Low rate of return to pre-injury sport level in athletes after cartilage surgery: a 10-year follow-up study.

PURPOSE: Although articular surface is frequently damaged in athletes, results in terms of return to sport and level of activity after cartilage surgery remain rather unpredictable and poorly documented. The aim of this study is to evaluate the clinical outcome in terms of rate and level of return to sport in a group of competitive athletes who underwent matrix-assisted autologous chondrocyte transplantation (MACT), as well as the impact on their athletic career. METHODS: Thirty-one male patients (mean age 22.6 ± 6.3 years) p racticing sport at competitive level, affected by focal chondral/osteochondral lesions of the distal femur, were enrolled and treated with arthroscopic hyaluronan-based MACT. Patients were evaluated prospectively at 1-year intervals with the IKDC subjective, Tegner, and EuroQol VAS scores during their pre-operative visit and subsequent follow-ups for up to 10 years. Return to sport in terms of level, time and maintenance of the activity level was documented, together with surgical or clinical failures. RESULTS: A marked improvement in all scores was found: IKDC increased from 40.3 ± 13.4 to 81.7 ± 14.4 (p < 0.0005) at 12 months; a further improvement was observed at 2 years (89.5 ± 11.3; p = 0.008), then results were stable for up to 10 years (87.3 ± 13.6). The analysis of return to sport documented that 64.5% of patients were able to return at a competitive level, and 58.1% performed at the same pre-injury level, with activity rates decreasing over time. The rate of patients returning to competitive level was 84% in those without previous surgery (vs. 33% who had undergone previous surgery), 87% for those with traumatic lesions (vs. 33% and 50% for degenerative and OCD lesions, respectively), and 92.3% in younger patients (age < 20 years). Among these factors, multivariate analysis demonstrated that previous surgery was the single most influencing factor for returning to the same sport level (p = 0.010). CONCLUSIONS: These long-term results showed that chondrocyte-based regenerative approach has some limitations in terms of sport-related outcomes. The level of high functional knee restoration needed for such high-demanding activity level can be challenging to achieve, especially in patients with a more compromised joint homeostasis. Return to sport rate varies significantly according to specific patient and lesion characteristics and best results are obtained in young patients with traumatic lesions without previous surgery, which should be considered when treating athletes affected by cartilage lesions. LEVEL OF EVIDENCE: IV.

Distal femoral medial closing wedge osteotomy for degenerative valgus knee : mid-term results in active patients.

Distal femoral medial closing wedge osteotomy (DFMCWO) may be a valuable treatment for arthritic valgus knees in young and active adults, with the possible aim of procrastinating knee replacement. 32 valgus knees (mean age : 41.4±11.2) treated with DFMCWO were retrospectively reviewed. All the knees had a lateral compartment osteoarthritis graded I-II-III according to Kellgren Lawrence classification. 20 knees had osteochondral lesions, treated with microfractures (8) or bone marrow derived cells transplantation (12). Patients were clinically (IKDC, KOOS, NRS, Tegner) and radiologically evaluated. A mean follow-up of 62.12±15.65 was achieved. KOOS score peaked at 24 months, showed a decremental trend, achieved a final results of 79,59±17,14. Similar trend was evident for IKDC. The final NRS score was 2.73±1.82 ; the final Tegner score was 4.81±1.56. Radiographs showed degenerative progression in 5 knees : 2 patients underwent knee replacement at the final follow-up. DFMCWO is an effective treatment to treat osteoarthritic symptomatology, delay degenerative progression and avoid knee replacement in valgus knees at mid-term follow-up.

Sport and early osteoarthritis: the role of sport in aetiology, progression and treatment of knee osteoarthritis.

Sports activities are considered favourable for general health; nevertheless, a possible influence of sports practice on the development of early osteoarthritis (OA) is a cause for concern. A higher incidence of OA in knees and ankles of former high-impact sports players than in those of the normal population has been shown and it is still debatable whether the cause is either to be recognized generically in the higher number of injuries or in a joint overload. The possibility to address knee OA in its early phases may be strictly connected to the modification of specific extrinsic or intrinsic factors, related to the patient in order to save the joint from further disease progression; these include sport practice, equipment and load. Non-surgical therapies such as continuative muscles reinforce and training play a strong role in the care of athletes with early OA, particularly if professional. There is an overall agreement on the need of an early restoring of a proper meniscal, ligament and cartilage integrity in order to protect the knee and resume sports safely, whereas alignment is a point still strongly debatable especially for professional athletes. Remaining questions still to be answered are the risks of different sports in relation to one another, although an actual protective effect of low-impact sports, such as walking, swimming or cycling, has been recognized on the appearance or worsening of OA, the effect of continuing or ceasing to practice a sport on the natural history of early OA, and even following appropriate treatment is still unknown.

