BACKGROUND: Osteochondral lesions of the talus are common in patients suffering even minor trauma; timely diagnosis and treatment can prevent the development of early osteoarthritis. The objectives of this systematic review and meta-analysis were to evaluate the effects of additional procedures on arthroscopic ankle microperforations for osteochondral lesions. METHODS: A systematic literature search was conducted using PubMed-Medline, Cochrane Central, and Google Scholar to select clinical studies analyzing the efficacy of platelet-rich plasma (PRP), hyaluronic acid (HA), and bone marrow concentrate (BMC) procedures. Ten articles following PRISMA guidelines with a total of 464 patients were included in this review. Quality assessment using MINORS was performed, and all studies demonstrated high quality. RESULTS: The results of the systematic review showed benefits in all patients undergoing infiltrative therapy with PRP, hyaluronic acid, and BMC. The best results in terms of AOFAS score and VAS scale were found in patients undergoing PRP injection. The meta-analysis showed improvements in pain relief and return to daily activities in patients undergoing arthroscopic microperforations and PRP, although not reporting statistically significant results (p = 0.42). CONCLUSION: All treatment strategies reported better scores compared to the control groups. Among the various treatments analyzed, the addition of PRP appears to be the most valuable probably for the larger population receiving this treatment, showing excellent outcomes in pain reduction, clinical outcomes, and return to daily activities. LEVEL OF EVIDENCE: II.
Cartilage, Articular , Fractures, Stress , Talus , Humans , Fractures, Stress/surgery , Hyaluronic Acid , Cartilage, Articular/surgery , Cartilage, Articular/injuries , Talus/injuries , Pain/surgery , Arthroscopy/methods , Treatment Outcome
Foot and ankle disorders are a common reason for orthopedic surgical intervention. After surgery, specific precautions such as partial weight bearing or complete unloading, and the use of walking aids, coupled with a period of rest, are usually implemented to ensure the surgical outcome. However, when these aids are discontinued and the patients resume load increase and normal daily activities, they may enter a transitional phase characterized by inflammation, swelling, and pain. We call this phenomenon the "classic three-month post-operative adaptation phase" (POAP). It is essential to differentiate this physiological transition phase from other conditions, such as from the immediate post-surgical inflammation, complex pain regional syndrome, or an infection. The objective of this expert opinion is to describe and raise medical awareness of this evidence-based phenomenon, which we commonly observe in our daily practice.
Introduction: Advanced urothelial carcinoma remains aggressive and very hard to cure, while new treatments will pose a challenge for clinicians and healthcare funding policymakers alike. The U-CHANGE Project aimed to redesign the current model of care for advanced urothelial carcinoma patients to identify limitations ("as is" scenario) and recommend future actions ("to be" scenario). Methods: Twenty-three subject-matter experts, divided into three groups, analyzed the two scenarios as part of a multidimensional consensus process, developing statements for specific domains of the disease, and a simplified Delphi methodology was used to establish consensus among the experts. Results: Recommended actions included increasing awareness of the disease, increased training of healthcare professionals, improvement of screening strategies and care pathways, increased support for patients and caregivers and relevant recommendations from molecular tumor boards when comprehensive genomic profiling has to be provided for appropriate patient selection to ad hoc targeted therapies. Discussion: While the innovative new targeted agents have the potential to significantly alter the clinical approach to this highly aggressive disease, the U-CHANGE Project experience shows that the use of these new agents will require a radical shift in the entire model of care, implementing sustainable changes which anticipate the benefits of future treatments, capable of targeting the right patient with the right agent at different stages of the disease.
Dislocations or subluxations of the metatarsophalangeal joints are rare, and open reduction is necessary in special cases. In this case report, we present the case of a 30-year-old man who had chronic dislocation of the V metatarsophalangeal joint after a motorcycle accident. Stiffening of the joint capsule prevented closed reduction therefore the patient underwent surgery, after performing a Gauthier-type osteotomy the joint was stabilized by k-wire. The patient had an excellent recovery with no new dislocation episodes.
Bone tissue is mainly composed at the nanoscale of apatite minerals, collagen molecules and water that form the mineralized collagen fibril (MCF). In this work, we developed a 3D random walk model to investigate the influence of bone nanostructure on water diffusion. We computed 1000 random walk trajectories of water molecules within the MCF geometric model. An important parameter to analyse transport behaviour in porous media is tortuosity, computed as the ratio between the effective path length and the straight-line distance between initial and final points. The diffusion coefficient is determined from the linear fit of the mean squared displacement of water molecules as a function of time. To achieve more insight into the diffusion phenomenon within MCF, we estimated the tortuosity and diffusivity at different quotes in the longitudinal direction of the model. Tortuosity is characterized by increasing values in the longitudinal direction. As expected, the diffusion coefficient decreases as tortuosity increases. Diffusivity outcomes confirm the findings achieved by experimental investigations. The computational model provides insights into the relation between the MCF structure and mass transport behaviour that may contribute to the improvement of bone-mimicking scaffolds.
