Pain control and functional recovery as therapeutic goals in patients with chronic musculoskeletal pain: two experiences with tapentadol hydrochloride.

OBJECTIVE: This study aimed to evaluate pain control, functioning, and quality of life (QoL) recovery in patients with chronic low back pain (cLBP) or post-traumatic osteoarthritis (OA) pain in the ankle/foot area, treated with tapentadol prolonged release and unresponsive to other treatments. PATIENTS AND METHODS: Two observational retrospective studies were conducted using clinical practice datasets of patients with chronic pain in cLBP and OA foot/ankle at different time points (total follow-up=60-90 days). The studies assessed pain intensity by the Numerical Rating Scale (NRS) pain scale (patients were classified as responder in case of ≥30% pain reduction), QoL by the 5-level EQ-5D (EQ-5D-5L) questionnaire, patient satisfaction by the 7-point Patients' Global Impression of Change (PGIC) scale; cLBP health status by the Roland Morris Disability Questionnaire (RMDQ); foot and ankle functional status by European Foot and Ankle Society (EFAS) score; and treatment-related AEs. RESULTS: For the cLBP setting, 37 patients were enrolled, of which 86.50% were classified as responders (n=32; CI: 75.5% ÷ 97.5%). For the foot/ankle OA pain setting, 21 patients were enrolled. Pain assessment at final follow-up was available only for 11 patients, of which 72.73% (n=8; CI: 39.0% ÷ 94.0%) were classified as responders. Statistically significant improvements were seen in the RMDQ, EQ-5D-5L, and PGIC scores in cLBP. Improvements in the EFAS, EQ-5D-5L, and PGIC scores were seen in OA as well. The incidence of treatment-related adverse reactions was low in both studies. CONCLUSIONS: In the study population, tapentadol prolonged release was effective and well tolerated in treating cLBP and post-traumatic foot/ankle OA chronic pain when used in a multimodal manner. The reduction in pain was accompanied by clinically relevant improvements in patients' functionality and QoL.

Stem cells application in meniscal tears: a systematic review of pre-clinical and clinical evidence.

OBJECTIVE: Conservative and surgical treatments for meniscal lesions are various and this field of orthopedic surgery is in continuous development. Stem cells represent one of the current options to stimulate meniscal healing. The present systematic review aimed at summarizing the state of art in the application of stem cells for the treatment of meniscal damage both at pre-clinical and clinical level. MATERIALS AND METHODS: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review. A systematic search was performed using the PubMed (MEDLINE), EMBASE and Cochrane Library databases. All the studies dealing with the application of stem cells as a treatment for meniscal tears were pooled, data were extracted and analyzed. The studies were divided into two groups (pre-clinical and clinical), and then, discussed independently. RESULTS: A total of 18 studies were included. Thirteen were classified as "pre-clinical" and five as "clinical". The most commonly used cells were mesenchymal stem cells (MSC), derived from bone marrow (BMMSC), synovial tissue (SMSC), or adipose tissue (ADSC). Follow-ups ranged from 2 to 16 weeks for the pre-clinical studies and from 3 to 24 months for the clinical studies. All studies documented good results in terms of laboratory markers/scores, clinical and radiologic evaluation. CONCLUSIONS: Based on the currently available data, it is not possible to establish the best cell source or delivery method for the treatment of meniscal injuries. Bone Marrow derived stem cells delivered through injection represent the most studied approach, with the most promising results. However, the full impact of these therapies through their different sub-type of stem cells and implantation techniques still needs to be critically analyzed through larger randomized controlled trials with longer follow-up.

Can platelet-rich plasma be an alternative to surgery for resistant chronic patellar tendinopathy in sportive people? Poor clinical results at 1-year follow-up.

INTRODUCTION AND PURPOSE: Patellar tendinopathy is a disease affecting particularly athletes. Platelet-rich plasma (PRP) injections have gained increasing interest for their potential benefits. Anyway, a tendon disease longer than 6 months should be considered as an indication for surgery. The aim of our study was to evaluate the efficacy of PRP in athletes with a severe chronic patellar tendinopathy longer than 6 months when surgery should be chosen. METHODS: We enrolled 17 sport practitioners (19 patellar tendons) who did not want to undergo surgery and who are nonresponders to other conservative treatments. We treated them with PRP and calculated the results using the visual analog scale (VAS), the Victorian Institute of Sport Assessment-Patellar (VISA-P) score, and Tegner Activity Scale. Every test has been conducted at T0, T1 (4 months), and T2 (12 months). RESULTS: We found a poor improvement at T1 and a clinical worsening at T2 through VAS. VISA-P showed a medium improvement both at T1 and T2. Tegner scale did not show improvements. CONCLUSIONS: Our study was not able to remove the doubts about the benefits of PRP in patellar tendinopathy, confirming ambiguous certainties. Further investigations are needed to assess its effectiveness.

