Surgical resolution of chronic thoracic pain stemming from a rare osteo-muscular conflict: A case report.

INTRODUCTION: Chronic thoracic pain presents significant diagnostic and therapeutic challenges, particularly when arising from rare osteo-muscular conflicts. This report details a unique case of chronic pain due to an osteo-muscular conflict between the right tenth rib and the internal oblique muscle, highlighting the complexities involved in diagnosis and the potential for surgical resolution. CASE PRESENTATION: A 33-year-old male with a decade-long history of chronic right hemithorax pain, unresponsive to conservative treatments, underwent diagnostic evaluation. Advanced imaging techniques, including a thoracic CT scan, revealed an ipodense area between the ninth and tenth ribs, suggesting an osteo-muscular conflict. Surgical intervention, specifically a partial costectomy of the right tenth rib, was pursued, resulting in significant symptom relief and improved quality of life. CLINICAL DISCUSSION: This case underscores the importance of considering advanced diagnostic evaluations in persistent chronic pain cases and the effectiveness of targeted surgical interventions in resolving anatomical conflicts. It contributes to the body of knowledge on managing complex musculoskeletal conditions and underscores the need for personalized treatment approaches. CONCLUSION: Surgical intervention in selected cases of chronic pain due to rare anatomical conflicts can offer significant relief and enhance patient outcomes. This case advocates for a nuanced approach to the diagnosis and treatment of chronic thoracic pain, emphasizing the role of advanced imaging and the potential benefits of surgical resolution.

Can Secondary Adhesive Capsulitis Complicate Calcific Tendinitis of the Rotator Cuff? An Ultrasound Imaging Analysis.

BACKGROUND: Adhesive capsulitis (AC) of the glenohumeral joint is a recognized cause of pain associated with both active and passive restricted ranges of movement. AC can be subdivided into primary and secondary forms. Trauma, surgery, immobilization, and diabetes mellitus are the leading well-recognized causes of secondary AC. Calcific tendinitis/tendinitis (CT) of the rotator cuff is considered a possible trigger for AC, as reported in a few previous articles. However, there are no original investigations that assess the frequency and characteristics of this association. The aim of our research was to evaluate the presence of AC in a cohort of patients with a known CT condition of the rotator cuff by an ultrasound (US) examination. MATERIALS AND METHODS: We prospectively enrolled all the patients admitted at our single institution (October 2022-June 2023) for the preoperative US evaluation of a known CT condition. In these patients, we searched for parameters related to secondary AC. An axillary pouch (AP) thickness equal to or greater than 4 mm (or greater than 60% of the contralateral AP) was considered diagnostic of AC. Moreover, rotator interval (RI) thickness and the presence of effusion within the long-head biceps tendon (LHBT) sheath was also assessed in all patients. RESULTS: A total of 78 patients (54F, 24M-mean age = 50.0 and range = 31-71 y.o.) were enrolled in the study. In 26 of those patients (26/78-33.3%), US signs of AC were detected. Notably, the mean AP thickness in patients with AC and CT was 3.96 ± 1.37 mm (Group 1) and 2.08 ± 0.40 mm in patients with CT only (Group 2). RI thickness was significantly greater in patients with superimposed AC: 2.54 ± 0.38 mm in Group 1 and 1.81 ± 0.41 mm in Group 2 (p < 0.00001). Moreover, effusion within the LHBT was significantly more frequently detected in patients with AC: 84.61% in Group 1 versus 15.79% in Group 2-p < 0.00001. CONCLUSION: US signs of AC are found in one-third of patients with CT of the rotator cuff, demonstrating that AC represents a frequent complication that should be routinely evaluated during US investigation to provide more personalized treatment strategies.

Medial or Lateral, That Is the Question: A Retrospective Study to Compare Two Injection Techniques in the Treatment of Knee Osteoarthritis Pain with Hyaluronic Acid.