Insufficiently treated shoulder pain may cause mental disturbances, including depression and anxiety. The Hospital Anxiety and Depression Scale (HADS) is a patient-reported outcome measure (PROM) that aims to identify depression and anxiety in patients in nonpsychiatric wards. The aim of this study was to identify the minimum clinically important difference (MCID) and patient acceptable symptom state (PASS) scores for the HADS in a cohort of individuals with rotator cuff disease. Using the HADS, participants' degrees of anxiety and depression were assessed at inception and at their final assessment 6 months after surgery. To calculate the MCID and the PASS, distribution and anchor approaches were employed. The MCID from inception to final assessment was 5.7 on the HADS, 3.8 on the HADS-A, and 3.3 on the HADS-D. A 5.7 amelioration on the HADS score, 3.8 on the HADS-A, and 3.3 on the HADS-D, from inception to final assessment, meant that patients had reached a clinically meaningful improvement in their symptom state. The PASS was 7 on the HADS, 3.5 on the HADS-A, and 3.5 on the HADS-D; therefore, for the majority of patients, a score of at least 7 on the HADS, 3.5 on the HADS-A, and 3.5 on the HADS-D at final evaluation was considered a satisfactory symptom state.
BACKGROUND: Total hip arthroplasty (THA) is an orthopaedic procedure that improves the quality of life in patients suffering from hip pain related to osteoarthritis, fractures, and avascular osteonecrosis of the femoral head. Different surgical approaches can be used for THA leading to different recovery times. Because of the lowering medium age of people undergoing THA, it is important to focus on the earlier return of physiological activity after surgery. AIM: To evaluate the best approach for THA in terms of earlier return to activity. METHOD: Studies comparing the postoperative outcomes in patients who underwent THA through different approaches were analysed focusing on patients' self-reported outcomes, ADL score and UCLA activity score with a short follow-up. RESULTS: A total of 1990 articles were identified in the search, and 14 met the inclusion criteria. The Review Manager software version 5.4 was used to conduct a meta-analysis to compare the direct anterior (DAA) and posterior (PA) approaches, which are the most adopted approaches. An earlier return to walk without aids and to independent ADLs were reported with DAA, but without statistical significance (respectively p = 0.06 and p = 0.10). The time to return to drive was similar among the 2 groups (p = 0.88). The return to work was faster with PA, but no statistical significance was reported (p = 0.47). CONCLUSIONS: Further studies are needed with a larger number of patients, that present homogeneous outcomes, follow-ups and rehabilitation programmes, and that compare similar surgical approaches to assess the early return to activity of daily living after THA.
Arthroplasty, Replacement, Hip , Humans , Arthroplasty, Replacement, Hip/adverse effects , Arthroplasty, Replacement, Hip/methods , Quality of Life , Treatment Outcome , Activities of Daily Living , Walking
Background: Total hip arthroplasty (THA) is estimated to grow in the following decades with a consequent increase of THA revisions (rTHA). This systematic review and meta-analysis aims to compare modular and monoblock stem in rTHA surgery, focusing on clinical and radiological outcomes and complication rates. Methods: A literature search was performed using the following search strategy: ((Modular stem) OR (monolithic stem)) AND (hip review) on PubMed, Scopus, and Cochrane. Randomized controlled trials (RCTs) and observational studies (OS) compared clinical and radiological outcomes, and complication rates for monoblock and modular revision femoral stem were included. The risk of bias was assessed through the Methodological Index for Non-Randomized Studies (MINORS) score. The Review Manager (RevMan) software was used for the meta-analysis. The rate of complications was assessed using odds ratio (OR) with 95% confidence intervals (CIs). Results: The authors included 11 OS and one RCT with 3,671 participants (mean age: 68.4 years old). The mean follow-up was 46.9 months. There was no prevalence of subsidence for one type of stem. Mean subsidence was from 0.92 to 10 mm for modular stem and from 1 to 15 mm for monoblock stem. Postoperative Harris Hip Score (HHS) showed better results with modular stems without statistical significance [mean difference (MD) =1.32; 95% CI: -1.62 to 4.27; P=0.38]. No statistically significant difference was found for dislocations (OR =2.48; 95% CI: 0.67 to 9.14; P=0.17), infections (OR =1.07; 95% CI: 0.51 to 2.23; P=0.86), intraoperative fractures (OR =1.62; 95% CI: 0.42 to 6.21; P=0.48), and postoperative fractures (OR =1.60; 95% CI: 0.55 to 4.64; P=0.39). Conclusions: Modular and monoblock stems show comparable and satisfactory clinical and radiological outcomes for rTHA. Both stems are valid and effective options for managing femoral bone deficit in hip revision surgery. The main limitation of this study is the small number and low quality of enclosed studies that compared the two stems. Moreover, the modular stem is usually used for more complex cases with lower quality femoral bone stock.
