Intraosseous injections of platelet rich plasma for knee bone marrow lesions treatment: one year follow-up.

PURPOSE: Cartilage lesions are usually accompanied by subchondral bone alterations or bone marrow lesions (BMLs). BML associated with joint degeneration and cartilage lesions are considered to be predictors of rapidly progressing OA. Currently no existing treatment can fully halt OA progression. One of the approaches is an autologous, biological treatment based on the use of platelet rich plasma (PRP) injections. The purpose of this study is to assess the short-term effectiveness of intraosseous PRP injections, within the BML of individuals affected by OA, in ameliorating pain and improving knee functionality. MATERIALS AND METHODS: The study involved 17 patients with an average age of 41.7 ± 14.3 years old. OA stage was determined using the Kellgren-Lawrence grading system by performing radiographic scanning of the knee joint before surgical intervention. Patients with K-L grade 3 knee joint OA prevailed. Patient OA history varied between one and nine years (average 5.2 ± 4.5 years). Clinical and functional state of the knee were assessed by pain visual analogue scale (VAS) score, the Western Ontario and McMaster Universities Score (WOMAC), and the Knee Injury and Osteoarthritis Outcome Score (KOOS) which were filled out by patients previous to the surgical procedure at one, three, six and 12 months post-operatively. Before surgery, in addition to standard blood tests, serum cartilage oligomeric matrix protein (COMP) levels were tested for all patients. RESULTS: Evaluation of preliminary results revealed a statistically significant reduction of pain based on the VAS score. A significant improvement was also observed in the patients' WOMAC score and in the overall KOOS score. Serum marker levels were initially elevated in our experimental patient group compared to the same marker in healthy control respondents, and continued to rise one month and three months following surgery, at six and 12 month the level was similar as at three months. CONCLUSIONS: In our opinion, first COMP increasing can be caused by injection of platelet rich plasma. It is not adequate to interpret this growth in COMP levels as increased osteochondral degeneration. One year follow-up period showed good quality of life improvement, significant pain reduction, and essential MRI changes. The long-term observation of these cohort of patients combined with an analysis of MRI images is still ongoing.

Effect of intravenous ferric carboxymaltose supplementation in non-anaemic iron deficient patients undergoing hip and knee arthroplasty.

Preoperative anaemia and non-anaemic iron deficiency are independent risk factors for perioperative blood transfusion, morbidity, and mortality. Although the efficacy to treat anaemia with iron infusion before elective surgery has been widely studied, the literature offers few data about the efficacy of treating iron deficient, non-anaemic patients before elective surgery. This retrospective study assessed the effect of preoperative ferric carboxymaltose (FC) administration on the concentration of Haemoglobin (Hb) in iron deficient, non-anaemic individuals following total knee or hip arthroplasty. A treatment group of 83 non-anaemic iron deficient individuals scheduled for arthroplasty were administered a 1000mg FC infusion over 15 minutes 4 weeks prior to surgery. In the control group (n=62) FC was not administered preoperatively. No individual from either group was given any iron supplement following the pre-operative visit. Blood tests were performed and analysed 4-weeks before surgery, on admission, and then 2-days, 4-days and 4-weeks postoperatively. Number of blood transfusions performed and adverse events were recorded. Hb concentration did not change substantially after iron supplementation prior to surgery. No difference in the number of blood transfusions was observed. In the treatment, group postoperative Hb concentration recovered significantly more quickly compared to control (p=0.0047). No adverse event was reported. The administration of FC in non-anaemic iron deficient individuals quickens the restoration of Hb concentration following THA or TKA procedures.

All-inside repair of meniscal bucket handle tears: a retrospective study at mean 4-years follow-up evaluation.

