Results of primary repair of distal triceps tendon ruptures in a general population: a multicentre study.

Aims: The aim of the study was to analyze the results of primary tendon reinsertion in acute and chronic distal triceps tendon ruptures (DTTRs) in the general population. Patients and Methods: A total of 28 patients were operated on for primary DTTR reinsertions, including 21 male patients and seven female patients with a mean age of 45 years (14 to 76). Of these patients, 23 sustained an acute DTTR and five had a chronic injury. One patient had a non-simultaneous bilateral DTTR. Seven patients had DTTR-associated ipsilateral fracture or dislocation. Comorbidities were present in four patients. Surgical treatment included transosseous and suture-anchors reinsertion in 22 and seven DTTRs, respectively. The clinical evaluation was performed using Mayo Elbow Performance Score (MEPS), the modified American Shoulder and Elbow Surgeons Score (m-ASES), the Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH), and the Medical Research Council (MRC) Scale. Results: A total of 27 patients (28 DTTRs) were available for review at a mean of 47.5 months (12 to 204). The mean MEPS, QuickDASH, and m-ASES scores were 94 (60 to 100), 10 (0 to 52), and 94 (58 to 100), respectively. Satisfactory results were observed in 26 cases (93%). Muscle strength was 5/5 and 4/5 in 18 and ten DTTRs, respectively. One patient with chronic renal failure experienced a traumatic rerupture of distal triceps. One patient (1 DTTR) experienced mild elbow stiffness. Conclusion: Primary repair of acute and chronic DTTRs in a general population yields satisfactory results in the majority of patients with a low rerupture rate. Cite this article: Bone Joint J 2018;100-B:610-16.

The posterior bundle of the elbow medial collateral ligament: biomechanical study and proposal for a new reconstruction surgical technique.

BACKGROUND: The medial collateral ligament (MCL) is one of the primary elbows stabilizers. It is composed of an anterior bundle (AB), a posterior bundle (PB) and a transverse bundle. In elbow dislocations, until today MCL reconstruction has addressed the AB only. The purpose of this paper is to understand the biomechanical role of the PB of the MCL and to propose a new surgical technique for the simultaneous reconstruction of the anterior and posterior bundles, preventing the risk of recurrent posterior dislocation or posteromedial rotational instability (PMRI). MATERIALS AND METHODS: Sixteen cadaveric elbows were subjected to a force in compression, supination valgus and pronation varus. The residual stability was evaluated in three conditions: intact MCL, sectioned AB and sectioned AB + PB. The tests were performed in collaboration with the Department of Mechanical and Aerospace Engineering of the Politecnico di Torino. In six elbows, the MCL was then reconstructed with the new technique. RESULTS: Complete posterior elbow dislocation does not occur until the PB is sectioned. The section of the AB alone causes elbow instability in valgus stress, but not a dislocation. The reconstruction of the AB and the PB using the described technique allows a good recovery of range of motion and joint stability. CONCLUSIONS: The PB of the MCL has a primary role in elbow stability against valgus stress, and it prevents elbow posterior dislocation at all flexion angles. The described reconstruction technique should reduce the risk of residual PMRI.

Radial head prosthesis: surgical tips and tricks.

Radial head prostheses (RHP) have been developed to decrease the complications rate following a radial head resection surgery. The aim of the RHP is to replicate the physiological radiocapitellar tracking, reproducing the mechanical function of the native radial head: to stabilize the elbow and to shear the forces passing through the elbow along with the other stabilizers. The currently used RHP models try to achieve this target with three different prosthesis' strategies: (a) loose fit stem, (b) bipolar radial head or (c) anatomical radial head. Even if the radial head fixation is the preferred technique in every possible case and the resection can be still considered a possible option, in the last years there has been a growing worldwide consensus in using the radial head replacement in patients with unfixable radial head fractures, especially if associated with complex elbow instability. However, complications after a RHP are not uncommon, and their rate is raising as long as the implants number are increasing. The main difficulties are due to the implantation technique that needs to be performed with the same attention and precision used for the replacement of all the other joints, and to the concurrent treatment of the associated lesions. A personalized postoperative rehabilitation program is essential for obtaining good results and decreasing the complications rate. Concern exists for the young age of the patients that often require a RHP: personal experience and literature analysis suggest that if the clinical and radiographic results are positive after a 6-12-month follow-up, good outcomes can be also expected at a medium- or long-term follow-up.

Differences in ion release after ceramic-on-ceramic and metal-on-metal total hip replacement. Medium-term follow-up.