Bone tissue is composed at the nanoscale of apatite minerals, collagen molecules and water that form the mineralized collagen fibril (MCF). Water has a crucial role in bone biomineralization. We developed a 3D random walk model to investigate the water diffusion process within the MCF for three different scenarios, namely low, intermediate and high mineral volume fraction. The MCF geometric model is obtained after applying 6·106 translational and rotational perturbations to an ordered arrangement of mineral. Subsequently, we compute 300 random trajectories of water molecules within the MCF for each mineral volume fraction. Every trajectory is constituted of up to 500 k positions of the water particle. We determined the diffusion coefficient from the linear fit of the mean squared displacement of water molecules as a function of time. We investigate changes in the diffusivity values in relation to variation of bone mineral content. The analysis performed on the random walk data, for all mineralization conditions, leads to diffusion coefficients in good agreement with the diffusivity outcomes achieved from previous experimental studies. Thus, the 3D geometrical configuration adopted in this numerical study appears suitable for modelling the MCF with different volume fractions, from hypo- to hyper-mineralized conditions. We observed that low mineral content is associated with an increase of the water diffusion, while lower values of diffusivity are determined in hypermineralized conditions. In agreement with experimental data, our results highlight the influence of the structural alterations on the mass transport properties.
Calcification, Physiologic , Extracellular Matrix , Bone and Bones , Collagen , Diffusion , Humans , Minerals
Bone is a hierarchical biological material, characterized at the nanoscale by a recurring structure mainly composed of apatite mineral and collagen, i.e. the mineralized collagen fibril (MCF). Although the architecture of the MCF was extensively investigated by experimental and computational studies, it still represents a topic of debate. In this work, we developed a 3D continuum model of the mineral phase in the framework of percolation theory, that describes the transition from isolated to spanning cluster of connected platelets. Using Monte Carlo technique, we computed overall 120 × 106 iterations and investigated the formation of spanning networks of apatite minerals. We computed the percolation probability for different mineral volume fractions characteristic of human bone tissue. The findings highlight that the percolation threshold occurs at lower volume fractions for spanning clusters in the width direction with respect to the critical mineral volume fractions that characterize the percolation transition in the thickness and length directions. The formation of spanning clusters of minerals represents a condition of instability for the MCF, as it could be the onset of a high susceptibility to fracture. The 3D computational model developed in this study provides new, complementary insights to the experimental investigations concerning human MCF.
Bone tissue is a hierarchically structured material composed at the nanoscale by an organic matrix of collagen type I, apatite mineral and water. We considered an idealized 3D geometrical model of the mineralized collagen fibril in order to analyze the influence of structural factors, i.e. tortuosity, constrictivity, on the water effective diffusivity. The average values of the factors investigated in the diffusivity are computed on 5000 iterations by means of the Montecarlo method. The input parameters of the numerical model are the geometrical dimensions of the apatite mineral, collagen fibrils and their spatial orientation obtained with random extractions from Gaussian probability distribution functions. We analyzed the diffusion phenomenon for concentration gradients parallel to three orthogonal directions (Length, Width and Thickness) and for different scenarios, namely low, intermediate and high apatite volume fraction. For each degree of volume fraction, in the thickness direction, the tortuosity assumes greater values, up to two orders of magnitude, in comparison with the tortuous factors computed in the other directions, highlighting the anisotropy of the nanostructure. Furthermore, it was found that the tortuosity is the dominant parameter which control the effective transport properties within the mineralized collagen fibrils.