Regenerative approaches for the treatment of early OA.

The diagnosis and the prompt treatment of early osteoarthritis (OA) represent vital steps for delaying the onset and progression of fully blown OA, which is the most common form of arthritis, involving more than 10 % of the world's population older than 60 years of age. Nonsurgical treatments such as physiotherapy, anti-inflammatory medications, and other disease-modifying drugs all have modest and short-lasting effect. In this context, the biological approaches have recently gained more and more attention. Growth factors, blood derivatives, such as platelet concentrates, and mesenchymal adult stem cells, either expanded or freshly isolated, are advocated amongst the most promising tool for the treatment of OA, especially in the early phases. Primarily targeted towards focal cartilage defects, these biological agents have indeed recently showed promising results to relieve pain and reduce inflammation in patients with more advanced OA as well, with the final aim to halt the progression of the disease and the need for joint replacement. However, despite of a number of satisfactory in vitro and pre-clinical studies, the evidences are still limited to support their clinical efficacy in OA setting.

Failures in bipolar fresh osteochondral allograft for the treatment of end-stage knee osteoarthritis.

PURPOSE: Bipolar fresh osteochondral allografts (BFOA) recently became a fascinating option for articular cartilage replacement, in particular in those young patients non-suitable for traditional replacement because of age. While the use of osteochondral allografts for the treatment of focal osteochondral lesions in the knee is well established, their use in the treatment of end-stage arthritis is far more controversial. The purpose of this paper is to describe our experience in a series of seven patients who underwent a resurfacing of both tibio-femoral and patello-femoral joints by BFOA. METHODS: From 2005 to 2007, seven patients (mean age 35.2 ± 6.3 years) underwent BFOA for end-stage arthritis of the knee. Patients were evaluated clinically, radiographically and by CT scan preoperatively and at established intervals up to the final follow-up. RESULTS: No intra-operative complications occurred. Nevertheless, joint laxity and aseptic effusion, along with a progressive chondrolysis, lead to early BFOA failure in six patients, which were revised by total knee arthroplasty at 19.5 ± 3.9 months follow-up. Only one patient, who received the allograft to convert a knee arthrodesis, gained a satisfactory result at the last follow-up control. CONCLUSIONS: BFOA in the knee joint still remains an inapplicable option in the treatment of post-traumatic end-stage arthritis of the young patient, due to the high rate of failure. Further studies are necessary in order to investigate the causes of failure and improve the applicability of this method. Still, after extensive counselling with the patient, BFOA may represent a salvage procedure aimed to revise scarcely tolerated knee arthrodesis. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Platelet-rich plasma for foot and ankle pathologies: a systematic review.

BACKGROUND: The aim of this article is to review systematically all the literature available on the clinical application of PRP for the treatment of foot and ankle pathologies, to understand its potential and best indications for clinical use. METHODS: A systematic search of the PubMed database was performed. Research criteria were the following: (1) papers in the English language, (2) dealing with the clinical application of PRP for the treatment of orthopedic-related conditions affecting the foot and ankle district, (3) with I to IV level of evidence, and (4) reporting clinical results. RESULTS: A total of 17 studies fulfilled the inclusion criteria. Nine papers dealt with Achilles tendon management, 2 articles with plantar fasciitis, 3 papers with talar osteochondral lesions, 2 with PRP application in total ankle replacement, and 1 article with PRP in foot and ankle fusions. The overall evaluation of the results reported does not clearly demonstrate the potential of PRP treatment in any of the specific fields of application. CONCLUSIONS: Considering the literature currently available, no clear indications for using PRP in the foot and ankle district emerged. LEVEL OF EVIDENCE: Level IV, systematic review of Level I, II, III and IV studies.

Bipolar fresh total osteochondral allograft in the ankle: Is it a successful long-term solution?