Modern metal-on-metal bearings produce less wear debris and osteolysis, but have the potential adverse effect of release of ions. Improved ceramic-on-ceramic bearings have the lowest wear of all, but the corrosion process has not been analysed. Our aim was to measure the serum ion release (ng/ml) in 23 patients having stable hip prostheses with a ceramic-on-ceramic coupling (group A) and to compare it with the release in 42 patients with a metal-on-metal bearing (group B) in the medium term. Reference values were obtained from a population of 47 healthy subjects (group C). The concentrations of chromium, cobalt, aluminium and titanium were measured. There was a significant increase of cobalt, chromium and aluminium levels (p < 0.05) in group B compared with groups A and C. Group A did not differ significantly from the control group. Despite the apparent advantage of a metal-on-metal coupling, especially in younger patients with a long life expectancy, a major concern arises regarding the extent and duration of ion exposure. For this reason, the low corrosion level in a ceramic-on-ceramic coupling could be advantageous.

Elbow instability: Are we able to classify it? Review of the literature and proposal of an all-inclusive classification system.

BACKGROUND: In the recent years, considerable improvements have come in biomechanical knowledge about the role of elbow stabilizers. In particular, the complex interactions among the different stabilizers when injured at the same time have been better understood. Anyway, uncertainties about both nomenclature and classification still exist in the definition of the different patterns of instability. MATERIAL AND METHODS: The authors examine the literature of the last 130 years about elbow instability classification, analyzing the intuitions and the value of each of them. However, because of the lack of a satisfactory classification, in 2015 a working group has been created inside SICSeG (Italian Society of Shoulder and Elbow Surgery) with the aim of defining an exhaustive classification as simple, complete and reproducible as possible. RESULTS: A new all-inclusive elbow instability classification is proposed. This classification considers two main parameters: timing (acute and chronic forms) and involved stabilizers (simple and complex forms), and four secondary parameters: etiology (traumatic, rheumatic, congenital…), the involved joint (radius and ulna as a single unit articulating with the humerus or the proximal radio-ulnar joint), the degree of displacement (dislocation or subluxation) and the mechanism of instability or dislocation (PLRI, PMRI, direct axial loading, pure varus or valgus stress). CONCLUSIONS: This classification is at the same time complete enough to include all the instability patterns and practical enough to be effectively used in the clinical practice. This classification can help in defining a shared language, can improve our understanding of the disorder, reduce misunderstanding of diagnosis and improve comparison among different case series.

The metal prosthesis in radial head fracture: indications and preliminary results.

Radial head displaced irreparable fracture is an indication for prosthesis; it becomes elective also when there are associated injuries of the skeletal and ligamentous stabilization systems. A retrospective study was conducted to evaluate the functional and radiographic results in 10 patients (mean age 39.6 yrs; minimum 20, maximum 80) submitted to radial head replacement. There were 4 Mason-Johnston type IV Rochwerger subtype "b" fractures, 7 type III fractures (1 associated with an Essex-Lopresti injury and 1 with fracture of the ulnar proximal metaepiphysis). Mean follow-up was 24.6 months (minimum 18, maximum 32). Postoperative functional evaluation of the elbow and ipsilateral wrist was carried out using the ESSSE/SECEC form (mean score 80.7/100; minimum 63, maximum 96) and the PRWE (mean score 11.1; minimum 0, maximum 36) respectively. Radiographically there were postoperative calcifications in 30% of cases and periprosthetic lucency in 40%. The results of this study encourage the use of a metal prosthesis, but a longer follow-up is needed for a better evaluation.

Algorithm for the treatment of calcific tendinitis in the rotator cuff: indications for arthroscopy and results in our experience.

Calcific tendinitis of the rotator cuff is a relatively frequent pathology and at times, in some phases, it is a disabling one: for this reason, numerous therapeutic options have been proposed. The authors propose an algorithm for the classification and treatment of calcific tendinitis and report their experience with arthroscopic treatment over a three-year period from 2001 to 2004. Based on the algorithm proposed, out of a total of 126 shoulders affected with calcific tendinitis of the rotator cuff for which debridement was indicated, 106 us-guided percutaneous surgeries (EPT), and only 20 arthroscopies were performed. Arthroscopy is indicated, on the basis of the algorithm that we followed, in patients affected by chronic and persistent calcific tendinitis who did not benefit from the execution of previous types of non-surgical treatment for a period of at least 6 to 12 months. Shoulder instability was found to be present in 8 patients out of 20 treated arthroscopically. After arthroscopy, short- and medium-term results were always positive with the exception of one case that evolved into adhesive capsulitis. Based on an analysis of this series, we were able to confirm the usefulness and clinical applicability of an algorithm to classify and treat calcific tendinitis of the rotator cuff; we also confirmed the role of arthroscopic treatment that in cases which did not respond to conservative procedures proved to be effective in resolving symptoms.