The orthogeriatric comanagement improves clinical outcomes of hip fracture in older adults.

Treatment of older adults with hip fracture is a healthcare challenge. Orthogeriatric comanagement that is an integrated model of care with shared responsibility improves time to surgery and reduces the length of hospital stay and mortality compared with orthopedic care with geriatric consultation service and usual orthopedic care, respectively. INTRODUCTION: Treatment of fractures in older adults is a clinical challenge due partly to the presence of comorbidity and polypharmacy. The goal of orthogeriatric models of care is to improve clinical outcomes among older people with hip fractures. We compare clinical outcomes of persons with hip fracture cared according to orthogeriatric comanagement (OGC), orthopedic team with the support of a geriatric consultant service (GCS), and usual orthopedic care (UOC). METHODS: This is a single-center, pre-post intervention observational study with two parallel arms, OGC and GCS, and a retrospective control arm. Hip fracture patients admitted to the trauma ward were assigned by the orthopedic surgeon to the OGC (n = 112) or GCS (n = 108) group. The intervention groups were compared each with others and both with the retrospective control group (n = 210) of older adults with hip fracture. Several clinical indicators are considered, including time to surgery, length of stay, in-hospital, and 1-year mortality. RESULTS: Patients in the OGC (OR 2.62; CI 95% 1.40-4.91) but not those in the GCS (OR 0.74; CI 95% 0.38-1.47) showed a higher probability of undergoing surgery within 48 h compared with those in the UOC. Moreover, the OGC (ß, - 1.08; SE, 0.54, p = 0.045) but not the GCS (ß, - 0.79; SE, 0.53, p = 0.148) was inversely associated with LOS. Ultimately, patients in the OGC (OR 0.31; CI 95 % 0.10-0.96) but not those in the GCS (OR 0.37; CI 95% 0.10-1.38) experienced a significantly lower 1-year mortality rate compared with those in the UOC. All analyses were independent of several confounders. CONCLUSIONS: Older adults with hip fracture taken in care by the OGC showed better clinical indicators, including time to surgery, length of stay and mortality, than those managed by geriatric consultant service or usual orthopedic care.

The arthroereisis procedure in adult flexible flatfoot grade IIA due to insufficiency of posterior tibial tendon.

BACKGROUND: To report on the functional, biomechanical, and radiographic results of patients who had undergone arthroereisis plus tensioning of the posterior tibial tendon for flexible flatfoot. The hypothesis is that arthroereisis associated to a tensioning of the posterior tibial tendon give a good correction with great satisfaction in patients with flexible flatfoot in grade IIA. METHODS: We evaluated 29 patients (31 feet), mean age of 46.4 years, who had been surgically treated for adult flatfoot grade IIA according to Myerson. Mean follow-up was 34.15 months. For clinical evaluation, the AOFAS hindfoot and VAS-FA scores were used. RESULTS: Postoperative results showed significant increases in both AOFAS and VAS-FA scores: 54.2-81.9 and 61.5-83.2 points, respectively. For the X-ray parameters, we observed a significant variation in the talo-first metatarsal angle, from 13.8° in pre-op to 7.4° in post-op. In lateral view, Djian Annonier angle was improved from 146.6° to 134.1°. The Meary's angle, compared to an average of 8.8° in pre-operative stage improved to 4.3° in the post-operative stage. Postoperative satisfaction was excellent-good according to 23 patients (79.4%). Pain in the tarsal sinus was reported in 5 out of 31 feet (16.1%) for the first three months after surgery. CONCLUSIONS: Arthroereisis and tensioning of the posterior tibial tendon provided good functional outcomes for patients under 60 years of age having stage IIA flexible flatfoot without arthritic manifestations.

A Fatal Sepsis Caused by Hyaluronate Knee Injection: How Much the Medical History and the Informed Consent Might Be Important?