Background: Mild-to-moderate knee osteoarthritis (KOA) can be successfully treated using intra-articular hyaluronic acid (IA-HA). The medial infrapatellar (MIP) approach and lateral infrapatellar (LIP) approach are two of the most used techniques for performing IA-HA, but it is still not clear which one is preferable. Objectives: The study aims to find the best knee injection technique between MIP and LIP approaches. Methods: In total, 161 patients were enrolled, divided into two groups (MIP or LIP). Each technique was performed once a week for three weeks. Patients were evaluated using the Numeric Rating Scale (NRS), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Roles and Maudsley Score (RMS) at T0 (before the first injection), T1 (one week after the third injection) and T2 (six months after). Results: NRS, KOOS and RMS showed a statistically significant improvement in both groups at all the detection times, without significant differences. No differences were detected between the groups in terms of systemic effect effusions, while the MIP group presented a mildly higher number of bruises in comparison with the LIP group (p = 0.034). Conclusions: Both the IA-HA techniques are equally effective in measured outcomes. The MIP approach seems to produce some local and transient side effects. So, the choice of the LIP or MIP approach depends on the operator's skill and experience.

Non-surgical treatment of oblique diaphyseal fractures of the fourth and fifth metacarpals in a professional athlete: A case report.

INTRODUCTION: Metacarpal fractures are common sports-related injuries, often requiring tailored treatment strategies, especially in athletes. The management of oblique diaphyseal fractures poses unique challenges due to their inherent instability. This case report discusses a non-surgical approach in treating such fractures in a professional athlete. CASE PRESENTATION: A 26-year-old professional soccer player sustained oblique diaphyseal fractures of the fourth and fifth metacarpals during training. Given the athlete's professional demands and the fracture's nature, a conservative treatment was implemented. This included the application of a modified ulnar gutter brace, allowing for immobilization of the metacarpophalangeal joints (MP) while permitting active mobilization of the interphalangeal joints(IP). CLINICAL DISCUSSION: The non-surgical treatment focused on achieving skeletal stability and maintaining hand function. Despite the complexity of oblique fractures, the conservative approach was successful, enabling the athlete to resume professional activities with minimal risk of fracture displacement. Regular radiographic follow-ups showed no further displacement, highlighting the effective management of such fractures through personalized conservative treatment plans. CONCLUSIONS: This case underscores the viability of conservative treatment for specific metacarpal fractures in athletes. Tailoring the treatment to accommodate the athlete's professional needs and understanding the biomechanical characteristics of the fracture are crucial for successful outcomes. The case also suggests that non-surgical management can be a viable option for certain complex metacarpal fractures, especially in high-demand patients.

Combined repair of scapholunate ligament (SL) and triangular fibrocartilage complex (TFCC) lesions in chronic trauma of the wrist: surgical treatment of 14 patients.

PURPOSE: Injuries of the scapholunate ligament (SL) and of the triangular fibrocartilage complex (TFCC) represent the main ligament injuries of the traumatic wrist. A double injury of the SL and TFCC ligaments is quite common in the trauma setting, and clinical examination is fundamental. MRI allows to detection of a TFCC and SL ligament injury, but wrist arthroscopy is still the gold standard for diagnosis. We present the clinical results of the combined reconstruction of chronic scapholunate ligament and TFCC injury. MATERIALS AND METHODS: Fourteen patients were treated at our hospital with a combined scapholunate ligament and TFCC complex repair. All patients were surgically treated by the same senior author, after a diagnostic arthroscopy that revealed a lesion of both structures. A comparison between the pre-operative and post-operative pain and function was carried out using VAS, Disability of Arm, Shoulder and Hand score (DASH) and Patient-Related Wrist/Hand Evaluation score (PRWHE). Wrist range of motion and strength were also compared following surgery. RESULTS: All patients had a mean follow-up of 54 months. A statistically significant improvement was observed both with the reduction in pain (VAS from 8.9 to 5) and with the improvement of functionality scores (DASH from 63 to 40 and PRWHE from 70 to 57) and with the increase in ROM and strength. In only one patient (7%), because of pain and instability, a supplement operation was needed (Sauve-Kapandji procedure) 3 months after the initial surgery. CONCLUSIONS: The simultaneous repair of the SL and TFCC complex has shown a good success rate in both decreasing pain and regaining functionality.

From Histopathology to High-Resolution Ultrasound Imaging of Skin Scars.

