Morphological Study: Ultrastructural Aspects of Articular Cartilage and Subchondral Bone in Patients Affected by Post-Traumatic Shoulder Instability.

Post-traumatic shoulder instability is a frequent condition in active population, representing one of most disabling pathologies, due to altered balance involving joints. No data are so far available on early ultrastructural osteo-chondral damages, associated with the onset of invalidating pathologies, like osteoarthritis-OA. Biopsies of glenoid articular cartilage and sub-chondral bone were taken from 10 adult patients underwent arthroscopic stabilization. Observations were performed under Transmission Electron Microscopy-TEM in tangential, arcuate and radial layers of the articular cartilage and in the sub-chondral bone. In tangential and arcuate layers chondrocytes display normal and very well preserved ultrastructure, probably due to the synovial liquid supply; otherwise, throughout the radial layer (un-calcified and calcified) chondrocytes show various degrees of degeneration; occasionally, in the radial layer evidences of apoptosis/autophagy were also observed. Concerning sub-chondral bone, osteocytes next to the calcified cartilage also show signs of degeneration, while osteocytes farther from the osteo-chondral border display normal ultrastructure, probably due to the bone vascular supply. The ultrastructural features of the osteo-chondral complex are not age-dependent. This study represents the first complete ultrastructural investigation of the articular osteo-chondral complex in shoulder instability, evaluating the state of preservation/viability of both chondrocytes and osteocytes throughout the successive layers of articular cartilage and sub-chondral bone. Preliminary observations here collected represent the morphological basis for further deepening of pathogenesis related to shoulder instability, enhancing the relationship between cell shape and microenvironment; in particular, they could be useful in understanding if the early surgical treatment in shoulder instability could avoid the onset of OA. Anat Rec, 300:1208-1218, 2017. © 2016 Wiley Periodicals, Inc.

Complex fractures of the humeral shaft treated with antegrade locked intramedullary nail: clinical experience and long-term results.

BACKGROUND: indications for surgical treatment of complex humeral shaft fractures are still controversial. The purpose of this study was to evaluate the outcomes of treating humeral shaft fractures using antegrade locked  intramedullary nail, compared to the treatment with traditional more aggressive techniques such as plate and screws. METHODS: between February 2008 and January 2011 38 patients were treated with antegrade locked intramedullary nail for humeral shaft fractures, divided according to the AO classification. 28 patients were clinically followed: disability, pain and functional recovery were evaluated using the Constant score and DASH score and the ROM of the shoulder was checked. RESULTS: Bony union was obtained in 27 patients at a mean time of 2.7 months. One fracture ended in nonunion, healed after replacing the nail with a longer one. Patients achieved satisfactory shoulder function with a mean Constant score of  90.57 points and with a mean DASH score of 4.69 points. There were no other complications. CONCLUSION: the antegrade locked intramedullary nail represents a recommended option for the treatment of humeral shaft fractures, obtaining a steady synthesis, a short time of consolidation and a rapid functional recovery. (www.actabiomedica.it).

Distal radius articular fractures: a comparison between ORIF with angular stability plate and percutaneous Kirschner wires.

PURPOSE OF THE STUDY: To analize and compare vantages and disadvantages in long-term of two different  techniques to treat distal radius articular fractures: ORIF with plate versus percutaneous pinning with K-wires. MATERIALS AND METHODS: We reviewed 77 distal radial articular fractures treated surgically from 2005 to 2009. Fractures were divided in two homogeneous groups according to patient age, gender, fracture-type and follow-up. The first group was treated with ORIF using angular stability volar plate, while the second one with closed reduction, K-wires percutaneous pinning and ante-brachial plaster casting. Functional outcomes were assessed with MAYO and DASH score, wrist range-of-movement and handgrip. Radiographic parameters were calculated in the post-operative and long-term x-rays. RESULTS: ORIF group showed better mean DASH and MAYO score, range of movement and handgrip strength compare to K-wires group. Expecially in type C fractures and in younger patients (<65 years). Minor differences were observed in type B fractures. About complications: two cases of surgically-treated medial nerve compression in ORIF group and one in K-wire group, one case of algodystrophy in K-wire group. Referring to radiographic parameters, long term values show data positive for ORIF. CONCLUSIONS: Though several studies about these techniques has been performed, but no scientific evidence proves the superiority of one surgical treatment. C-type need to be treated with plate in young patients or in elderly patients with high functional demand. Elderly patients with low functional demand can achieve satisfactory results also with percutaneous pinning, especially in Btype fractures.

