The Role of Low-Level Laser Therapy in Bone Healing: Systematic Review.

Low-level laser therapy (LLLT) is a treatment that is increasingly used in orthopedics practices. In vivo and in vitro studies have shown that low-level laser therapy (LLLT) promotes angiogenesis, fracture healing and osteogenic differentiation of stem cells. However, the underlying mechanisms during bone formation remain largely unknown. Factors such as wavelength, energy density, irradiation and frequency of LLLT can influence the cellular mechanisms. Moreover, the effects of LLLT are different according to cell types treated. This review aims to summarize the current knowledge of the molecular pathways activated by LLLT and its effects on the bone healing process. A better understanding of the cellular mechanisms activated by LLLT can improve its clinical application.

The Role of PEMFs on Bone Healing: An In Vitro Study.

Bone responses to pulsed electromagnetic fields (PEMFs) have been extensively studied by using devices that expose bone cells to PEMFs to stimulate extracellular matrix (ECM) synthesis for bone and cartilage repair. The aim of this work was to highlight in which bone healing phase PEMFs exert their action. Specifically, we evaluated the effects of PEMFs both on human adipose mesenchymal stem cells (hASCs) and on primary human osteoblasts (hOBs) by testing gene and protein expression of early bone markers (on hASCs) and the synthesis of late bone-specific proteins (on hOBs) as markers of bone remodeling. Our results indicate that PEMFs seem to exert their action on bone formation, acting on osteogenic precursors (hASCs) and inducing the commitment towards the differentiation pathways, unlike mature and terminally differentiated cells (hOBs), which are known to resist homeostasis perturbation more and seem to be much less responsive than mesenchymal stem cells. Understanding the role of PEMFs on bone regenerative processes provides important details for their clinical application.

Biomarkers for Ehlers-Danlos Syndromes: There Is a Role?

Ehlers-Danlos syndromes (EDS) are an inherited heterogeneous group of connective tissue disorders characterized by an abnormal collagen synthesis affecting skin, ligaments, joints, blood vessels, and other organs. It is one of the oldest known causes of bruising and bleeding, and it was described first by Hippocrates in 400 BC. In the last years, multiple gene variants involved in the pathogenesis of specific EDS subtypes have been identified; moreover, new clinical diagnostic criteria have been established. New classification models have also been studied in order to differentiate overlapping conditions. Moreover, EDS shares many characteristics with other similar disorders. Although distinguishing between these seemingly identical conditions is difficult, it is essential in ensuring proper patient care. Currently, there are many genetic and molecular studies underway to clarify the etiology of some variants of EDS. However, the genetic basis of the hypermobile type of EDS (hEDS) is still unknown. In this review, we focused on the study of two of the most common forms of EDS-classic and hypermobile-by trying to identify possible biomarkers that could be of great help to confirm patients' diagnosis and their follow up.

MRI can assess glenoid bone loss after shoulder luxation: inter- and intra-individual comparison with CT.

OBJECTIVE: Computed tomography (CT) is the gold standard for evaluating glenoid bone loss in patients with glenohumeral dislocations. The aim of this study was to verify if magnetic resonance imaging (MRI) can quantify the area of bone loss without any significant difference from CT. MATERIALS AND METHODS: Twenty-three patients, who had experienced one or more post-traumatic unilateral glenohumeral dislocations, underwent MRI and CT. MR and multiplanar reconstruction CT images were acquired in the sagittal plane: the glenoid area and the area of bone loss were calculated using the PICO method. Mean values, percentages, Cohen's kappa coefficients and Bland-Altman plots were all used to confirm the working hypothesis. RESULTS: The mean glenoid surface area was 575.29 mm(2) as measured by MRI, and 573.76 mm(2) as measured by CT; the calculated mean glenoid bone loss was respectively 4.38% and 4.34%. The interobserver agreement was good (k>0.81), and the coefficient of variance was 5% of the mean value using both methods. The two series of measurements were within two standard deviations of each other. CONCLUSIONS: MRI is a valid alternative to CT for measuring glenoid bone loss in patients with glenohumeral dislocation.

The use of a large diameter glenosphere in Reverse Shoulder Arthroplasty for proximal humeral fractures in elderly patients undergoing tuberosity removal.