Nowadays, modern ultrasound machines and high-frequency transducers allow us to accurately assess the superficial soft tissues of the human body. In this sense, sonographic evaluation of the skin and related pathologies is progressively growing in the pertinent literature. To the best of our knowledge, a standardized sonographic protocol focused on the assessment of pathological skin scars is still lacking. As such, the main purpose of the present study was to propose a technical guide to sonographically assess skin scars in the daily practice of clinicians-starting from knowledge on their histopathological features. In order to standardize the ultrasound examination, a superficial-to-deep, layer-by-layer approach has been proposed to optimize its reproducibility and to promote a common language among the different healthcare providers.

Ultrasound-Guided Infiltrative Treatment Associated with Early Rehabilitation in Adhesive Capsulitis Developed in Post-COVID-19 Syndrome.

Background and Objectives: Post-COVID-19 syndrome is commonly used to describe signs and symptoms that continue or develop after acute COVID-19 for more than 12 weeks. The study aimed to evaluate a treatment strategy in patients with adhesive capsulitis (phase 1) developed in post-COVID-19 syndrome. Materials and Methods: The method used was an interventional pilot study in which 16 vaccinated patients presenting with the clinical and ultrasound features of adhesive capsulitis (phase 1) developed during post-COVID-19 syndrome were treated with infiltrative hydrodistension therapy under ultrasound guidance associated with early rehabilitation treatment. Results: Sixteen patients with post-COVID-19 syndrome treated with ultrasound-guided infiltration and early rehabilitation treatment showed an important improvement in active joint ROM after 10 weeks, especially in shoulder elevation and abduction movements. The VAS mean score before the treatment was 6.9 ± 1.66. After 10 weeks of treatment, the VAS score was 1 ± 0.63. Conclusions: The study demonstrated that the management of adhesive capsulitis (phase 1) developed in post-COVID-19 syndrome, as conducted by physiotherapists in a primary care setting using hydrodistension and a rehabilitation protocol, represented an effective treatment strategy.

Ultrasound Evaluation of Tendinopathy in Hemophiliac Patients for the Purpose of Rehabilitation Indications.

BACKGROUND: Hemophilia is a inherited bleeding disorder that is characterized by intra-articular bleeding (hemarthrosis). The aim of the study was to evaluate the state of the satellite tendons of the target joints in the patient with hemophilic arthropathy and propose rehabilitation treatment with eccentric exercises. METHODS: The tendons of the joints mainly affected by hemophilic arthropathy were evaluated by ultrasound. The ultrasound evaluation is associated with the use of evaluation clinical scales, such as the Hemophilia Joint Health Score (HJHS), the Functional Independence Score in Hemophilia (FISH), the Hemophilia Activity List (HAL), the DASH, the VISA-A, the VISA-P, and the VAS scale. RESULTS: In 20 patients with hemophilic arthropathy, the thickness of the tendons that were examined was normal. In six subjects with severe joint damage, echostructural alterations were present, and signs of hyperemia and neo-vascularization were detected on color Doppler, as well as the presence of intratendinous calcifications. CONCLUSIONS: The tendons of the target joints in patients with hemophilic arthropathy are compromised by the indirect biomechanical damage caused by the joint disease, and rehabilitation treatment with eccentric exercises can be considered safe and effective in improving the tenso-elastic properties of the tendons.

Osteoid Osteoma of the Hand: Surgical Treatment versus CT-Guided Percutaneous Radiofrequency Thermal Ablation.

(1) Background: Osteoid osteoma (OO) is one of the most common benign bone tumors. This type of osteogenic tumor is generally characterized by a well-defined lytic area with a vascularized central nidus surrounded by sclerosis and bone thickening. The wrist and hand bones are infrequent sites for osteoid osteoma: only 10% of the cases arise in these areas. Standard treatments are surgical excision and radio-frequency ablation (RFA), both with advantages and disadvantages. This study aimed to compare the two techniques to prove if RFA could be a potential alternative to surgery in the treatment of OO of the hand. (2) Methods: Patients treated for OO of the hand between January 2011 and December 2020 were evaluated and data was collected regarding the lesions' characteristics and the treatment outcome. Each patient was followed up for 24 months and VAS pain (Visual Analogue Scale), DASH (Disability of the Arm, Shoulder and Hand), and PRWE (Patient-Related Wrist Evaluation) scores were collected. (3) Results: A total of 27 patients were included in the study: 19 surgical and 8 RFA. Both treatments showed a significant improvement in pain and functionality. Surgery was associated with a higher complication rate (stiffness and pain), while RFA was associated with a higher recurrence rate (2/8 patients). RFA allowed for a speedier return to work. (4) Conclusions: We believe that osteoid osteoma treatment with RFA in the hand should be an available alternative to surgery as it allows rapid pain relief and a swift return to work. Surgery should be reserved for cases of diagnostic uncertainty or periosteal localization.