Comparative and experimental study on different tendinous grasping techniques in rotator cuff repair: a new reinforced stitch.

Arthroscopic repair of wide rotator cuff ruptures is burdened by a percentage of recurrences that is greater than the repair carried out when an open technique is used. One of the main reasons for this difference can be searched for in the minor hold of stitching on the tendinous aspect obtained with arthroscopic repair. In fact, when an open technique is used, good hold can be guaranteed by using reinforced stitches such as the modified Mason-Allen. Thus, arthroscopic repair technique on the tendinous aspect, particularly in wide and massive injuries, must be improved. It was the purpose of this study to compare a new reinforced stitch that can easily be obtained in arthroscopy (simple stitch that orthogonally crosses a horizontal stitch previously knotted on the tendon: SS-HL), with traditional stitches (simple stitch, mattress-stitch and modified Mason-Allen stitch). Tests were carried out on sheep infraspinatus tendons in order to evaluate the resistance of pull-out. The SS-HL stitch showed resistance to loading that was similar to that when the modified Mason-Allen was used, but it was greater than that shown by the simple stitch (+48%) and the mattress stitch (+35%).

Proximal humeral fracture fixation: multicenter study with carbon fiber peek plate.

BACKGROUND: Locking plate fixation is a reliable treatment for many displaced proximal humeral fractures. Carbon fiber-reinforced-poly-ether-ether-ketone (CFR-PEEK) plates have recently been introduced as an alternative to traditional metallic plates. METHODS: In a multicenter study involving the Orthopedic Services of 6 Italian hospitals, 182 patients with a proximal humeral fracture were treated with a Diphos H (Lima Corporate, San Daniele del Friuli, Italy) CFR-PEEK plate, 160 of whom were followed clinically and radiographically for 2 years or more. Fractures were classified by Neer's system. The functional results were assessed by Constant and DASH scores. RESULTS: The average time to radiographic healing was 5.6 months in 158 of 160 cases. Mean Constant score was 76, and mean DASH score was 28 at 2 years. There were two nonunions (one septic and one aseptic) and 13 cases of partial (9) or massive (4) humeral head necrosis. In three of the 78 patients treated with the first-generation plates, hardware breakage happened during the operation and the plate was replaced. There was no failure among the cases treated with the thicker second-generation plate. In eight cases, there was a perforation of the humeral head by the cephalic screws. CONCLUSIONS: CFR-PEEK plates proved as reliable as metallic plates in the treatment of proximal humeral fractures. The advantages of these new devices include a better visualization of fracture reduction during intraoperative fluoroscopic assessment and easy hardware removal due to the absence of screw-plate cold fusion.

Expression of the CD69 activation antigen on lymphocytes of patients with hip prosthesis.

The aim of the study was to evaluate the sensitization to metals in patients with Co-Cr hip prosthesis. Peripheral blood mononuclear cells (PBMC) were collected from 14 healthy donors and three groups of patients: 10 candidates for primary total joint replacements, 11 patients with well-fixed implant and 13 patients with aseptic loosening of the hip prosthesis. PBMCs were cultured with the metal ions employed for implant manufacturing and the expression of CD69 activation antigen on CD3/T lymphocytes was detected by flow cytometry. Chromium extract increased significantly the expression of CD3/CD69 phenotype in patients with loosening of hip prosthesis. The chromium-induced 'activation index' was higher in patients with loosening of hip prosthesis than in healthy donors and in pre-implant patients. The cobalt-stimulated PBMC of patients with either well-fixed or loosened prosthesis had an 'activation index' significantly higher than healthy donors. The activation index values were used to graduate the PBMC-response as 'normal' (> or = 0.9 and < 2), 'low' (< 0.9) and 'high' (> or = 2): an high-activation index was observed only in chromium-exposed PBMC of patients with prosthesis. Our data show that chromium released from orthopedic implants could be responsible for the lymphocyte sensitization and flow cytometry is an easy and reliable method for monitoring the hypersensitivity state in patients with metal prostheses. Activated lymphocytes in the peri-implant tissue are likely to elicit a localized immune response and contribute to maintain the inflammatory process evolving in the implant failure.