Bone and Bones/chemistry , Calcification, Physiologic , Collagen/chemistry , Minerals/chemistry , Models, Theoretical , Algorithms , Diffusion
Bone tissue at nanoscale is a composite mainly made of apatite crystals, collagen molecules and water. This work is aimed to study the diffusion within bone nanostructure through Monte-Carlo simulations. To this purpose, an idealized geometric model of the apatite-collagen structure was developed. Gaussian probability distribution functions were employed to design the orientation of the apatite crystals with respect to the axes (length L, width W and thickness T) of a plate-like trabecula. We performed numerical simulations considering the influence of the mineral arrangement on the effective diffusion coefficient of water. To represent the hindrance of the impermeable apatite crystals on the water diffusion process, the effective diffusion coefficient was scaled with the tortuosity, the constrictivity and the porosity factors of the structure. The diffusion phenomenon was investigated in the three main directions of the single trabecula and the introduction of apatite preferential orientation allowed the creation of an anisotropic medium. Thus, different diffusivities values were observed along the axes of the single trabecula. We found good agreement with previous experimental results computed by means of a genetic algorithm.
Apatites/chemistry , Bone and Bones/chemistry , Collagen/chemistry , Nanostructures , Diffusion , Humans , Monte Carlo Method , Porosity
We firstly measured the swelling of single trabeculae from human femur heads during water imbibition. Since the swelling is caused by water diffusing from external surfaces to the core of the sample, by measuring the sample swelling over time, we obtained direct information about the transport of fluids through the intimate constituents of bone, where the mineralization process takes place. We developed an apparatus to measure the free expansion of the tissue during the imbibition. In particular, we measured the swelling along three natural axes (length L, width W, and thickness T) of plate-like trabeculae. For this aim, we developed a 3D analytical model of the water uptake by the sample that was performed according to Fickian transport mechanism. The results were then utilized to predict the swelling over time along the three sample directions (L, W, T) and the apparent diffusion coefficients D T, D W, and D L.
Apatites/chemistry , Collagen/chemistry , Femur Head/chemistry , Water/chemistry , Aged , Female , Humans , Porosity
The swelling of air-dried single trabeculae from human femur heads was obtained by complete immersion in water and the dimensional changes of the samples were measured over time. The experimental results were analyzed under the viewpoint of the diffusion through a porous material. The dimensional changes of the single trabeculae were 0.26 ± 0.15 percent (length), 0.45 ± 0.25 percent (width) and 1.86 ± 0.97 percent (thickness). The diffusion coefficients were then calculated from the swelling recorded over time and a value of (4.12 ± 0.8) x 10(-10)(m (2)s(-1)) (mean ± standard deviation) was found. Since the dimensional variations of the specimens is due to the swelling of the collagen bone matrix, this technique could offer new insights for (1) a selective characterization of bone microstructure at the collagen matrix level and (2) the dynamics of diffusion through bone tissue.
Bone Matrix/physiology , Femur Head/physiology , Water/physiology , Absorptiometry, Photon , Aged , Diffusion , Female , Humans , Male , Middle Aged , Models, Theoretical , Specimen Handling
BACKGROUND: By implanting electrodes inside peripheral nerves, amputee's intentions are picked up and exploited to control novel dexterous sensorized hand prostheses. Under the pretext of presenting surgical technique and clinical outcomes of the implant of invasive peripheral neural interfaces in a human amputee, this article critically comments, from the point of view of the surgeon, strengths and weaknesses of the procedure. MATERIALS AND METHODS: Four multielectrodes were implanted in the medial and ulnar nerves of a young volunteer, which, following a car-crash, had a left transradial amputation. Both nerves were approached with a single incision in the medial aspect of the upper arm. Four weeks later, the electrodes were removed. RESULTS: Even if the trauma and the postamputation plastic processes altered the anatomy, electrodes were proficiently implanted with an overall success of 66%. Looking at the procedure from the surgeon's viewpoint unveils few still open issues. Electrodes weaknesses were related to the absence of stabilizing structures, the cable transit through the skin, the implant angle, and the unproven magnetic resonance imaging compatibility. Future investigations are needed to definitely address the better anesthesia, number and sites of incisions, the nerves to implant, and the convenience of performing epineural microdissection. CONCLUSIONS: Invasive neural interfaces developmental process almost completely relies on the efforts of bioengineers and neurophysiologists; however, the surgeon is responsible for intra and perioperative factors. Therefore, he deserves to play a major role also at the stage of specifying the requirements, to satisfy the requisites of a safe, stable, and long-lasting implant.
