Supraspinatus repair and biceps tenodesis in competitive CrossFit athletes allow for a 100% of return to sport.

PURPOSE: The shoulder is the most commonly injured body part in CrossFit training. The aim of this study is to report the clinical and MRI results of an arthroscopic repair of supraspinatus tear associated with SLAP lesion in competitive CrossFit athletes. METHODS: Competitive CrossFit athletes affected by a full-thickness supraspinatus tear associated with SLAP lesion secondary to training injury were prospectively enrolled in the study. Clinical diagnosis was confirmed with MRI (> 1.5 T). Functional evaluation was done using the Constant Score (CS) and ASES score (ASES). All lesions were treated with single-row repair and biceps tenodesis. Minimum follow-up (clinical, MRI) was 24 months. RESULTS: Nineteen patients were available at the final follow-up. The average age was 43-year-old (range 28-52, SD 8), 12 were males and 7 females. Pre-operative CS and ASES were 67 (range 61-77, SD 7) and 71 (range 62-79, SD 5), respectively. At the 24-month follow-up, 19/19 athletes resumed intensive training and 17/19 returned to competitions. CS and ASES rose to 90 (p = 0.039) and 93 (p = 0.04), respectively. At the final follow-up, MRI indicated complete healing of the tendon in 15 (79%) cases and 4 (21%) cases with type II Sugaya repair integrity. Two of the patients of the latter group did not return to their usual training level and showed type II (Kibler) scapular dyskinesis. CONCLUSIONS: Arthroscopic repair of the supraspinatus tendon associated with biceps tenodesis led to a 100% of return-to-CrossFit training and 90% rate of individuals resuming competitions at 24 months of follow-up. MRI showed 15 (79%) cases of complete healing and 4 (21%) cases with type II Sugaya repair integrity; biceps tenodesis clinically failed only in 1 case and the athlete complained of a decrease in the competitions scores and opted to discontinue CrossFit competitions. LEVEL OF EVIDENCE: IV.

Intramedullary nailing for pertrochanteric fractures of proximal femur: a consecutive series of 323 patients treated with two devices.

INTRODUCTION: Pertrochanteric fractures (PFs) frequently affect the lower limb of osteoporotic patients and represent an important cause of morbidity and mortality in the elderly. In this prospective randomized controlled trial, we have compared functional and radiological results and complications of patients affected by PFs treated with two intramedullary proximal femoral nails. MATERIALS: We enrolled 323 subjects with PFs, classified according to AO/OTA system as 31.A1 (pertrochanteric simple) and 31.A2 (pertrochanteric multifragmentary). Patients were divided into two groups according to the osteosynthesis devices: group A, Elos-Intrauma® nail (155 cases) and group B, Gamma 3-Stryker® nail (168 cases). Pre-operatively, the baseline characteristics of each patient (gender, age, weight and BMI) were collected. Intraoperative blood loss, subjective pain by visual analogue scale (VAS), esthetic satisfaction, functional scores of the hip by Harris Hip Score (HHS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) were noted. The post-operative degree of fracture reduction was assessed. Each patient had a minimum follow-up of 12 months. RESULTS: The study group was composed of 106 male and 217 female with an average age of 85.4 (range, 65-90, standard deviation (SD) 5.95) years. No statistical differences about sex and age distribution were noted between the two groups. Group A reported lower intraoperative blood loss, 45 ml vs 51 ml, respectively (p < 0.001). There was not any statistical difference about operative time. Group A had a better reduction of fracture (p = 0.0347). The greatest difference was detectable comparing subgroups 31.A2 (p = 0.032). There were no statistical differences about complication frequency and the overall rate was 25% (80 cases). Finally, there was no difference in terms of VAS, HHS, and WOMAC score between the two groups on each follow-up. Patients of group A showed a higher subjective satisfaction index at 1 post-operative year, 7.42 (SD 1.19) vs 6.45 (SD 1.35) of group B (p < 0.001). CONCLUSION: Elos® nail is a reliable device on a short-term follow-up and represents an alternative choice to the Gamma 3® nail, a well-known and appreciated system for over 25 years.

Complex humeral head fractures treated with blocked threaded wires: maintenance of the reduction and clinical results with two different fixation constructs.