Bucket-handle tears represent approximately 10% of all meniscal tears. Despite the common treatment is subtotal meniscectomy, repair is technically feasible although complex, and represents a key strategy to avoid severe meniscal tissue loss that could accelerate joint degeneration over time. The aim of this retrospective study was to determine the outcomes of arthroscopically-assisted bucket-handle tear repair, and to identify factors correlating with clinical results. Fifty-four patients affected by meniscal bucket handle tear were included in the present retrospective analysis and evaluated up to mean 4-years follow-up. All patients were treated by arthroscopic-assisted all-inside repair. The primary outcome was considered the need for a re-operation due to failure of meniscal repair. Patients were also evaluated by the following items: KOOS, Lysholm, Tegner, IKDC-subjective and Quadruple-VAS score. Subgroup analysis was performed to identify whether concurrent ACL reconstruction, side of the lesion, age at surgery and time from injury to repair could influence clinical outcome. Ten out 54 patients (18.5%) were considered failed and needed reoperation, mainly within one year from surgery. Overall, there was a significant increase in all clinical scores considered and patients were able to get back to previous sport activity level. Patients with concurrent ACL reconstruction presented a lower risk of failure (p=0.025). Patients with lateral meniscus repair showed better clinical outcome compared to medial meniscus. Timing from injury and age at surgery did not correlated with clinical outcome. Our series showed fair results in bucket handle repair up to middle term evaluation. Concomitant ACL reconstruction was associated with lower failure rate whereas lateral meniscus involvement was associated with higher functional scores at final follow-up evaluation.

The Iron Man of the Renaissance: the contribution of Girolamo Fabrizi d'Acquapendente.

PURPOSE: To highlight the most relevant contributions of the Italian Renaissance surgeon Girolamo Fabrizi d'Acquapendente in the field of orthopaedics and traumatology. METHODS: An extensive research on the life and achievements of Girolamo Fabrizi was conducted on University Libraries as well as on electronic databases like PubMed. RESULTS: Girolamo Fabrizi d'Acquapendente is known for his embryology and physiology studies, particularly on sensory organs and blood circulation. He founded the world's first permanent anatomical theater established at the University of Padua and inaugurated in 1595. His most notable publications include surgical and definitely orthopedics works such as "De fracturis" (On fractures) and "De luxationibus" (On joint displacement). He outlined some principles of treatment that are still valid nowadays such as anatomical reduction and stabilization of the fracture, that were applied using the equipment available at that time. He described and illustrated maneuvers and instruments, such as pulleys, winches, splint, and bandages. He further depicted the famous "Oplomochlion" ("the armored man"), which is actually a collection of all of the braces used at the time to correct congenital and post-traumatic deformities. CONCLUSION: Bracing and prosthetic replacements have accompanied medical history throughout the centuries, from Ancient Egypt to the present, but it was the ingenuity of Renaissance surgeons that pushed biomedical technology to new heights: Girolamo Fabrizi d'Acquapendente was one of the most illustrious contributors to these great achievements.

Allograft tendons are a safe and effective option for revision ACL reconstruction: a clinical review.

Revision anterior cruciate ligament reconstruction remains a challenge, especially optimising outcome for patients with a compromised knee where previous autogenous tissue has been used for reconstruction. Allograft tissue has become a recognized choice of graft for revision surgery but questions remain over the risks and benefits of such an option. Allograft tendons are a safe and effective option for revision ACL reconstruction with no higher risk of infection and equivalent failure rates compared to autografts provided that the tissue is not irradiated, or any irradiation is minimal. Best scenarios for use of allografts include revision surgery where further use of autografts could lead to high donor site morbidity, complex instability situations where additional structures may need reconstruction, and in those with clinical and radiologic signs of autologous tendon degeneration. A surgeon needs to be able to select the best option for the challenging knee facing revision ACL reconstruction, and in the light of current data, allograft tissue can be considered a suitable option to this purpose.Level of evidence IV.

Implant strategy affects scaffold stability and integrity in cartilage treatment.