Assessment of bone defects in anterior shoulder instability.

Glenohumeral bone defects are a common finding in shoulder instability and they are strongly correlated with recurrence of dislocation and failure following arthroscopic Bankart repair. Most authors agree that open surgery should be considered in the presence of certain conditions: glenoid bone loss > 25%, a lesion involving > 30% of the humeral head, an engaging Hill-Sachs lesion, bipolar bone lesions even without engagement. A careful imaging evaluation must therefore be performed in order to identify, quantify and characterize the bone defects. Even though magnetic resonance has important additional value in the assessment of the glenoid labrum and rotator cuff, computed tomography scan is the examination of choice for studying bone defects. Several methods have been proposed to quantify the extent of the glenoid bone defect; the most accurate ones utilize two-dimensional computed tomography images with multiplanar reconstructions (PICO method) or more sophisticated three-dimensional reconstruction software. Conversely, the literature lacks studies that accurately quantify humeral bone defects and, above all, that demonstrate definitively the clinical and prognostic significance of the lesion location and size.

Displaced mid-shaft clavicular fractures: surgical treatment with a pre-contoured angular stability plate.

The treatment for displaced mid-shaft clavicle fracture is highly controversial. In the last years, several biomechanical studies showed better functional results after surgical treatment. The purpose of this study is to evaluate the use of pre-contoured angular stability plate in this type of fracture. From June 2005 to July 2009, we have surgically treated 89 patients with displaced clavicle fracture. We have reevaluated 68 patients for a total of 70 interventions. Outcomes were assessed with Constant score, Dash questionnaire and X-rays. The mean follow-up period was 2 years. Excellent and good results were achieved for all the patients revaluated. The mean Constant score was 94.1 pt, and DASH score was 4.1. We had two cases of nonunion (2.9 %), while there was no case of infection and vascular or nervous lesions. A review of the international literature indicates that there is not a largely accepted gold standard for the treatment for displaced mid-shaft clavicle fractures. In the last 10 years, biomechanical and clinical studies have shown that nonoperative treatment for this type of fractures, with marked shortening or diastasis of the clavicle superior to 2 cm, may result in lower functional outcomes or higher percentage of nonunion. Nowadays, a lot of surgical options are available for the treatment for displaced mid-shaft clavicle fractures. Our experience with pre-contoured angular stability plates has shown excellent clinical outcome. On the basis of our study, we support the use of pre-contoured angular stability plate.

[Epicondylitis: etiology, pathogenesis and therapy]. / Epicondylites: etiologie, pathogénie et traitement.

Epicondilites are pathologies poorly understood from the aetiopathogenetic point of view. In this regard, many hypotheses have been considered and numerous anatomical structures are involved. Current therapeutic options are either conservative or surgical. Conservative treatments are: immobilization of the elbow flexed at 90-degrees, stretching the forearm muscles, manipulating the wrist, the application of low-energy extracorporeal shock waves, acupuncture, autologous blood injection under the extensor carpi radialis brevis, laser therapy and pulsed electromagnetic field therapy. Surgical treatments are: fasciotomy, excision of angiofibroblastic hyperplasias located at the origin of extensor carpi radialis brevis, partial release of the orbicular ligament, release of the extensor muscles, elongation of the tendon of extensor carpi radialis brevis and arthroscopic treatment. Advantages and disadvantages are described for each treatment according to the international literature.