The incidence of Osteoarthritis (OA) is gradually increasing worldwide due to two main reasons: longer life expectation and increased functional demand. Several treatment options have been proposed for this disease. Conservative treatment has the goal to improve the quality of life, reduce pain, and prevent the progression of the disease. Hyaluronate viscosupplementation is one of the most used infiltrative treatments for OA, but, despite its common use, clinical efficacy is still under question. Though adverse reactions for this medical option are actually rare, septic arthritis is a very scaring complication. We present a case report of a 59-year-old man who has been submitted to only one knee hyaluronate injection and consequently reported a severe septic arthritis and systemic sepsis, which lead to the death of the patient. We recommend producing correct guidelines for a clean aseptic procedure of injection to obtain proper consensus from the patient and to pay attention to his clinical history and comorbidities before acting any kind of invasive treatment, including joint injection.

Surgical Repair of an Atraumatic Avulsion of Patellar Tendon at the Tibial Tuberosity in an Adult Patient.

Atraumatic avulsion of the tibial attachment of patellar tendon in adults is a very rare injury with only few published case reports. Here we are sharing the successful management and follow-up of a similar case with a different suture material for repair of the tendon, the FiberWire. We believe that the management we are discussing allows for early return to activity with good functional outcome.

The clinical diagnosis of meniscal tear is not easy. Reliability of two clinical meniscal tests and magnetic resonance imaging.

AIM: to clarify the reliability of two clinical meniscal tests, McMurray's and Apley's and the MRI imaging, in order to establish how to reduce unjustified arthroscopies. METHODS: 102 patients were selected out of 160. All patients were submitted to a triple clinical examination (by a young surgeon and two skilled surgeons), MRI and an arthroscopic procedure. The investigated clinical tests were McMurray's and Apley's test. The positivity or negativity of the tests and MRI were compared to arthroscopic findings. Arthroscopy is considered the gold standard for the diagnosis of meniscal lesions. We measured the length of the meniscal lesions in order to correlate it to the clinical findings. RESULTS: From the clinical examination, we got the following data: McMurray's test: sensitivity 79.7%, specificity 78.5%, accuracy 79.4%, positive likelihood ratio 3.7, negative likelihood ratio 0.2. Apley's test: sensitivity 83.7%, specificity 71.4%, accuracy 80.3%, positive likelihood ratio 2.9, negative likelihood ratio 0.2. The composite assessment is strictly dependent on how the discordance of the two tests is evaluated. The assessment of the clinical tests was done even in relation to medial or lateral meniscal lesion. No statistical difference was found about the length of the meniscal tear. MRI gave the following results: sensitivity 78.3%, specificity 85.7%, accuracy 80.3%. CONCLUSIONS: If we use, as diagnostic means, McMurray's and Apley's clinical tests and MRI as imaging procedure, we have an accuracy of about 80%. It is important to keep in mind that it is not possible to have the absolute certainty of make a correct diagnosis in case of meniscal lesions. Patients, too, have to be informed about the risk of a negative arthroscopy.

Single-bundle versus double-bundle arthroscopic reconstruction of the anterior cruciate ligament: what does the available evidence suggest?

The introduction of the double-bundle technique as a surgical option for primary anterior cruciate ligament (ACL) surgery stems from the hypothesis that replicating the double-bundle anatomy of the native ACL improves knee kinematics by supplying better rotational control. We performed a systematic review of the literature comparing double-bundle with standard single-bundle reconstruction methods. One RCT and three quasi-RCTs with a one-to two-year follow-up were included in this review. On the basis of these studies, ACL reconstruction with a double-bundle technique leads to less residual pivot-shift as assessed on manual and instrumented tests. Conflicting results exist as to whether the double-bundle technique leads to less side-to-side anterior tibial translation, and no significant differences were found regarding proprioception, flexorextensor peak torque and knee function as assessed with the International Knee Documentation Committee score. On the other hand, better subjective knee functionwas found in one quasi-RCT. However, there is a lack of correlation between these kinematic differences and an as yet unproven clinical effect. Uncertainties also exist regarding the mid- and long-term performances of the ACL reconstructed with a double-bundle technique. Comparison between the single-bundle and double-bundle techniques should be expanded to cover unresolved issues such as the rate of complications from a more challenging surgical technique, the risk of complicating revision surgery due to the presence of two tunnels, and the cost-effectiveness of a procedure with a higher consumption of fixation devices. The doublebundle technique should be further investigated by experienced knee surgeons in studies with higher methodological quality.

Tibial intercondylar eminence fractures in adults: arthroscopic treatment.