PURPOSE: To identify the most appropriate implantation strategy for a novel chondral scaffold in a model simulating the early post-operative phase, in order to optimize the implant procedure and reduce the risk of early failure. METHODS: Eight human cadaveric limbs were strapped to a continuous passive motion device and exposed to extension-flexion cycles (0°-90°). Chondral lesions (1.8 cm diameter) were prepared on condyles, patella and trochlea for the implant of a bi-layer collagen-hydroxyapatite scaffold. The first set-up compared four fixation techniques: press-fit (PF) vs. fibrin glue (FG) vs. pins vs. sutures; the second compared circular and square implants; the third investigated stability in a weight-bearing simulation. The scaffolds were evaluated using semi-quantitative Drobnic and modified Bekkers scores. RESULTS: FG presented higher total Drobnic and Bekkers scores compared to PF (both p = 0.002), pins (p = 0.013 and 0.001) and sutures (p = 0.001 and < 0.0005). Pins offered better total Drobnic and Bekkers scores than PF in the anterior femoral condyles (p = 0.007 and 0.065), similar to FG. The comparison of round and square implants applied by FG showed worst results for square lesions (Drobnic score p = 0.049, Bekkers score p = 0.037). Finally, load caused worst overall results (Drobnic p = 0.018). CONCLUSIONS: FG improves the fixation of this collagen-HA scaffold regardless of lesion location, improving implant stability while preserving its integrity. Pins represent a suitable option only for lesions of the anterior condyles. Square scaffolds present weak corners, therefore, round implants should be preferred. Finally, partial weight-bearing simulation significantly affected the scaffold. These findings may be useful to improve surgical technique and post-operative management of patients, to optimize the outcome of chondral scaffold implantation.

Patients control preferences and results in knee arthroplasty.

PURPOSE: Patient engagement in a patient-physician decision-making process has been correlated with satisfaction and clinical outcomes. Aim of this study is to evaluate if patient control preference may also influence TKA results. METHODS: One hundred and seventy-six patients (120w-56m, age 66 ± 9 years, BMI 28 ± 4) underwent TKA and were prospectively evaluated, before surgery and at 6 and 12 months. The preoperative assessment included the Control Preference Scale (CPS) and other scales measuring psychological aspects (STAI, BDI, TSK), as well as SF12 (physical and mental subscales) and the assessment of pain and function. Pain, function, and SF12 subscales were then used to evaluate the improvement at 6- and 12-month follow-up. RESULTS: Pain, function, and SF12 scores improved at 6 and 12 months. CPS correlated with the outcome: pain and functional improvement at 6 months (p = 0.014; p = 0.003, respectively), patient function at 6 months (p = 0.022), improvement of SF12 physical subscale at 6 and 12 months (p = 0.027; p = 0.037, respectively), and satisfaction at 6 months (p = 0.033). Moreover, the multivariate analysis confirmed the importance of CPS regardless of other demographic, physical or psychological characteristics. CONCLUSION: In contrast with previous literature findings, this study shows that patients with more propensity for control presented lower improvements of pain and function than those more prone to rely on the physician making the decision. Physicians should be aware that the patient control preference may influence the treatment outcome and undertake measurements to optimize patient participation in the shared process to optimize the chances of TKA success. LEVEL OF EVIDENCE: IV.

Polyurethane-based cell-free scaffold for the treatment of painful partial meniscus loss.

PURPOSE: The aim of this study was to document, at mid-term follow-up, the clinical and MRI outcome of a polyurethane-based cell-free scaffold implanted to treat painful partial meniscus loss. METHODS: Eighteen consecutive patients were enrolled and treated with arthroscopic polyurethane meniscal scaffold implantation and, in case of other comorbidities, with concurrent surgical procedures: 16 patients (9 men and 7 women, mean age 45 ± 13 years, mean BMI 25 ± 3, 12 medial and 4 lateral implants) were prospectively evaluated with the subjective and objective IKDC and the Tegner scores at 24, 36, 48, 60, and 72 months of follow-up. Eleven patients were also evaluated by 1.5-T MRI at the final follow-up. RESULTS: The IKDC subjective score showed a significant improvement from baseline to 24 months (45.6 ± 17.5 and 75.3 ± 14.8, respectively; p = 0.02) and subsequent stable results over time for up to 72 months (final score 75.0 ± 16.8). The Tegner score improvement between pre-operative status and final follow-up was also significant (p = 0.039). Nevertheless, the final score remained significantly lower than the pre-injury sports activity level (p = 0.027). High-resolution MRIs documented the presence of abnormal findings in terms of morphology, signal intensity, and interface between the implant and the native meniscus. Implant extrusion and bone oedema at the treated compartment were also observed in most of the cases, even though no correlation was found between imaging findings and clinical outcome. CONCLUSIONS: The present study reports satisfactory clinical outcomes at mid-term follow-up after polyurethane-based meniscal cell-free scaffold implantation. The treatment was effective both in cases of isolated partial meniscal lesions and in complex cases requiring the combination with other surgical procedures. On the other hand, a high rate of altered MRI aspects was documented. However, no correlation was found between the altered imaging parameters and the overall positive clinical findings, thus supporting the use of this procedure to treat painful partial meniscus loss. LEVEL OF EVIDENCE: Case series, Level IV.