BACKGROUND AND AIM: Prosthetic replacement with reverse shoulder arthroplasty (RSA) is commonly indicated for complex proximal humerus fractures (PHFs) in elderly patients. Aim of this study was to evaluate the clinical and radiological outcomes of RSA performed for comminuted PHFs, without periprosthetic reconstruction of the tuberosities. Our hypothesis was that a large diameter glenosphere could ensure satisfactory RSA mobility and stability, regardless of tuberosity removal. METHODS: We selected 32 patients (4 men, 28 women) with comminuted PHFs who underwent RSA with tuberosity excision and implantation of a 44-mm glenosphere between 2009 and 2015. Active range of motion (ROM), stability, Constant-Murley Score (CMS) (1) and Subjective Shoulder Value (SSV) (2) were assessed one year and four years after surgery. RESULTS: Clinical and radiological information were collected for 23 patients (72%). At one-year follow-up, active anterior elevation (AE) was 96±28 degrees, external rotation with adducted arm (ER1) 9±7 degrees, external rotation with abducted arm (ER2) 14±10 degrees, internal rotation (IR) to L4; CMS was 56±10 and SSV 65±22. Clinical assessment at 4-year follow up showed a decrease in active ROM (AE was 88±20 degrees, ER1 8±2 degrees, ER2 12±10 degrees, IR to L4), CMS (52±9) and SSV (62±8). No RSA dislocation occurred during the study. In 4 patients, grade I glenoid notching without any sign of component loosening was observed 4 years after surgery. CONCLUSIONS: A large diameter glenosphere does not ensure results comparable to those achieved after RSA with tuberosity reconstruction. However, the 44-mm glenosphere was effective in preventing RSA instability.

Pain in Ehlers-Danlos Syndrome: A Non-Diagnostic Disabling Symptom?

BACKGROUND: Ehlers-Danlos syndrome (EDS) is a phenotypically and genetically heterogeneous group of connective tissue disorders. Currently, diagnosis of EDS is based on a series of clinical and genetic tools. On the other hand, the hypermobile form has not yet been characterized from a genetic point of view: it is considered a part of a continuous spectrum of phenotypes, ranging from isolated non syndromic joint hypermobility, through to the recently defined hypermobility spectrum disorders (HSD). The aim of this study is to characterize the pain symptom that is not considered among the diagnostic criteria but is relevant to what concerns the quality of life of patients with EDS. (2) Methods: A review of the literature was performed on two medical electronic databases (PubMed and Embase) on 20 December 2022. Study selection and data extraction were achieved independently by two authors and the following inclusion criteria were determined a priori: published in the English language and published between 2000 and 2022. (3) Results: There were fifty eligible studies obtained at the end of the search and screen process. Pain is one of the most common symptoms found in Ehlers-Danlos (ED) patients. Different causes seem to be recognized in different phases of the syndrome. (4) Conclusions: Pain is a nonspecific symptom and cannot be considered among the diagnostic criteria, but it is a negative predictive factor in the quality of life of patients with EDS. Therefore, proper evaluation and treatment is mandatory.

The Reamer-Irrigator-Aspirator (RIA) System for the treatment of aseptic femoral nonunions: Report of two cases and literature review.

Femoral shaft nonunions are disabling complications of fractures, with relevant socioeconomic and psychological impact. The incidence of femoral shaft nonunions is not negligible, ranging between 1% and 10% after intramedullary nailing, but can exceed 20% in case of subtrochanteric fractures. Treatment options are influenced by pathomechanical, anatomical, and clinical factors. Hypertrophic nonunions are usually treated by enhancing stability of fixation, while atrophic nonunions require additional biological stimulation to achieve bone union. The Reamer-Irrigator-Aspirator (RIA) System® was developed to reduce intramedullary pressure and heat generation during intramedullary reaming, thus preventing thermal necrosis and decreasing the risk of fat embolism. The RIA System allows to provide large volumes of high-quality morselized autologous bone, that has shown high osteogenetic and osteoinductive properties. Therefore, its use has been expanded as a valuable source of autologous bone graft for the treatment of large bone defects of different nature. In this article, we present two cases of complex femoral nonunions treated with the use of the RIA System. A review of the published literature on the treatment of femoral nonunions with RIA was also performed. Core tip: In case of atrophic nonunions, the RIA System can be used to obtain biologically active tissue to enhance bone healing. Despite the absence of high-quality studies focused on femoral nonunions, the efficacy of RIA is well-known and orthopaedic surgeons should be aware of this powerful tool.