Adhesive capsulitis after COVID-19 vaccine injection: a peculiar case treated with combined bursa distention and glenohumeral capsular hydrodilatation.

Frozen shoulder is a common and self-limiting condition affecting the soft tissues of the shoulders, characterized by severe pain, impaired range of motion (ROM) and limitation of daily activities. Its prevalence is 5% and it occurs most commonly in the fifth and sixth decades of life; women are more affected [DePalma in Clin Orthop Relat Res 466:552-560, 2008]. It can be idiopathic or associated with other conditions such as metabolic disorders, diabetes, thyroid diseases, prolonged immobilization, trauma [DePalma in Clin Orthop Relat Res 466:552-560, 2008], or complications after vaccine administration known as SIRVA (Shoulder injury related to vaccine administration). SIRVA is not caused by the vaccine itself but by inappropriate vaccination techniques [Martín Arias et al. in Vaccine 35:4870-4876, 2017]. The natural history of the frozen shoulder is a progression through three stages based on clinical and arthroscopic presentations: freezing, frozen and thawing [DePalma in Clin Orthop Relat Res 466:552-560, 2008; Do et al. in Orthop J Sport Med 9:232596712110036, 2021]. The onset is characterized by disabling pain, that worsens at night; it is induced by inflammation and hypervascularity and lasts from 10 to 36 weeks [Do et al. in Orthop J Sport Med 9:232596712110036, 2021]. The second stage is predominated by stiffness and severe reduction of ROM. This phase typically lasts from 9 to 12 months [Do et al. in Orthop J Sport Med 9:232596712110036, 2021]. Eventually, a recovery phase occurs, with a gradual recovery of the ROM that can last between 12 and 42 months. Ultrasound is an emerging diagnostic tool that contributes to differential diagnosis and treatment [Zappia et al. in Insights Imaging 7:365-371, 2016; Ricci et al. in J Ultrasound Med 39:633-635, 2020]: signs of adhesive capsulitis consist of thickening of the inferior recess of the glenohumeral joint capsule, thickening of the coracohumeral ligament and soft tissue structures in the rotator cuff interval, with hypervascularity. An unspecific sign is increased fluid in the tendon sheath of the long head of the biceps [Martín Arias et al. in Vaccine 35:4870-4876, 2017; Tandon et al. in J Ultrasound 20:227-236, 2017].

From histology to sonography in skin and superficial tissue disorders: EURO-MUSCULUS/USPRM* approach.

BACKGROUND: In clinical practice, ultrasound assessment of the skin and superficial tissues is progressively becoming a valuable diagnostic tool to support physical examination in the outpatient setting. OBJECTIVES: The aim of this study was to define a standardized sonographic approach to (layer-by-layer) accurately evaluate multiple histological layers of the skin and superficial tissues. METHODS: Using high-frequency ultrasound probes and high-level ultrasound machines, we matched the histological microarchitecture of superficial tissues with multiple sonographic patterns in physiological and pathological conditions. Moreover, high-sensitive color/power Doppler assessments have also been performed to evaluate the microcirculation. RESULTS: Modern equipment allow for a detailed "sonographic dissection" of the skin and superficial tissues by evaluating different histological layers in various clinical scenarios. High-sensitive Doppler imaging clearly depicts the microvasculature, especially of pathologies. CONCLUSIONS: In clinical practice, using adequate technological equipment, a detailed sonographic assessment of the superficial (soft) tissues can be performed with the use of high-frequency B-mode and high-sensitive Doppler imaging.

Environmental commitment of large US publicly traded companies producing healthcare equipment: a cross-sectional comparative study.