Kinesiophobia and depression affect total knee arthroplasty outcome in a multivariate analysis of psychological and physical factors on 200 patients.

PURPOSE: To evaluate the effects of kinesiophobia on the outcomes of total knee arthroplasty (TKA), and to investigate whether kinesiophobia represents an independent factor influencing the surgery success or whether the observed effects are driven by other physical or psychological aspects such as anxiety and depression. METHODS: Two hundred patients were evaluated prospectively (mean age 65.7 ± 9.1 years, 134 women and 66 men) at 12 months after TKA. Kinesiophobia was assessed with the Tampa Scale for kinesiophobia (TSK: Activity Avoidance-TSK1 and Harm-TSK2 subscales); anxiety and depression were assessed with STAI and BDI, respectively, and preoperative pain and function, sex, age, BMI, education level, number of painful joints and years of symptoms' duration before surgery were documented as well. Results were evaluated with pain and function on 0-10 numeric rating scales, while the overall clinical outcome was documented with WOMAC and SF-12 (Physical and Mental subscales) scores. RESULTS: TSK1 was correlated with WOMAC results at 12 months (p = 0.005, ρ = 0.197). STAI (p = 0.002, ρ = 0.222), BDI (p < 0.0005, ρ = 0.307), and sex (p = 0.004) also influenced the outcome after TKA, while other parameters, such as age, BMI, education level, and number of painful joints and years of symptoms' duration before surgery, did not correlate with the clinical outcome. The multivariate analysis confirmed the role of BDI (p = 0.006, partial η 2 = 0.038), TSK1 (p = 0.011, partial η 2 = 0.033), and sex (p = 0.048, partial η 2 = 0.020), and a synergic interaction of BDI and TSK1, which together presented an even stronger correlation (p < 0.0005, partial η 2 = 0.111) with WOMAC at 12-month follow-up. CONCLUSIONS: Kinesiophobia is a factor influencing the outcome after TKA independently from other psychological and physical variables. This risk factor may affect TKA results, especially in women, and shows a further synergic interaction with depression in terms of lower surgical outcome. These findings are of clinical relevance because they show the impact of psychological factors such as kinesiophobia, and suggest the possibility of adopting co-interventions to overcome the fear of physical activity, and in the end improve patient recovery and final outcome after TKA. LEVEL OF EVIDENCE: IV.

Regenerative approaches for the treatment of early OA.

The diagnosis and the prompt treatment of early osteoarthritis (OA) represent vital steps for delaying the onset and progression of fully blown OA, which is the most common form of arthritis, involving more than 10 % of the world's population older than 60 years of age. Nonsurgical treatments such as physiotherapy, anti-inflammatory medications, and other disease-modifying drugs all have modest and short-lasting effect. In this context, the biological approaches have recently gained more and more attention. Growth factors, blood derivatives, such as platelet concentrates, and mesenchymal adult stem cells, either expanded or freshly isolated, are advocated amongst the most promising tool for the treatment of OA, especially in the early phases. Primarily targeted towards focal cartilage defects, these biological agents have indeed recently showed promising results to relieve pain and reduce inflammation in patients with more advanced OA as well, with the final aim to halt the progression of the disease and the need for joint replacement. However, despite of a number of satisfactory in vitro and pre-clinical studies, the evidences are still limited to support their clinical efficacy in OA setting.

Platelet-rich plasma: why intra-articular? A systematic review of preclinical studies and clinical evidence on PRP for joint degeneration.