Functional outcome of arthroscopic debridement for massive, irreparable rotator cuff tears.

Rotator cuff tears are a common cause of shoulder pain in the middle-aged population. The treatment of these lesions must be individualized on the basis of the type of patient, the clinical and anatomical picture. Arthroscopic debridement is indicated in painful massive tears, in the absence of severe functional impairment of the shoulder. The aim of this study is the evaluation of the medium term clinical results of this procedure.  We retrospectively assessed patients who underwent arthroscopic debridement surgery for massive rotator cuff injury in the period between January 2011 and December 2016 at our institution. A group of patients underwent a follow-up evaluation during which the Constant Score, Oxford Shoulder Score and NRS pain score were compiled. Those who were unable to attend the evaluation were assessed through a telephone questionnaire aimed at investigating pain and degree of satisfaction with the  treatment.  93% of patients were satisfied with the results obtained, with an average NRS of 1.31 for patients undergoing the medical examination and 0.68 for patients contacted by telephone. The mean Constant score of the evaluated patients was 75.6 ± sd, with a mean strength of 3.92 ± sd, while the mean value of the Oxford Shoulder Score was 16.8 ± sd.  The study suggests that arthroscopic debridement is a viable option for the surgical treatment of massive rotator cuff tears. The clinical results and patient satisfaction are conditioned by the preoperative functional status: an optimal outcome can be expected for painful shoulders with sufficiently preserved active mobility.

Subtrochanteric femoral fractures: A case series of 194 patients treated with long and short intramedullary nails.

Background: IM nails are the gold standard of subtrochanteric fractures management. Indications to use a short rather than a long nail remain unclear. Operative complications of subtrochanteric fractures reach up to 25%. Objective: Retrospectively compare clinical and radiographic outcome of subtrochanteric fractures treated by long and short intramedullary nailing, analysing rates of complications. Methods: 390 patients were chosen from the archives. 194 patients were available: 70 treated with a short intramedullary nail (Group A), while 124 with long one (Group B). Radiographic evaluation at 6 and 12 months assess failure of the osteosynthesis. Clinical outcomes were the return to normal activities prior trauma and VAS scale. Group A mean age was 81.37 years, group B mean age was 78.9 years (29-99, SD: 15.38). Results: Radiografic Healing was found in 66 patients (94.28%) in group A, while in 116 patients (94.54%) in group B. Pseudarthrosis was found in 4 cases (5.71%) in group A, while in 8 cases (6.45%) in group B. Implant failure occurred in 5 cases: one required revision of fixation, while 4 require hip replacement. 59 patients of group A (84.29%) returned to social life, while 102 patients (81.94%) in group B. Group A mean VAS was 1.55, Group B mean VAS was 1.49. Conclusion: Comparison of the two group showed no differences. Complication percentages are in line with literature. Optimal reduction and fixation allow high percentage of healing and return to social life.

Fast Functional Rehabilitation Protocol versus Plaster Cast Immobilization Protocol after Achilles Tendon Tenorrhaphy: Is It Different? Clinical, Ultrasonographic, and Elastographic Comparison.

BACKGROUND: the incidence of Achilles tendon (AT) rupture is rising; however, there is no clear consensus regarding the optimal treatment. The aim of this retrospective study was to compare instrumental and patient-reported outcome scores after fast functional rehabilitation (group A) versus plaster cast immobilization (group B) programs in patients who underwent AT tenorrhaphy. METHODS: 33 patients, with similar clinical and demographic features, underwent open AT tenorrhaphy between January and July 2018. Of these, 15 patients were treated with fast functional rehabilitation program (group A), and 18 patients were treated with plaster cast immobilization protocol (group B). Sural triceps hypotrophy and functional scores (American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, and Achilles tendon Total Rupture Score (ATRS)) were recorded at a 12-month follow-up. Ultrasonography (US) and elastosonography (ES) were used to compare the characteristics of the tendons after surgery. RESULTS: At 12 months, no significant differences in any of the patient-reported outcomes or the instrumental measurement tests were seen between the two groups. CONCLUSIONS: fast functional rehabilitation after AT surgical repair is safe, effective, and may be the first choice of treatment, especially in young, collaborative, and active patients.