BACKGROUND: Locking plates are the gold standard for treatment of 3-part humeral head fractures, although major complications range from 9% to 36%. Percutaneous techniques may allow vascular supply preservation, maintenance of fracture hematoma, scarce blood loss. Many configurations with Kirschner wires can be performed, generating confusion on result interpretation. We studied the correlation between system configuration, stability, and clinical results in patients with 3-part humeral head fractures treated with the same fixation system but with 2 different biomechanical constructs. MATERIALS AND METHODS: There were 52 consecutive patients (19 men, 33 women; mean age, 63.1 [standard deviation, 5.6] years; range, 48-82 years) with Hertel 7 humeral head fractures. Two fixation constructs composed of 3 couples (construct A) or 4 couples (construct B) of blocked threaded wires were used in 17 and 35 patients, respectively. At the final follow-up, the individual relative Constant Score (irCS) and visual analog scale were measured. Radiographic evaluation according to the Bahr criteria was performed. Statistical analysis was performed. RESULTS: The mean follow-up was 22 months. The mean irCS at the final follow-up was 89.7%. The mean irCS in patients treated with construct A and construct B was 86% and 93%, respectively (P = .043). One nonunion and 2 superficial infections occurred (6%). The postoperative reduction was excellent in 97% of patients and remained excellent in 89%. The mean postoperative neck shaft angle was 135.0° (construct A: 134.7°; construct B: 135.1°), and the final neck shaft angle was 132.9° (construct A: 131.3°; construct B: 133.8°; P = .047). CONCLUSIONS: The functional and radiologic outcomes obtained with percutaneous fixation or locking plates are similar; however, the percentage of major complications after percutaneous treatment is lower. Results of percutaneous fixation depend on the biomechanical construct.

Shoulder pain due to cervical radiculopathy: an underestimated long-term complication of herpes zoster virus reactivation?

PURPOSE: To evaluate if herpes zoster virus (HZV) reactivation may be considered in the aetiology of cervical radiculopathy. METHODS: The study group was composed of 110 patients (52 M-58F;mean age ± SD:46.5 ± 6.12; range:40-73) with a clinical diagnosis of cervical radiculopathy. Patients with signs of chronic damage on neurophysiological studies were submitted to an X-ray and to an MRI of the cervical spine in order to clarify the cause of the cervical radiculopathy and were investigated for a possible reactivation of HZV; HZV reactivation was considered as "recent" or "antique" if it occurs within or after 24 months from the onset of symptoms, respectively. Data were submitted to statistics. RESULTS: Thirty-eight patients (34,5%,16 M-22F) had a history of HZV reactivation: four (2 M-2F) were "recent" and 34 (14 M-20F) were "antique". In 68 of 110 participants (61,8%,30 M-38F), pathological signs on X-ray and/or MRI of the cervical spine appeared; in the remaining 42 (38,2%,22 M-20F) X-ray and MRI resulted as negative. Among patients with HZV reactivation, seven (18,4%) had a "positive" X-ray-MRI while in 31 (81,6%) the instrumental exams were considered as negative. The prevalence of "antique" HZV reactivations was statistically greater in the group of patients with no pathological signs on X-ray/MRI of the cervical spine with respect to the group with a pathological instrumental exam (p < 0.01). CONCLUSIONS: It may be useful to investigate the presence of a positive history of HZV reactivation and to consider it as a long-term complication of a cervical root inflammation especially in patients in which X-ray and MRI of the cervical spine did not show pathological findings.

Epidemiology of proximal humeral fractures: a detailed survey of 711 patients in a metropolitan area.

BACKGROUND: Literature lacks data concerning several epidemiologic aspects of proximal humeral fractures (PHFs). METHODS: This retrospective study included 711 consecutive patients (209 men, 502 women) who sustained a PHF in the last 3 years. Participants were divided into 2 groups, adults and children. Data regarding age, sex, date, and fracture side were collected. According to the mechanism of injury, we arbitrarily distinguished 7 subgroups. PHFs were classified according to the head-greater-lesser-shaft (HGLS)-Hertel classification and to the Salter-Harris classification using x-ray and computed tomography imaging. RESULTS: PHFs represent 5.03% of the overall fractures. The right side was involved in 389 patients (54.7%; P = .6). The mean age of male and female patients was 55.4 (standard deviation, 21.9) years and 67.0 (standard deviation, 16.1) years, respectively (P = .0001). Significant differences in the trauma mechanism between female patients (street/home low-energy trauma) and male patients (high-energy trauma) were found. A significant correlation between trauma mechanisms from 1 to 5 and fracture patterns H-G-L-S, HL-G-S, HGL-S, and HLS-G was observed. The occurrence of the same patterns significantly varied according to different age subgroups. Considering the pediatric population, a significant incidence of Salter-Harris 2 in both genders was found. No correlation was observed between the fracture patterns and the trauma mechanism. CONCLUSIONS: PHFs have a higher prevalence and incidence in females and in older age, respectively; they are more frequent in the winter months. In addition, male fractures are due to different traumatic events than those in females. A correlation between trauma and PHF pattern was evident only for adults. Some fracture patterns are correlated with different ranges of age in all patients.