PURPOSE: The aim of this review was to analyze the available evidence on the clinical application of this biological approach for the injective treatment of cartilage lesions and joint degeneration, together with preclinical studies to support the rationale for the use of platelet concentrates, to shed some light and give indications on what to treat and what to expect from intra-articular injections of platelet-rich plasma (PRP). METHODS: All in vitro, in vivo preclinical and clinical studies on PRP injective treatment in the English language concerning the effect of PRP on cartilage, synovial tissue, menisci, and mesenchymal stem cells were considered. A systematic review on the PubMed database was performed using the following words: (platelet-rich plasma or PRP or platelet concentrate or platelet lysate or platelet supernatant) and (cartilage or chondrocytes or synoviocytes or menisci or mesenchymal stem cells). RESULTS: Fifty-nine articles met the inclusion criteria: 26 were in vitro, 9 were in vivo, 2 were both in vivo and in vitro, and 22 were clinical studies. The analysis showed an increasing number of published studies over time. Preclinical evidence supports the use of PRP injections that might promote a favourable environment for joint tissues healing. Only a few high-quality clinical trials have been published, which showed a clinical improvement limited over time and mainly documented in younger patients not affected by advanced knee degeneration. CONCLUSIONS: Besides the limits and sometimes controversial findings, the preclinical literature shows an overall support toward this PRP application. An intra-articular injection does not just target cartilage; instead, PRP might influence the entire joint environment, leading to a short-term clinical improvement. Many biological variables might influence the clinical outcome and have to be studied to optimize PRP injective treatment of cartilage degeneration and osteoarthritis.

Fibrin glue improves osteochondral scaffold fixation: study on the human cadaveric knee exposed to continuous passive motion.

OBJECTIVE: To evaluate stability and integrity of bi-layer and three-layer collagen-hydroxyapatite (C-HA) osteochondral scaffolds in a human cadaveric knee exposed to continuous passive motion (CPM) with and without loading and the role of added fibrin glue to improve the press-fit fixation of C-HA scaffolds. DESIGN: Osteochondral lesions (2.0 × 1.5 cm) were chiseled out on both condyles and trochlea in eight human cadaveric knees. A total of 24 bi-layer (5 mm, four in each condyle) or three-layer C-HA scaffolds (8 mm, eight in the trochlea, four in each condyle) were first press-fit implanted and underwent testing with CPM, 90 cycles, 0°-90°. The second set of 24 scaffolds was implanted in cleaned lesions with the addition of fibrin glue. Two knees with fibrin glue fixation were additionally exposed to 15 kg loading, with 30 cycles of CPM, 0°-30°. Then, the knees were reopened and the scaffolds were evaluated using semi-quantitative Drobnic and modified Bekkers scores. RESULTS: All but two scaffolds remained in the lesions site throughout CPM. Two implants failed: both were bi-layer osteochondral scaffolds, press-fit implanted at the lateral femoral condyle (LFC). A statistically significant difference was obtained between press-fit and fibrin glue implants with both Drobnic (2.9 ± 0.7 vs 4.3 ± 0.1, P < 0.0005) and Bekkers (3.3 ± 1.0 vs 5.0 ± 0.1, P < 0.0005) scores. Additional knee loading did not affect fibrin glue scaffold fixation or integrity. CONCLUSION: This cadaveric study showed fibrin glue notably improved bi-layer or three-layer C-HA scaffold press-fit fixation regardless of lesion location. It is therefore recommended that fibrin glue be used during surgery to improve early post-operative C-HA scaffold stability and integrity.

Osteochondral regeneration using a novel aragonite-hyaluronate bi-phasic scaffold in a goat model.