Patients with Musculoskeletal Disorders Presenting to the Emergency Department: The COVID-19 Lesson.

BACKGROUND: Musculoskeletal disorders (MSKDs) are the most common class of complaints among patients presenting for care in the Emergency Department (ED). There is a non-urgent patient population with musculoskeletal complaints attending ED services that creates a burgeoning waiting list and contributes to overcrowding in Emergency Departments (EDs), which is a major concern worldwide. The recent (Coronavirus disease-19) COVID-19 pandemic is an unprecedented challenge that is revealing the structural and situational strengths and weaknesses of healthcare systems. METHODS: This study retrospectively and prospectively assessed patients presenting to the Emergency Department before and after the COVID-19 outbreak (from 21 February 2019 to 3 May 2019 and from 21 February 2020 to 3 May 2020) with non-traumatic or low-severity musculoskeletal conditions to test the hypothesis that these patients should have access to care outside the ED and that the COVID-19 outbreak has changed patients' care and health perception. RESULTS: A total of 613 patients were identified, and 542 of them (87.56%) participated in a personalized survey. From this number, 81.73% of the total accesses took place in 2019, and only 18.27% of the accesses took place during the first outbreak and lockdown. More than 90% of patients admitted to the ED accessed care during the day shift in both periods. A total of 87.30% of patients presenting to the ED with a MSKD followed their general practitioner's (GP) advice/referral in 2019, and 73.87% did so in 2020. The differences in the means of transport to the ED was statistically significant (p-value 0.002). CONCLUSIONS: The outbreak and lockdown period confirmed that there is an inappropriate use of the ED related to patients with MSKD. However, the ED appears to be the only available solution for these patients. New services and pathways are therefore needed to enhance MSKD management and reduce ED crowding. Additional observational studies shall be developed to confirm and compare our findings with those of various EDs. The main limit of the inferential part of the study is probably due to the small sample of patients in 2020.

Detection of SARS-CoV-2 in Cancellous Bone of Patients with COVID-19 Disease Undergoing Orthopedic Surgery: Laboratory Findings and Clinical Applications.

An emerging issue for orthopedic surgeons is how to manage patients with active or previous COVID-19 disease, avoiding any major risks for the surgeons and the O.R. personnel. This monocentric prospective observational study aims to assess the prevalence of SARS-CoV-2 viral RT-PCR RNA in cancellous bone samples in patients with active or previous COVID-19 disease. We collected data about 30 consecutive patients from our institution from January 2021 to March 2021 with active or previous COVID-19 disease. The presence of SARS-CoV-2 in the samples was determined using two different PCR-based assays. Eighteen of the thirty patients included in the study had a positive nasopharyngeal swab at the time of surgery. Twelve patients had a negative nasopharyngeal swab with a mean days since negativization of 138 ± 104 days, ranging from 23 to 331 days. Mean days of positivity to the nasal swab were 17 ± 17. Twenty-nine out of thirty (96.7%) samples were negative for the presence of SARS-CoV-2 RNA. In one sample, low SARS-CoV-2 load (Cycle threshold (Ct) 36.6.) was detected but not confirmed using an additional confirmatory assay. The conducted study demonstrates the absence of the viral genome within the analyzed cancellous bone. We think that the use of personal protection equipment (PPE) to only protect from aerosol produced during surgery, both in active and recovered patients, is not strictly necessary. We think that the use of PPE should not be employed by surgeons and the O.R. personnel to protect themselves from aerosols produced from the respiratory tract. Moreover, we think that our results could represent a valid basis for further studies related to the possibility of bone donation in patients that suffered and recovered from COVID-19.

Bilateral neglected posterior dislocation of the shoulder treated by reverse arthroplasty and contralateral osteochondral autograft. A case report.