Erratum.

Results - Total alcohol consumption, wine consumption, and duration of alcohol intake were higher in both men and women with RCT than in both men and women in the control group. Excessive alcohol consumption was found to be a risk factor for the occurrence of RCT in both sexes (men: OR =3.0, CI: 1.5-6.0, p < 0.001; women: OR =3.6, CI: 1.7-7.8, p < 0.001). Massive tears were associated with a higher intake of alcohol (especially wine) than smaller lesions.

Association between alcohol consumption and rotator cuff tear.

BACKGROUND AND PURPOSE: Long-term alcohol intake is associated with various negative effects on capillary microcirculation and tissue perfusion. We hypothesized that alcohol consumption might be a risk factor for both the occurrence and the severity of rotator cuff tears (RCTs). PATIENTS AND METHODS: A case-control study was performed. We studied 249 consecutive patients (139 men and 110 women; mean age 64 (54-78) years) who underwent arthroscopic rotator cuff repair. Tear size was determined intraoperatively. The control group had 356 subjects (186 men and 170 women; mean age 66 (58-82) years) with no RCT. All participants were questioned about their alcohol intake. Participants were divided into: (1) non-drinkers if they consumed less than 0.01 g of ethanol per day, and (2) moderate drinkers and (3) excessive drinkers if women (men) consumed > 24 g (36 g) per day for at least 2 years. RESULTS: Total alcohol consumption, wine consumption, and duration of alcohol intake were higher in both men and women with RCT than in both men and women in the control group. Excessive alcohol consumption was found to be a risk factor for the occurrence of RCT in both sexes (men: OR = 1.7, 95% CI: 1.2-3.9; women: OR = 1.9, 95% CI: 0.94-4.1). Massive tears were associated with a higher intake of alcohol (especially wine) than smaller lesions. INTERPRETATION: Long-term alcohol intake is a significant risk factor for the occurrence and severity of rotator cuff tear in both sexes.

The association between body fat and rotator cuff tear: the influence on rotator cuff tear sizes.

BACKGROUND: Rotator cuff tear (RCT) has a multifactorial etiology. We hypothesized that obesity may increase the risk of RCT and influence tear size. MATERIALS AND METHODS: A case-control design study was used. We studied 381 consecutive patients (180 men, 201 women; mean age ± standard deviation, 65.5 ± 8.52 years; range, 43-78 years) who underwent arthroscopic rotator cuff repair. Tear size was determined intraoperatively. The control group included 220 subjects (103 men, 117 women; mean age ± standard deviation, 65.16 ± 7.24 years; range, 42-77 years) with no RCT. Body weight, height, and bicipital, tricipital, subscapularis, and suprailiac skinfolds of all participants were measured to obtain body mass index (BMI) and the percentage of body fat (%BF). For the purposes of the study, the 601 participants were divided into 2 groups by BMI (group A, BMI ≥ 25; group B, BMI < 25). The odds ratios (ORs) were calculated to investigate whether adiposity affects the risk of RCT. Data were stratified according to gender and age. Multiple linear regression analyses were applied to explore the association between obesity and tear size. RESULTS: The highest ORs for both men (OR, 2.49; 95% confidence interval, 1.41-3.90; P = .0037) and women (OR, 2.31; 95% confidence interval, 1.38-3.62; P = .0071) were for individuals with a BMI ≥ 30; 69% (N = 303) of group A and 48% (N = 78) of group B had RCTs. Patients with RCT had a BMI higher than that of subjects with no RCT in both groups (P = .031, group A; P = .02, group B). BMI and %BF significantly increased from patients with a small tear (BMI, 27.85; %BF, 37.63) to those with a massive RCT (BMI, 29.93; %BF, 39.43). Significant differences were found (P = .004; P = .031). CONCLUSIONS: Our results provide evidence that obesity, measured through BMI and %BF, is a significant risk factor for the occurrence and severity of RCT.