PURPOSE: The objective of this study was to examine whether different mechanical modifications and/or impregnation of hyaluronic acid (HA) might enhance aragonite-based scaffold properties for the regeneration of cartilage and bone in an animal model. METHODS: Bi-phasic osteochondral scaffolds were prepared using coralline aragonite with different modifications, including 1- to 2-mm-deep drilled channels in the cartilage phase (Group 1, n = 7) or in the bone phase (Group 2, n = 8), and compared with unmodified coral cylinders (Group 3, n = 8) as well as empty control defects (Group 4, n = 4). In each group, four of the implants were impregnated with HA to the cartilage phase. Osteochondral defects (6 mm diameter, 8 mm depth) were made in medial and lateral femoral condyles of 14 goats, and the scaffolds were implanted according to a randomization chart. After 6 months, cartilage and bone regeneration were evaluated macroscopically and histologically by an external laboratory. RESULTS: Group 1 implants were replaced by newly formed hyaline cartilage and subchondral bone (combined histological evaluation according to the ICRS II-2010 and O'Driscoll et al. 34 ± 4 n = 7). In this group, the cartilaginous repair tissue showed a smooth contour and was well integrated into the adjacent native cartilage, with morphological evidence of hyaline cartilage as confirmed by the marked presence of proteoglycans, a marked grade of collagen type II and the absence of collagen type I. The average scores in other groups were significantly lower (Group 2 (n = 8) 28.8 ± 11, Group 3 (n = 8) 23 ± 9 and Group 4 (empty control, n = 4) 19.7 ± 15). CONCLUSIONS: The implants with the mechanical modification and HA impregnation in the cartilage phase outperformed all other types of implant. Although native coral is an excellent material for bone repair, as a stand-alone material implant, it does not regenerate hyaline cartilage. Mechanical modification with drilled channels and impregnation of HA within the coral pores enhanced the scaffold's cartilage regenerative potential. The modified implant shows young hyaline cartilage regeneration. This implant might be useful for the treatment of both chondral and osteochondral defects in humans.

Platelet-rich plasma for foot and ankle pathologies: a systematic review.

BACKGROUND: The aim of this article is to review systematically all the literature available on the clinical application of PRP for the treatment of foot and ankle pathologies, to understand its potential and best indications for clinical use. METHODS: A systematic search of the PubMed database was performed. Research criteria were the following: (1) papers in the English language, (2) dealing with the clinical application of PRP for the treatment of orthopedic-related conditions affecting the foot and ankle district, (3) with I to IV level of evidence, and (4) reporting clinical results. RESULTS: A total of 17 studies fulfilled the inclusion criteria. Nine papers dealt with Achilles tendon management, 2 articles with plantar fasciitis, 3 papers with talar osteochondral lesions, 2 with PRP application in total ankle replacement, and 1 article with PRP in foot and ankle fusions. The overall evaluation of the results reported does not clearly demonstrate the potential of PRP treatment in any of the specific fields of application. CONCLUSIONS: Considering the literature currently available, no clear indications for using PRP in the foot and ankle district emerged. LEVEL OF EVIDENCE: Level IV, systematic review of Level I, II, III and IV studies.

Effect of diet on the gut mycobiome and potential implications in inflammatory bowel disease.

The gut microbiome is a complex, unique entity implicated in the prevention, pathogenesis, and progression of common gastrointestinal diseases. While largely dominated by bacterial populations, advanced sequencing techniques have identified co-inhabiting fungal communities, collectively referred to as the mycobiome. Early studies identified that gut inflammation is associated with altered microbial composition, known as gut dysbiosis. Altered microbial profiles are implicated in various pathological diseases, such as inflammatory bowel disease (IBD), though their role as a cause or consequence of systemic inflammation remains the subject of ongoing research. Diet plays a crucial role in the prevention and management of various diseases and is considered to be an essential regulator of systemic inflammation. This review compiles current literature on the impact of dietary modulation on the mycobiome, showing that dietary changes can alter the fungal architecture of the gut. Further research is required to understand the impact of diet on gut fungi, including the metabolic pathways and enzymes involved in fungal fermentation. Additionally, investigating whether dietary modulation of the gut mycobiome could be utilized as a therapy in IBD is essential.

Intramuscular injections of botulinum toxin for the treatment of upper back myofascial pain syndrome: A systematic review of randomized controlled trials.