Bilateral posterior dislocation of the glenohumeral joint is an uncommon event, that can be missed at the initial presentation. We report the case of a 76-year old woman, who suffered a traumatic bilateral posterior dislocation, that was diagnosed three months later. She underwent surgical treatment on both shoulders in a single stage. Since the right shoulder showed a defect of the articular surface >50%, a reverse shoulder arthroplasty was performed on this side. The resected portion of the humeral head was retrieved and used as osteochondral graft to fill the reverse Hill-Sachs lesion of the left shoulder. At 18-month follow up, the patient was pain-free and had recovered excellent shoulder function on both sides: Constant score was 79 for the right shoulder and 88 for the left one. X-rays showed a grade 1 scapular notch of the right reverse prosthesis and good incorporation of the graft in the left shoulder, with no evidence of degenerative joint changes. Neglected posterior dislocations of the shoulder can be surgically treated by replacement or reconstruction. In case of bilateral injuries, the surgeon should carefully evaluate the pathoanatomy of both glenohumeral joints in order to choose and plan the most suitable procedure. If shoulder replacement is required on one side, the resected portion of the humeral head can be used as osteochondral autograft for a reconstruction procedure in the opposite side. The choice is influenced by several variables and decision-making might be challenging.

Osteosynthesis devices in absorbable Magnesium alloy in comparison to standard ones: a Systematic Review on effectiveness and safety.

BACKGROUND AND AIM OF THE WORK: Magnesium (Mg) is a metal physiologically present in bone tissue and essential for bone health. Mg-based-alloys exhibit mechanical properties, namely density and strength, similar to human cortical bone. These features have been exploited for the development of osteosynthesis devices in biodegradable Mg-based-alloys. Accordingly, the aim of this study was to rank the effectiveness and safety of Mg-based alloys applied in bone surgery in comparison to other suitable metals, focusing in particular on Mg superior biocompatibility and biodegradability. METHODS: a systematic-review of the literature was conducted including only primary research studies dealing with patients suffering from fractured or osteotomized bones fixed using Mg-based osteosynthesis-devices. RESULTS: literature revision suggested Mg-alloys holding comparable properties and side effects in comparison with titanium (Ti) screws, thus showing similar efficacy and safety. In particular, the gas formation in the carpal bones was identified as the main side effect of the Mg-alloys, during the corrosion/degradation phase of Mg. CONCLUSIONS: according to the considered literature, the main advantages exploiting Mg-alloys for bone implants are related to their biocompatibility, bio-absorbability/-degradability, the lack of surgical removal, osteoconductivity and antibacterial activity. On the opposite, the main limitation of Mg-alloys is due to the poor mechanical resistance of small devices for internal fixation of bone fragments that lack of sufficient strength to withstand high forces. Therefore, an important future prospect could rely in the development of innovative hybrid systems aimed at fixing high load-bearing fractures, as well as in regenerative-medicine by developing new Mg-based engineered scaffolds.

Optimization of transdisciplinary management of elderly with femur proximal extremity fracture: A patient-tailored plan from orthopaedics to rehabilitation.

Fractures of femur proximal extremity (FFPE) are the most common fragility fractures requiring hospitalization, with a high risk of mortality, low independence in the activities of daily living and severe consequences on health-related quality of life. Timing for surgery has a key role in the management of elderly patients with FFPE as recommended by the Australian and New Zealand guidelines and the National Institute for Health and Care Excellence guidelines. Early surgery (within 48 h from hospital admission) allows significant benefits in terms of lower rates of postoperative complications and risk of death and can provide better functional outcomes. Therefore, time for surgery could be considered as a comorbidity marker. The choice between conservative or surgical approach surprisingly seems to be still not strongly supported by available literature, but it seems that both 30 d and 1 year risk of mortality is higher with the conservative treatment rather than with surgery. In light of these considerations, the optimization of FFPE management care is mandatory to improve functional outcomes and to reduce sanitary costs. Albeit it is widely accepted that transdisciplinary approach to patients suffering from FFPE is mandatory to optimize both short-term and long-term outcomes, the feasibility of a comprehensive approach in clinical practice is still a challenge. In particular, the large variability of figures involved could be considered both a resource and an additional disadvantage taking into account the difficulty to coordinate multidisciplinary approach covering care in all settings. Therefore, the aim of the present article was to summarize current evidence supporting transdisciplinary management of patients with FFPE, highlighting the benefits, feasibility and limitations of this approach.