Intensity and distribution of shoulder pain in patients with different sized postero-superior rotator cuff tears.

BACKGROUND: The vast majority of studies regarding rotator cuff tears (RCTs) are focused on etiopathogenesis and treatments, but information on shoulder pain characteristics needs further investigation. We analyzed the intensity and distribution of shoulder pain in patients with different sizes of RCTs. METHODS: Two hundred eighty-five consecutive patients with postero-superior RCTs were enrolled for this study. Tear size was intraoperatively classified. Before surgery, all patients completed an upper limb pain map (dermatome map made by Keegan). Shoulder pain intensity was assessed with a visual analogue scale (VAS). Data were submitted to statistical analysis. RESULTS: Shoulder pain intensity caused by a RCT was greater in females (P = .024); it did not vary with the side nor with age. Pain intensity was less in massive tears (P < .05) and in patients whose pain was distributed only to the shoulder (P = .035). Furthermore, patients whose pain persisted for more than 6 months maintained the same pain intensity. Pain was localized predominantly on dermatomes C5-C6, was more diffuse in massive tears (P < .05), and rarely extended beyond the elbow. In the presence of intense shoulder pain, its precise distribution was not well-delimited. CONCLUSION: Shoulder pain characteristics in patients with RCTs may be influenced by gender and size of tear. Cuff tear pain distribution principally involves the antero-lateral aspect of the shoulder with extension down the lateral surface of the arm to the elbow. Information about pain intensity and distribution in patients with RCTs may contribute to a more accurate diagnosis. LEVELS OF EVIDENCE: Level III, cross sectional study.

The association between arterial hypertension and rotator cuff tear: the influence on rotator cuff tear sizes.

BACKGROUND: This study was conducted to establish whether hypertension increases the risk of occurrence of rotator cuff tear and influences its size. MATERIALS AND METHODS: A case-control design was used. We studied 408 consecutive patients (228 men, 180 women) who underwent arthroscopic rotator cuff repair. Tear size was determined during surgery. The control group included 201 individuals. For the study purpose, participants were divided into 2 groups by presence or absence of hypertension. We applied a logistic regression model to investigate if hypertension affects the risk of cuff tear. A multinomial logistic regression model was applied to explore the association between hypertension and tear size. We used the analysis of covariance method to determine if the duration of hypertension influences the severity of the tear; finally, we compared mean duration of antihypertensive therapy in patients with small, large, and massive tears. All analyses were adjusted for age and sex. RESULTS: Hypertension was associated with a 2-fold higher risk of tear occurrence (odds ratio [OR], 2.05; 95% confidence interval [CI], 41-2.98). No association was detected between hypertension and the probability of a small tear (OR, 0.63, 95% CI, 0.33-1.19). Hypertensive individuals were 2 times more likely to experience large tear (OR, 02.09; 95% CI, 1.39-3.16) and 4 times more likely to experience massive tear (OR, 04.30; 95% CI, 2.44-7.58) than normotensive individuals. Mean duration of antihypertensive therapy significantly increased from small tear (1.08 years) to large tear (3.20 years) to massive tear (6.34 years) patients (analysis of covariance: F((2,403)) = 16.357, P = 1.48 × 10(-7)). CONCLUSIONS: Our data provide evidence that hypertension is a significant risk factor for the occurrence and severity of rotator cuff tears.

Use of the Z-plasty technique in nasal skin cancers. Two clinical cases.

Basal cell carcinoma (BCC) is the most common type of cancer in Europe, Australia and the U.S.A. After nasal skin cancer excision, especially if it is less than 1-2 cm in diameter, several surgical techniques can be used to reconstruct the lack of substance.In the management of our two patients we have chosen to utilize, instead, a well-known plastic surgery technique, Z-plasty, which is both easy to perform that effective to achieve excellent cosmetic results. As shown by our two clinical cases, the use of Z-plasty for lack of substance of the nose tip and bridge can be extremely effective in terms of cosmetic results. In comparison with the other reconstructive techniques, in fact, it is very easy to perform and allows to avoid or minimize the distortion of the nasal tip and wing, to orient the incision along the skin tension lines and, finally, to replace the lack with very similar structures regarding color, thickness and tissue architecture to those removed.

Subdeltoid lipomas: a consecutive series of 13 cases.