BACKGROUND AND OBJECTIVE: Myofascial pain syndrome (MPS) is a chronic musculoskeletal disorder characterized by the presence of trigger points. Among the treatment options, botulinum toxin injections have been investigated. The aim of this paper was to provide a synthesis of the evidence on intramuscular botulinum toxin injections for upper back MPS. DATABASES AND DATA TREATMENT: A systematic review of the literature was performed on the PubMed, Scopus and Cochrane Library, using the following formula: ("botulinum") AND ("musculoskeletal") AND ("upper back pain") OR ("myofascial pain"). RESULTS: Ten studies involving 651 patients were included. Patients in the control groups received placebo (saline solution) injections, anaesthetic injections + dry needling or anaesthetic injections. The analysis of the trials revealed modest methodological quality: one "Good quality" study, one "Fair" and the other "Poor". No major complications or serious adverse events were reported. Results provided conflicting evidence and did not demonstrate the superiority of botulinum toxin over comparators. Most of the included trials were characterized by a small sample size, weak power analysis, different clinical scores used and non-comparable follow-up periods. Even if there is no conclusive evidence, the favourable safety profile and the positive results of some secondary endpoints suggest a potentially beneficial action in pain control and quality of life. CONCLUSION: The currently available studies show conflicting results. Their overall low methodological quality does not allow for solid evidence of superiority over other comparison treatments. Further insights are needed to properly profile patients who could benefit more from this peculiar injective approach. SIGNIFICANCE: The randomized controlled trials included in this review compared using botulinum toxin to treat upper back MPS with placebo or active treatments (e.g., dry needling or anaesthetics) showing mixed results overall. Despite the lack of clear evidence of superiority, our study suggests that the use of botulinum toxin should not be discouraged. Its safety profile and encouraging results in pain control, motor recovery and disability reduction make it an interesting treatment, particularly in the subset of patients with moderate to severe chronic pain and active trigger points. To support the safety and efficacy of botulinum toxin, further high-quality studies are needed.

Early rehabilitation vs. conventional immobilization in nonoperative treatment of proximal humeral fracture: a systematic review.

OBJECTIVE: Fractures of the proximal humerus (PHF) are commonly treated conservatively. Evidence suggests that a period of immobilization of one week or less may lead to some advantages compared to a traditional 3-4 weeks of immobilization. The purpose of this systematic review was to assess the clinical and radiological results in the case of early rehabilitation vs. delayed rehabilitation after PHF. MATERIALS AND METHODS: In July 2023, a literature search was carried out on the PubMed, MEDLINE, and Embase databases to identify all the randomized trials comparing early rehabilitation vs. delayed rehabilitation after PHF. The following data were extracted from each included study: patients' demographics, study design and level of evidence, follow-up times, treatment groups, evaluation scores adopted, and overall clinical and radiological findings. The quality of the trials was assessed using the Cochrane Risk of Bias Assessment. RESULTS: A total of 5 studies, including 378 patients and dealing with early vs. delayed rehabilitation in case of conservative treatment of PHF, were included in this study. Early rehabilitation was started within 1 week and consisted mainly of pendulum exercise and progressive passive mobilization. Early rehabilitation was associated with better pain and functional scores within the first 3 months in 3 studies. No difference in pain or function was reported at 6 months or longer follow-up, and no differences in complications rate were observed between early vs. delayed rehabilitation groups. CONCLUSIONS: This systematic review suggests that early mobilization within one week in case of conservative treatment of PHF leads to improved function recovery and reduced pain, especially in the first months of rehabilitation, without differences at longer follow-up and without increasing complications rate. Reducing immobilization time could accelerate function recovery and regaining independence in daily life activities.

Unicompartmental osteoarthritis: an integrated biomechanical and biological approach as alternative to metal resurfacing.

