characterize its contents.