Results obtained from the surgical treatment of 15 cases of type II and III tibial intercondylar eminence fractures-according to the classification of Meyers and McKeever [12, 13]-are reported in this paper. The average age of the patients observed was 22 years (range 18-41). All patients underwent an arthroscopic procedure of reduction and fixation. We used a bioabsorbable suture in ten patients and a nonabsorbable suture in five patients. The suture was passed at the ACL insertion, then pulled out through drilled tunnels and tied onto the anterior surface of the tibial metaphysis. Two of the 15 patients treated underwent an additional arthroscopic procedure because of arthrofibrosis, 2 months after the first surgical intervention. All patients were examined clinically and radiographically with an average follow-up of 18 months. According to the IKDC scoring system, recovery of the 13 patients not undergoing additional intervention was graded as normal or near normal. In 14 patients, anterior laxity was inferior to 5 mm at the KT-1000 arthrometer evaluation. Absorbable or nonabsorbable suture fixation is effective for obtaining a secure fixation and achieves good clinical and functional mid-term results.

Results of autologous osteochondral grafts in chondral lesions of the knee.

BACKGROUND: To evaluate multiple osteochondral autografts for the treatment of traumatic chondral lesions of the knee. METHODS: Twenty-four (19 male and 5 female) patients underwent multiple osteochondral transplantation from 1995 to1999, the age ranging from 19 and 47 years old. Osteochondral lesion was localized on the femoral condyle in 21 cases, on the patella in 1 case and on the femoral groove in other 2 cases. The size of the lesion varied from 1 cm2 to 3 cm2. In 7 cases a single osteochondral graft and in 14 multiple ostechondral grafts has been harvested from non weight bearing areas of the knee. All patients except four were operated by arthroscopy. Four patients underwent arthrotomy because of the location of the lesion. The patients were examined with a 1 and 3 month follow-up and yearly thereafter (average f.u. 2 years and 4 months). For the clinical evaluation we used the IKDC Subjective Knee Evaluation Form. Before surgery, and, thereafter, during the follow-up sessions, the circumference of the thigh 10 cm proximally to the superior apex of the patella was measured. RESULTS: The results were evaluated as satisfactory in 75% of the cases (18/24). Best results were obtained in isolated chondral lesions and in cases that requested a smaller number of grafts. All the patients had an excellent recovery of the ROM, while a 1.3 cm side to side difference of muscle trophism (thigh circumference) was present during the one year follow-up. CONCLUSIONS: We report good results with multiple autologous osteochondral grafts. Multiple osteochondral grafts appears to be the "Golden standard", in the treatment of chondral lesions lesions between 1.5 and 3.5 cm2.

The surgical treatment of spondylolisthesis with transpedicular stabilization: a review of 25 cases.

The present study concerns a series of 25 patients submitted to vertebral stabilization and fusion for the treatment of spondylolisthesis. In all of the cases a transpedicular screw system was used. The Steffee plates and screws system was used in 22 cases; the Cotrel-Dubousset (CD) system was used in 3. The listhetic vertebra was L5 in 14 cases, it was L4 in 11 cases. Based on Meyerding radiographic criteria there were: grade I: 8 cases, grade II: 13 cases, grade III: 4 cases. Instrumented fusion was performed at only 1 level in 20 cases, at 2 levels in 5 cases. Mean follow-up was 29 months. Clinical results were evaluated based on the White criteria. The results were satisfactory in 78% of cases. The present study shows that transpedicular vertebral stabilization constitutes a safe method, offering excellent stability essential to consolidation of fusion.

Ultrastructural appearance of chondroblastoma.

The ultrastructural appearance of two chondroblastoma were examined by scanning and transmission electron microscopy. The polygonal basal cells, with a scanty pericellular matrix, show a poorly developed endoplasmic reticulum and many Golgi bodies. The highly differentiated chondroid cells are assembled in isogenous clusters and show intracytoplasmic inclusions of glycogen and lipids, numerous mitochondria and superficial secretion vesicles arising from a well developed rough endoplasmic reticulum. Clusters of crystals, in close contact with the matrix collagen fibres are found near to the tumour cells. These ultrastructural characteristics, together with the basal undifferentiated cells that proliferate and differentiate into cartilaginous tissue, distinguish this neoplasm from chondroma, mesenchymal chondrosarcoma and chondromyxoid fibroma and confirm its chondroid origin.