Sarcopenia Diagnosis: Reliability of the Ultrasound Assessment of the Tibialis Anterior Muscle as an Alternative Evaluation Tool.

Sarcopenia is a skeletal muscle disorder characterized by reduced muscle mass, strength, and performance. Muscle ultrasound can be helpful in assessing muscle mass, quality, and architecture, and thus possibly useful for diagnosing or screening sarcopenia. The objective of this study was to evaluate the reliability of ultrasound assessment of tibialis anterior muscle in sarcopenia diagnosis. We included subjects undergoing total or partial hip replacement, comparing measures with a healthy control group. We measured the following parameters: tibialis anterior muscle thickness, echogenicity, architecture, stiffness, skeletal muscle index (SMI), hand grip strength, and sarcopenia related quality of life evaluated through the SarQoL questionnaire. We included 33 participants with a mean age of 54.97 ± 23.91 years. In the study group we found reduced tibialis anterior muscle thickness compared to the healthy control group (19.49 ± 4.92 vs. 28.94 ± 3.63 mm, p < 0.05) with significant correlation with SarQoL values (r = 0.80, p < 0.05), dynamometer hand strength (r = 0.72, p < 0.05) and SMI (r = 0.76, p < 0.05). Moreover, we found reduced stiffness (32.21 ± 12.31 vs. 27.07 ± 8.04 Kpa, p < 0.05). AUC measures of ROC curves were 0.89 predicting reduced muscle strength, and 0.97 predicting reduced SMI for tibialis anterior muscle thickness, while they were 0.73 and 0.85, respectively, for muscle stiffness. Our findings showed that ultrasound assessment of tibialis anterior muscle might be considered a reliable measurement tool to evaluate sarcopenia.

Autologous Platelet Rich Plasma (PRP) in the treatment of elbow epicondylitis and plantar fasciitis: medium to long term clinical outcome.

BACKGROUND AND AIM: Platelet-Rich-Plasma (PRP) is a popular biological therapy especially used to regenerate different musculoskeletal tissues by releasing growth-factors and cytokines promoting cell proliferation, chemotaxis, differentiation, and angiogenesis. The aim was to evaluate the clinical effectiveness and safety of PRP for Lateral-Epicondylitis (LE) of the elbow and Plantar-Fasciitis (PF). METHODS: A retrospective study was conducted including patients treated with a single topic autologous-PRP-injection between 1-1-2009 and 7-18-2019 for LE or PF at our institution; patients operated for the same problem, patients refusing the study or not traceable were excluded. Patients were assessed with VAS for pain and clinical scales. RESULTS: 33 patients were treated with PRP and 13 (8F, 5M) included: 4LE and 9PF for a total of 16 cases. The average pain level was 0.61±0.63: 1±1.41 for LE and 0,44±0 for PF. No significant side effect was reported. 4 PRP-treatments failed: 2LE and 2PF. OES and PRTEE gave excellent results for elbow. Average foot scores were AOFAS 98.2±5 and FADI 91.3±1. Patients were stratified and compared according to plantar arch conformation, follow-up length, healing time, time from diagnosis to PRP-treatment, therapies before PRP (physiotherapy, steroid infiltration or shock-waves), risk factors (standing work, sport, age, sex). CONCLUSIONS: As in other studies, our results do not allow to draw sufficiently valid conclusions regarding the effectiveness and safety of PRP in the treatment of LE and PF: in particular the statistical significance is limited by the small sample size. PRP can be chosen as a non-first-line treatment for LE and PF.

Indications and results of osteosynthesis for proximal humerus fragility fractures in elderly patients.