INTRODUCTION: Severe post-traumatic ankle arthritis poses a reconstructive challenge in young and active patients. Although technically demanding and despite unsolved immunological issues, bipolar fresh total osteochondral allograft (BFTOA) represent an intriguing option to arthrodesis and prosthetic replacement. The purpose of this paper is to evaluate the outcomes of a series of 48 ankle BFTOA at 10 years follow up and to investigate the rate of survival long term. METHODS: 58 patients underwent BFTOA, of these 48 were available for follow up. The allograft was prepared with the help of specifically designed jigs and the surgery was performed using either a lateral or a direct anterior approach. Patients were evaluated clinically and radiographically preoperatively, and at a mean 121±18months of follow-up. RESULTS: The AOFAS score improved from 31±11 pre operatively, to 65±25 at the last (p<0.0005). Fourteen failures occurred, with 70.8% allograft rate of survival. All the surviving allografts showed a reduction of the ankle joint movement, still associated with a satisfactory clinical result. CONCLUSION: The use of BFTOA represents an intriguing option to arthrodesis or arthroplasty. A satisfactory clinical result associated to a good movement of the transplanted joint is to be expected up to short-mid-term, overtime. Long term, the range of motion (ROM) is progressively decreased up to spontaneous arthrodesis in some cases, still the joint results pain free and patient's perception is of a well functioning ankle. A deeper knowledge of the immunological behavior of transplanted cartilage is needed in order to improve the durability of this fascinating technique.

Bradykinin stimulates fructose 2,6-bisphosphate metabolism in human fibroblasts.

Bradykinin (BK), a peptide released during inflammatory response, has been investigated for its ability to regulate glucose metabolism in human fibroblasts. The peptide is able to significantly increase glycolytic flux in these cells. The strict relationship between the glycolytic rate and the levels of fructose 2,6-bisphosphate (Fru-2,6-P2) strongly suggests that the metabolite plays a key role in the regulation of glucose metabolism by bradykinin. The mechanism by which bradykinin increases Fru-2,6-P2 content involves the activation of 6-phosphofructo-2-kinase (PFK-2), the enzyme responsible for the synthesis of the metabolite. The study of the multiple signalling systems triggered by bradykinin demonstrates the involvement of the rise in intracellular Ca2+ concentration and of protein kinase C mediated pathway in the mechanism by which bradykinin increases Fru-2,6-P2 content and PFK-2 activity.

Functional and clinical evaluation at 5-year follow-up of a three-component prosthesis and osteochondral allograft transplantation for total ankle replacement.

BACKGROUND: Severe ankle arthritis is a life-limiting condition which often requires surgery. Ankle arthroplasty via artificial or "biological" reconstruction is a viable option in those patients who are not comfortable with arthrodesis. More functional studies are needed to compare the performance and outcomes of the two function-preserving arthroplasties. METHODS: In this study two groups of 10 patients affected by severe ankle arthritis were treated either with a 3-component ankle prosthesis or with bipolar fresh osteochondral allograft transplantation. Patients were evaluated pre-operatively and at 5-year follow-up. The American Orthopaedic Foot and Ankle Society score was used for clinical evaluation, and gait analysis for functional assessment. Activation pattern of lower limb muscles was obtained by surface electromyography (EMG). In each group, kinematic, kinetic, and EMG data were compared between pre-op and follow-up assessments, and also versus corresponding data from a 20 healthy subject control group. The median clinical score significantly increased between pre-op and follow-up from 53 to 74.5 in the transplantation and from 28.5 to 80 in the prosthesis group. Spatio-temporal parameters showed a statistically significant improvement in cadence and cycle time. Improvement of gait speed was also observed only in the prosthesis group. EMG patterns at follow-up were strongly correlated with the corresponding control data for both groups. Although no significant amelioration in the joints' range of motion was detected in either surgical procedure, preservation of the functional conditions at medium-term, along with significant improvement of the clinical score, may be considered a positive outcome for both techniques.

Involvement of protein kinase C and arachidonate signaling pathways in the alteration of proliferative response of senescent IMR-90 human fibroblasts.