The environmental commitment of healthcare stakeholders is poorly described despite the sector pollution and the social needs of more sustainable behaviors. A cross-sectional study comparing the environment commitment of US publicly traded companies producing healthcare equipment (HE), healthcare companies (H), and large capitalization corporates (LC) was designed. Using a financial database, the 20 largest US publicly traded companies by market capitalization were selected for each cohort. The last available sustainability report was investigated, aiming to assess (1) the year and the method of dissemination of the last report; (2) the adhesion to environmental standards; (3) the presence of environmental policies, quantitative targets, and tracking; (4) the third-party evaluations about company environmental sustainability. HE companies published sustainability reports in time (p = 0.048), usually as standalone reports (p < 0.001). Half of HE companies adhered to standards, less than the control groups (p < 0.001). HE companies had an acceptable environmental policy, improving over the time and posing targets, similarly to control groups (p > 0.05). The number of companies reporting quantitative targets/tracking about carbon footprint, water, and renewable energy managements differed among the three cohorts (p = 0.013, p = 0.013, and p < 0.001, respectively), with HE cohort achieving the lowest rates (70%, 70%, and 50%, respectively). Carbon neutrality and all renewable energy statements were rare among HE companies (10% and 5% of companies, p < 0.007). In HE, CDP (The Carbon Disclosure Project) scores were lower than controls (p < 0.001). US publicly traded companies producing healthcare equipment demonstrated to be far less committed to environmental sustainability than healthcare companies and large capitalization corporates. Level of evidence: IV.

Anatomy and ultrasound imaging of the tibial collateral ligament: A narrative review.

Medial knee pain is commonplace in clinical practice and ultrasound assessment of the tibial collateral ligament-medial meniscus complex is increasingly becoming a valuable examination tool in the outpatient setting. In the pertinent literature, basic sonographic protocols have been proposed to evaluate the medial compartment of the knee joint. Using high-frequency ultrasound probes and high-level ultrasound machines; we matched the histo-anatomical features of the tibial collateral ligament-medial meniscus complex and its different sonographic patterns in physiological/pathological conditions to define a standardized (layer-by-layer) sonographic approach. Moreover, high-sensitive power Doppler assessments have also been performed to evaluate the nearby microcirculation. Modern ultrasound equipment appears to provide optimal "sonographic dissection" of the tibial collateral ligament-medial meniscus complex for its various physiological/pathological patterns. Likewise, high-sensitive power Doppler allows clear visualization of the microcirculation as regards the local ligamentous and capsular structures. In clinical practice, using adequate technological equipment, a detailed sonographic assessment of the tibial collateral ligament-medial meniscus complex can be performed. High-frequency B-mode ultrasound imaging and high-sensitive power Doppler perfusion patterns can be matched/integrated with the clinical findings to optimize the management of patients with medial knee pain.

Histopathology and high-resolution ultrasound imaging for peripheral nerve (injuries).

BACKGROUND: Neuropathies are commonplace in clinical practice and ultrasound assessment of the peripheral nerves is increasingly becoming a valuable diagnostic tool to support the physical and electrophysiological examinations. In the pertinent literature, several sonographic approaches have been proposed to evaluate the peripheral nerve tissue-mainly based on (semi)-quantitative measures. OBJECTIVE: To define a standardized sonographic approach aiming to evaluate the different sono-histological sections of the peripheral nerve also in a qualitative way. METHODS: Using high-frequency ultrasound probes and high-level ultrasound machines, we matched the histopathological features of the peripheral nerve (in acute and chronic phase) and the different sonographic patterns. Moreover, high-sensitive power Doppler assessments have been performed to assess the microcirculation of the peripheral nerve in physiological and pathological conditions. RESULTS: Modern ultrasound equipment allows a "real-time dissection" of the peripheral nerve evaluating the sonographic patterns of its different histological compartments in physiological and pathological conditions. Moreover, high-sensitive power Doppler allows clear visualization of the microcirculation of the peripheral nerve both in the acute and chronic phases of the neuropathy. CONCLUSION: In clinical practice, using adequate technological equipment, (semi)-quantitative measurements of the peripheral nerve can be coupled with different sonographic patterns of its histological components-both in the acute and chronic phase of the peripheral neuropathy. This way, better/prompt diagnosis and optimal management of the patients would be possible.