Proximal humerus fractures (PHF) are common injuries in the elderly population. Conservative treatment is indicated for undisplaced and stable fractures, which account for almost 80% of the cases. More complex fracture patterns might need surgery, with a wide variety of indication criteria and surgical techniques described in the literature. Surgical treatment should be reserved for patients in good clinical conditions, autonomous in daily living activities and able to adhere to postoperative rehabilitation protocols. In the elderly population with severe osteoporosis, cognitive impairment and clinical comorbidities, the risk of surgical failures is high. In these patients, the choice between surgical and conservative treatment, as well as for the type of procedure, is even more difficult, with no general consensus in the literature. Final indication is usually conditioned by surgeon's experience and preference. Two independent reviewers (B.H and G.G) independently extracted studies on proximal humeral fractures. All selected studies were screened independently (B.H and G.G) based on title and abstract. Then the full text of any article that either judged potentially eligible was acquired and reviewed again. Any disagreement was resolved by discussing the full text manuscripts. Aim of the present paper is to review the literature about indications and results of osteosynthesis for proximal humerus fragility fractures in the elderly population.

Arthroscopically-assisted Reduction and Internal Fixation (ARIF) of tibial plateau fractures: clinical and radiographic medium-term follow-up.

BACKGROUND AND AIM OF THE WORK: Tibial plateau fractures include a wide spectrum of lesions with potentially disabling sequelae. Arthroscopically-assisted Reduction and Internal Fixation (ARIF) is an alternative to traditional ORIF. The aim of this retrospective single centre study is to evaluate medium-term clinical and radiographic outcomes achieved in a consecutive series of patients treated with ARIF. METHODS: 21 patients, with a mean age of 52.2 ± 13.4 years at surgery, were included. According to Schatzker classification, there were 9 type II, 10 type III, 2 type IV fractures. Associated intra-articular injuries (meniscal tears, tibial spine fractures, chondral lesions) were detected in 8 patients. At follow up, patients were clinically and radiographically evaluated according to knee ROM, KOOS, OKS and Rasmussen Clinical and Radiological Scores. RESULTS: At an average follow-up of 84 ± 22.5 months, 18 patients were evaluated. Mean values recorded were the following: knee ROM 1° - 135°, OKS 41.6 / 48 ± 8.18, subscale KOOS scores ranged from 75% ± 25.4 (Quality of Life) to 91.1% ± 11.2 (Pain), Rasmussen Clinical e Radiological 27.2 ± 2.64 (14 excellent, 3 good, 1 fair) and 9.1 ± 0.64 (15 excellent, 3 good) respectively. Worse results were observed in 5 patients with pre-existing degenerative chondropathy. CONCLUSIONS: ARIF revealed to be an effective technique for surgical treatment of unicondylar tibial plateau fractures. Our findings support the favourable results reported by other authors. ARIF is not a simple technique and requiresspecific experience in knee arthroscopy and a steep learning curve.(www.actabiomedica.it).

Translation, cross-cultural adaptation, reliability, and validation of the italian version of the Foot and Ankle Disability Index (FADI).

BACKGROUND AND AIM OF THE WORK: Foot-and-Ankle-Disability-Index (FADI) is one of the most widely used evaluation questionnaires for this anatomical district, but an italian validated version lacks and is necessary to properly evaluate italian people. In fact a correct interpretation of the items by patients is essential to obtain a precise subjective response, making the questionnaire valid to evaluate patients' satisfaction and wellness. Our purpose was to translate and culturally adapt into Italian the FADI questionnaire, and to check its reproducibility and validity. MATERIALS AND METHODS: The original english version of FADI questionnaire was translated into Italian and checked for medical part coherence. It was submitted to 10 italian randomized patients to verify a correct cultural adaptation, and then to other 50 randomized patients operated at their ankle or hallux to assess intra- and inter-observer reproducibility by the Pearson's-Correlation-Coefficient (PCC) and the Intra-Class-Correlation (ICC) coefficient. Moreover, Short-Form-36 (SF36) questionnaire for Quality-of-Life and Visual-Analogue-Scale (VAS) for pain were also administered to the same 60 people and compared to italian-FADI to perform validation analysis by PCC and ICC coefficient. RESULTS: Cultural adaptation of the translated version of the scale resulted good in terms of understandability by patients. An optimal correlation of the inter- and intra-observer reproducibility was obtained. The correlation obtained between FADI and SF-36 as well as between FADI and VAS indicates success in the validation process. CONCLUSIONS: Validation of the FADI italian version has been performed successfully, its use can be considered appropriate and is indicated in italian clinical practice. (www.actabiomedica.it).