The proliferative response of IMR-90 fibroblasts at low and high population doubling level (PDL) to protein kinase C activation has been investigated to clarify whether the reduced mitogenic responsiveness of senescent cells can be ascribed to an alteration in protein kinase C signal transduction pathway. The results show that the signaling pathway leading to DNA synthesis through protein kinase C activation, appears to be modified in senescent IMR-90 human fibroblasts. High PDL fibroblasts exhibit a different sensitivity to phorbol 12-myristate 13-acetate (PMA) and dioctanoylglycerol (diC8); high glucose reduced responsiveness to PMA only in these cells. In addition, high PDL fibroblasts are characterized by an increase in diacylglycerol (DAG) cellular mass that could contribute to the different regulatory properties of the signaling pathway. On the other hand, the ability of the cyclooxygenase inhibitor indomethacin to strikingly improve the proliferative response of high PDL cells to PMA indicates that an altered overall metabolism of arachidonate may represent a crucial step in the reduced mitogenic response involving protein kinase C activation.

Cast vs external fixation: a comparative study in elderly osteoporotic distal radial fracture patients.

AIM: This study compared fracture treatment with plaster cast vs external fixation. METHODS: Forty elderly female osteoporotic wrist fracture patients were randomized to be treated with either plaster cast (Group A) or external fixation (Group B). Bone mineral density less than -2.5 T-score was among the inclusion criteria. RESULTS: In Group A, four redisplacements occurred, whereas in Group B there were none (p = 0.005). Horesh score was higher in Group B (p < 0.006) than in Group A. Volar angle deformity (p < 0.0005) and radial angle deformity (p = 0.008) were lower in Group B. CONCLUSIONS: This study shows that external fixation improves stability in elderly osteoporotic wrist fracture patients.

Autologous chondrocyte transplantation in osteochondral lesions of the ankle joint.

The aim of this study was to assess the repair of osteochondral defects of the ankle joint with hyaline cartilage. For this purpose we have been using a technique of autologous chondrocyte transplantation for osteochondral defects of the talus for the last two years. Until the method described in the paper, treatment methods proposed for the repair of cartilaginous defects have not been histologically effective in restoring the hyaline cartilage sheath, and in all cases the neoformation of cartilage was of a fibrocartilaginous nature with varying cellular characteristics. Clinical and histological results obtained using this surgical technique have confirmed its validity. Furthermore, neither subjective nor objective complications have been reported. Less pain and better articular function have also been observed. According to the AOFAS score, an improvement from an average score of 32/100 points pre-op. to 91/100 points at 24 months of follow up was obtained. Laboratory data have confirmed the presence of reconstructed cartilage with chondrocytes and expression of collagen II, characteristic of hyaline cartilage.

[School performance: a question that divides. Analysis of learning difficulty]. / Il rendimento scolastico: una questione che divide. Analisi delle difficoltà di apprendimento.

The difficulty of learning is getting always more important, also in relation of a better knowledge of these problems. One factor which has to be taken in consideration as the behaviour of the school.

[They way adolescents live at home]. / Come l'adolescente vive la casa.

The kids, observing the relationship of their parents, are learning from them. Today the home is less home for everyone. At home you are eating, you are learning, especially you are watching a lot of TV. Often there is non a lot of trust between each other. Because of this the conversation is necessary and not the control of the adolescent secretly.

[Adolescence and family life cycle. Role of the pediatrician]. / L'adolescenza e il ciclo di vita della famiglia. Il ruolo del pediatra.

Adolescence observed as one of the step of the life cycle from the point of view of changes in the family. The role of paediatricians in the conversation with the adolescent and his parents is to pay attention to the influence that the whole family system could have on producing symptoms.

[Eating disorders in adolescence: anorexia in children]. / I disturbi alimentari in adolescenza: l'anoressia nel bambino.

When doctor visits adolescents have to pay attention to the massage of body like a mirror of difficulty about growth. Adolescents change their eating habits because they need to distinguish to the family. The doctor have to see first signals of more serious behaviour join to eating: anorexia nervosa.

[Advanced adolescence]. / L'adolescenza avanzata.

The advanced adolescence is the one after the eighteenth birthday. The adolescent tries to accomplish 3 engagements: 1. social and economic stability, 2. the research of a system of values, 3. record of concepts.

[Adolescence and alcohol abuse. Relevance of information given by the pediatrician]. / Gli adolescenti e l'abuso di alcol. L'importanza dell'informazione per il pediatra.

Often we don't see alcohol abuse among adolescents, but this kind of drug, easy to find, could be used to trying their limits. Contemporary group has an important role in the habit of drinking. Often family don't think that it's real problem and it's important that paediatrician grasp this dangerous signals.