Do chronic pain syndromes in lower limb amputees have an effect on the use of prostheses?

BACKGROUND: The use of a prosthesis is critical to regain the ability to walk in lower limb amputees but the relationship between the use of a prosthesis and chronic pain syndromes (PLS, PLP, RLP), common in amputees patients, is still poorly understood. OBJECTIVE: This long-term follow-up study investigates the possible correlation between prosthesis use and the presence of PLP, PLS and RLP in lower limb amputees. METHODS: Patients undergoing transtibial, transfemoral or hemipelvectomy amputation of any aetiology at the Rizzoli Orthopaedic Institute from 2008 to 2018 were included. The Houghton scale was used to assess functional use of the prosthesis. The PEQ was used for pain assessment. RESULTS: The results show that, in lower limb amputees, prosthesis use is greater in individuals with below-the-knee amputation and in those who were younger at the time of amputation. No significant correlation between the presence of pain syndromes (PLS, PLP, RLP) and the various items on the Houghton scale was found. CONCLUSIONS: The study found no significant correlation indicating that phantom limb pain syndromes affect amputee use of a prosthesis in the long term follow up.

Chronic pain in lower limb amputees: Is there a correlation with the use of perioperative epidural or perineural analgesia?

BACKGROUND: Chronic pain is common in patients who undergo lower limb amputation. The use of epidural or perineural catheters seems to reduce acute pain after surgery but their effects in a longer follow up are unknown. OBJECTIVE: To evaluate the long-term prevalence of phantom limb sensation (PLS), phantom limb pain (PLP), and residual limb pain (RLP) and their correlation with perioperative use of epidural or perineural catheters. METHODS: Postal survey. Patients with trans-femoral, trans-tibial or hemi-pelvectomy amputation were asked to partake in the study. The Prosthetic Evaluation Questionnaire was used for the presence of chronic post-surgical pain. Use of catheters was retrieved from medical notes. RESULTS: 57 patients at a mean of 4.4 years follow up were included. PLS was reported in 68.4%, PLP in 63.2 % and RLP in 54.4% of amputees. No correlation was identified between pain syndromes and the presence of individual catheters and the duration of their permanence. The simultaneous use of 2 catheters was related to a lesser presence of PLP. CONCLUSIONS: Data on prevalence of PLP, PLS and RLP are consistent with the literature. Favourable effects in PLP reduction in the long term follow up was related to the simultaneous use of two catheters.

Implementation of the ERAS (Enhanced Recovery After Surgery) protocol for colorectal cancer surgery in the Piemonte Region with an Audit and Feedback approach: study protocol for a stepped wedge cluster randomised trial: a study of the EASY-NET project.

INTRODUCTION: The ERAS protocol (Enhanced Recovery After Surgery) is a multimodal pathway aimed to reduce surgical stress and to allow a rapid postoperative recovery. Application of the ERAS protocol to colorectal cancer surgery has been limited to a minority of hospitals in Italy. To promote the systematic adoption of ERAS in the entire regional hospital network in Piemonte an Audit and Feedback approach (A&F) has been adopted together with a cluster randomised trial to estimate the true impact of the protocol on a large, unselected population. METHODS: A multicentre stepped wedge cluster randomised trial is designed for comparison between standard perioperative management and the management according to the ERAS protocol. The primary outcome is the length of hospital stay (LOS). Secondary outcomes are: incidence of postoperative complications, time to patients' recovery, control of pain and patients' satisfaction. With an A&F approach the adherence to the ERAS items is monitored through a dedicated area in the study web site. The study includes 28 surgical centres, stratified by activity volume and randomly divided into four groups. Each group is randomly assigned to a different activation period of the ERAS protocol. There are four activation periods, one every 3 months. However, the planned calendar and the total duration of the study have been extended by 6 months due to the COVID-19 pandemic.The expected sample size of about 2200 patients has a high statistical power (98%) to detect a reduction of LOS of 1 day and to estimate clinically meaningful changes in the other endpoints. ETHICS AND DISSEMINATION: The study protocol has been approved by the Ethical Committee of the coordinating centre and by all participating centres. Study results will be timely circulated within the hospital network and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04037787.