We describe 13 consecutive cases of patients presenting with shoulder mass and limited function, and to whom we formulated a diagnosis of subdeltoid lipoma. Between 2002 and 2010, 14 patients had a diagnosis of subdeltoid lipoma. Of these, one was excluded from this review because of a concomitant cuff tear. Shoulder was evaluated with X-ray, MRI, EMG and pre-/post-operatively with constant score (CS) and subjective shoulder value (SSV). All patients had complete excision of the mass. Minimum follow-up was 12 months. In 14 cases, the lipoma was causing slight pain or discomfort, and in four cases (28.57 %), it was causing limitation of joint movement. EMG showed axillary nerve neuro apraxia in two cases (14.28 %). Preoperative CS and SSV were on average 80 and 80, respectively. At one-year follow-up, CS and SSV were meanly 92 and 95, respectively (p = 0.034). No recurrence of the lesion was noted. Subdeltoid lipomas quickly grow up and may cause compression of axillary nerve. Surgery is the treatment of these lesions if symptomatic. After complete excision, subdeltoid lipomas do not recur, and clinical signs disappear. Level of evidence Case series, Level IV.

The relationship between acromion thickness and body habitus: practical implications in subacromial decompression procedures.

To define the bone's amount that should be removed during an acromioplasty has always been a challenge. We aimed to verify the correlations between scapular dimensions and acromial thickness, assess the differences between the two genders, investigate the relationship between acromial type and thickness. We examined 500 dried scapulae, measuring the major axis of the scapular body and the acromial thickness; these were also catalogued according to gender. Acromial shape was classified according to Bigliani's method. Frequencies: Type I 38.9 %, Type II 39.4 %, Type III 21.7 %. The mean acromial thickness was 0.85 cm, and it resulted wider in men. There was a direct linear relationship between scapular dimensions and acromial thickness. The range of thickness of Type III acromion was significantly different from the others. We should be aware that gender, scapular dimensions and acromial shape should be evaluated preoperatively since they influence the acromial thickness.

Skin metastasis in patient with hairy cell leukemia: case report and review of literature.

The reported case of Hairy cell leukemia (HCL) refers to a 47-year-old man with pancytopenia, splenomegaly, a month and a half history of dyspnea on mild effort and in common daily activities and a purplish-brown cutaneous node on the back of the left hand at the time of hospital admission. Bone marrow aspiration showed an infiltration by a lymphoproliferative malignancy and the following cytochemical studies on bone marrow sample led to diagnosis of HCL. The biopsy of the skin lesion revealed a infiltrate of medium and large-size cells in the dermis with the the same cytologic features of leukemic blasts appearing in the bone marrow, upon which the diagnosis of Leukemia cutis was established. The differential diagnosis of leukemia includes other neoplastic hematopoietic disorders, such as lymphoma, myelodysplastic syndromes, multiple myeloma, aplastic anemia, severe megaloblastic anemia, severe lymphocytosis, severe monocytosis, and bone marrow failure. In our case, the skin lesion was surgically removed and then left to heal by secondary intention due to the presence of bacterial infection by Staphylococcus aureus and Streptococcus pyogenes. The wound was finally medicated to total healing with Promogran®, an advanced dressings which consists of a sterile, freeze-dried matrix composed of collagen and oxidised regenerated cellulose. The importance of our case lies in the fact that cases with association of HCL with leukemia cutis are very rare, and furthermore that after the excision of the skin lesion of the left hand, the surgeons heal to let the wound close by secondary intention.

Comparison between two classifications of humeral head fractures: Neer and AO-ASIF.

Our purpose was to verify if the Neer and AO-ASIF classifications for fractures of the proximal humerus satisfy the requisites of simplicity and reproducibility and if the parameters that they consider to establish the severity of the fracture are similar. Two of the authors classified the proximal humeral fractures of 227 patients based on plain radiographs, and they repeated the classification five years later. The reliability, reproducibility and coherence of the classifications were investigated. Inter-observer reliability was K = 0.77 (Neer) and K = 0.65 (AO-ASIF) while intra-observer reproducibility was K = 0.68 (examiner I) and K = 0.63 (examiner II). In 1/5 of the cases, disagreement led to a different classification of the same fracture. Furthermore, neither classification establishes a linear scale of gravity able to provide an indication for treatment. The Neer and AO-ASIF classifications have a low reproducibility and reliability when fractures, especially those with 3 or 4 parts, are assessed by means of plain radiographs. Therefore, patients with complex fractures should be submitted to CT to have a correct pre-operative diagnosis.