Artificial Limbs , Electrodes, Implanted , Median Nerve/surgery , Prosthesis Implantation , Ulnar Nerve/surgery , Adult , Device Removal , Hand/innervation , Humans , Male , Neurosurgery , Neurosurgical Procedures
INTRODUCTION: Micro-CT analysis is a powerful technique for a non-invasive evaluation of the morphometric parameters of trabecular bone samples. This elaboration requires a previous binarization of the images. A problem which arises from the binarization process is the partial volume artifact. Voxels at the external surface of the sample can contain both bone and air so thresholding operates an incorrect estimation of volume occupied by the two materials. AIM: The aim of this study is the extraction of bone volumetric information directly from the image histograms, by fitting them with a suitable set of functions. METHODS: Nineteen trabecular bone samples were extracted from femoral heads of eight patients subject to a hip arthroplasty surgery. Trabecular bone samples were acquired using micro-CT Scanner. Hystograms of the acquired images were computed and fitted by Gaussian-like functions accounting for: a) gray levels produced by the bone x-ray absorption, b) the portions of the image occupied by air and c) voxels that contain a mixture of bone and air. This latter contribution can be considered such as an estimation of the partial volume effect. RESULTS: The comparison of the proposed technique to the bone volumes measured by a reference instrument such as by a helium pycnometer show the method as a good way for an accurate bone volume calculation of trabecular bone samples.
Bone and Bones/anatomy & histology , Femur Head/diagnostic imaging , Absorptiometry, Photon , Algorithms , Humans , Image Processing, Computer-Assisted , Magnetic Resonance Imaging , Tomography, X-Ray Computed , Trabecular Meshwork/anatomy & histology , X-Ray Microtomography
BACKGROUND: Sesamoid bones and accessory ossicles of the foot and ankle, although mostly asymptomatic, can be sources of pain or degenerative changes in response to overuse and trauma. We investigated the prevalence of accessory ossicles and sesamoid bones in a population of Italian women with hallux valgus. METHODS: A single-center study was performed to determine the prevalence of accessory ossicles and sesamoid bones in the ankle and foot. A total of 505 women with hallux valgus aged 26 to 80 years at the time of hallux valgus correction were examined. Anteroposterior, oblique, lateral foot radiographs and a Muller view were examined regarding the presence, prevalence, coexistence, and distribution of accessory ossicles and sesamoid bones in both feet. The radiographs were analyzed independently by three experienced specialists in foot and ankle surgery. Disagreements were discussed in a consensus meeting, where the radiographs were reevaluated and a final decision was made. RESULTS: There was no statistically significant difference between data of the accessory ossicles and sesamoid bones according to the χ(2) test. Sesamoid bones were detected in 404 of the 505 patients. The fifth metatarsal sesamoid bone was found in 97 patients. All of the patients presented hallucal sesamoid bones. CONCLUSIONS: This is the first detailed report of the prevalence of accessory ossicles and sesamoid bones of the feet in Italian women with hallux valgus. These findings could help clinicians in the diagnosis and management of disorders of accessory ossicles and sesamoid bones, which are often undiagnosed, painful foot syndromes.
Hallux Valgus/diagnosis , Metatarsal Bones/abnormalities , Sesamoid Bones/abnormalities , Adult , Aged , Aged, 80 and over , Decision Making , Female , Hallux Valgus/surgery , Humans , Middle Aged , Prevalence
Due to the nature of articular cartilage of being poorly vascularized the capabilities of self repair are limited. Mesenchymal stem cells transplantation is a modern technique which has been developed after the high success rates obtained by microfracturing and drilling techniques which promote the release of growth factors and the infiltration of bone marrow derived cells in the lesion. In order to increase the concentration of bone marrow derived cells appropriate devices, the scaffolds, are necessary. These three dimensional constructs mimic the physiological ambient of chondrogenesis.The race for new scaffold materials, which will show high biocompatibility to prevent inflammatory response, high cellular adhesion properties with three dimensional architecture, high bioactivity to deliver growth factor appropriately and possibly high biodegrability has just begun. New studies will concentrate on the role, on the interaction and on the temporal sequence of growth factors to improve ostheocondral differentiation, but the necessity to increase the number of clinical studies with more patients and longer follow ups seems mandatory. The aim of this review is to update and summarise the evidence-based knowledge of treatment of talus chondral defect with new tissue engineering techniques.
Cartilage, Articular/pathology , Talus/pathology , Tissue Engineering/methods , Cartilage, Articular/drug effects , Clinical Trials as Topic , Humans , Intercellular Signaling Peptides and Proteins/pharmacology , Mesenchymal Stem Cell Transplantation , Talus/drug effects , Talus/surgery