PURPOSE: Although traditionally not indicated for the treatment of osteoarthritis (OA), regenerative procedures are becoming a focus of increased interest due to their potential to provide pain relief and alter the progression of degenerative diseases. The purpose of this study was to assess whether a combined biomechanical and biological approach could offer good results in unicompartmental OA, thus delaying the need for unicompartmental arthroplasty in patients too young or refusing metal resurfacing. METHODS: Forty-three patients (mean age = 40.1 ± 11 years, 33 men and 10 women, mean BMI = 25 ± 3) affected by unicompartmental OA (Kellegren-Lawrence score = 3) in stable joints were enrolled and treated consecutively. Fifteen patients were treated with osteotomy and osteochondral biomimetic scaffold implant (3 of them also with meniscal substitution), 11 with osteotomy and meniscal scaffold implant, 9 with osteotomy and meniscal allograft implant, and 8 with both cartilage and meniscal reconstruction, depending on the specific joint compartment main requirements. Clinical evaluation was performed at 3-year (2-4) median follow-up using the following scoring systems: IKDC subjective and objective, VAS for pain, and Tegner scores. Failures, adverse events, and complications were also reported. RESULTS: The IKDC subjective score improved from 47.3 to 79.6 at the final evaluation (p < 0.0005), VAS improved from 6.1 to 2.3 (p < 0.0005), and also sport activity level evaluated with the Tegner score showed a significant improvement, from 2 (1-5) to 4 (3-10; p < 0.0005), even if without achieving the pre-injury level (6, p = 0.001). A further subanalysis confirmed the positive outcome obtained in all the treatment subgroups and showed a higher clinical improvement in patients under the age of 40 years (IKDC subjective 84.4 ± 13.2 vs 76.5 ± 17.3; p = 0.03). CONCLUSION: This integrated biological and biomechanical approach produced a marked improvement at short-medium follow-up in patients affected by unicompartmental OA. Even though a good outcome was achieved at all ages, patients under the age of 40 years presented a greater clinical and subjective improvement. Longer follow-up studies are needed to show results over time and confirm this approach as an effective alternative to unicompartmental implants.

External fixator-assisted plating osteosynthesis in a rabbit model of femoral bone defects appears to be a feasible and reproducible surgical technique: preliminary insights from a bone substitute study.

PURPOSE: The aims of this study were to assess the complications associated with the use of an external fixator-assisted plate osteosynthesis technique to stabilize a femoral bone defect in a rabbit model and to evaluate if this technique could avoid the mispositioning and the displacement of the femoral fragments during the surgical procedure. METHODS: A preliminary cadaveric animal study was conducted to develop a new technique of external fixator-assisted plating. Thirty rabbits underwent a surgical procedure consisting in the creation of a femoral bone defect and, subsequently an implantation of a bone substitute through the assistance of a temporary external fixator. The fixator's ability to maintain length and alignment during surgery was documented. All intraoperative complications were prospectively collected. RESULTS: No complications related to the use of the temporary external fixator were reported. The technique successfully prevented mispositioning and dislocation during plating in all the rabbits. CONCLUSION: In a rabbit animal model, the use of an external fixator-assisted plate osteosynthesis technique appears to be feasible and effective in avoiding misposition and rotation of femoral fragments when performing osteotomy and plating to create a mid-diaphyseal femoral defect.

Use of chloroprocaine in orthopedic day surgery: a brief report in a cohort of patients undergoing knee arthroscopy.

OBJECTIVE: Spinal anesthesia with local anesthetics is a viable alternative to general anesthesia in orthopedic surgery, and it is currently considered the standard of care for knee arthroscopy. The use of chloroprocaine may offer several potential advantages over other local anesthetics, including, above all, its rapid onset and short duration of action. The aim of the present retrospective study is to evaluate the post-surgical outcomes of patients who underwent knee arthroscopy using spinal anesthesia with chloroprocaine in an outpatient orthopedic setting. PATIENTS AND METHODS: Data from patients who underwent elective knee arthroscopy between January 2022 and December 2022 were collected for the present study. Spinal anesthesia with chloroprocaine 10 mg/mL was administered in the designated subarachnoid space (L3-L4 in the majority of patients). A dosage of 40 mg was used to obtain a satisfactory sensory and motor block. RESULTS: A total number of 302 patients met the inclusion criteria. No complications were reported during surgery in the present series of patients. None of the patients required bladder catheterization. In 84% of cases, the PADSS (Post-Anesthetic Discharge Scoring System) score at discharge was 10, whereas in 16% of cases, the PADSS score was 9. The mean time from anesthesia induction to first urination was 75±9.4 minutes, while the mean time from the anesthesia induction to the discharge from the hospital was 152±18.5 minutes. CONCLUSIONS: Spinal chloroprocaine for knee arthroscopy demonstrated a short motor block duration, resulting in a fast time to discharge. These limited data show that chloroprocaine may be safely and effectively applied in outpatient knee arthroscopy procedures. However, more studies, possibly with a randomized design, are required to confirm these findings.