Ion release in stable hip arthroplasties using metal-on-metal articulating surfaces: a comparison between short- and medium-term results.

The use of metallic heads articulating with metallic cups could solve the problem of polyethylene (PE) wear in total hip replacement (THR) with metal-on-PE bearings. A conspicuous release of metal ions from new models of metal-on-metal bearings has been found in the short-term, but it is yet unclear whether the medium-term corrosion rate is high or, on the contrary, it becomes negligible, because of the continuous surface finishing. Our purpose was to compare the serum ion values (nanograms per milliliter) in 15 patients with metal-on-metal stable prosthesis (Group A), in the short-term (subgroup A(1); mean follow-up: 24 mo) and medium-term (subgroup A(2); mean follow-up: 52 mo), in order to determine whether the ion release decreased with time of implant. Chromium (Cr), cobalt (Co), molybdenum (Mo) and aluminum (Al) were analyzed. Twenty-two presurgical patients were used for comparison (Group B). The reference range was obtained from a population of 27 healthy subjects (Group C). Co and Cr levels in the medium-term (subgroup A(2)) were not decreased in comparison with the short-term values (subgroup A(1)) and were significantly higher (p < 0.001) than presurgical and reference values. Otherwise, Mo and Al concentrations were not significantly increased in comparison with reference values. In conclusion, despite the apparent advantage of metal-on-metal coupling, especially in younger patient populations, there is a major concern about the extent and duration of the relevant "internal" exposure to Cr and Co ions. This exposure should be carefully monitored, in order to clarify the biologic effects of ion dissemination and, consequently, to identify risks concerning long-term toxicity of metals.

Phalangeal ultrasonography in forearm fracture discrimination.

Over the last decade, the use of ultrasounds has been developed into an effective tool for investigating bone tissue and predicting the risk of fracture in osteoporosis. Studies have focused on hip and vertebral fractures while no information is available on the use of phalangeal ultrasonography to identify patients with forearm fractures. Thus, the current authors decided to compare 50 postmenopausal women with low energy forearm fractures (Fractured Group) with a control age-matched group of 94 women (Control Group). Measurements were taken at the distal metaphysis of the proximal phalanxes of the hand of the non-fractured arm using the DBM Sonic Bone Profiler. The reproducibility of the method was assessed by amplitude-dependent speed of sound (AD-SoS) CV% = 0.64 and by Ultrasound Bone Profiler Index (UBPI) CV% = 2.38. In the Control Group, the AD-SoS and UBPI mean values and standard deviations were significantly higher compared to the group with fractures (P < 0.0005). The receiver operating characteristic (ROC) curves were calculated and the areas under the curve (AUC) were 0.78 +/- 0.04 for AD-SoS and 0.77 +/- 0.05 for UBPI, respectively. Logistic regression analysis adjusted to age revealed that both AD-SoS (78.2%, ORAD-SoS = 12.03, P < 0.0005) and UBPI (76.0%, ORAD-SoS = 7.39, P < 0.0005) parameters discriminated correctly between fractured and non-fractured control women whereas the association of both parameters could not allow better discrimination. The present results showed that ultrasound investigation at the phalanxes is reproducible and efficiently discriminates between subjects with forearm fractures and those in the control subjects.

Bone-resorbing cytokines in serum of patients with aseptic loosening of hip prostheses.

Our aim was to determine if the serum levels of bone-resorbing cytokines (IL-1beta, TNF-alpha, IL-6, GM-CSF) are altered in patients with aseptic loosening of a total hip prosthesis, and if such levels are influenced by the type of implant. We determined cytokine levels in sera from 35 patients before revision for failed total hip arthroplasty and compared them with those in 25 healthy donors. We also assessed the soluble receptor of interleukin-2 (sIL-2r) in serum as an indication of a specific immune reaction against the implant. Our findings showed that the sIL-2r and TNF-alpha serum level did not change. The IL-6 level was not significantly altered, but was higher in patients with TiAIV prostheses than in those with a CrCoMo implant and in patients with cemented prostheses. The IL-1beta level was found to be higher in those with a TiAIV cemented prosthesis than in the control group (p=0.0001) and other groups of patients (p=0.003 v uncemented TiAIV, p=0.01 v cemented CrCoMo, p=0.001 v uncemented CrCoMo). The GM-CSF level significantly increased in patients compared with healthy subjects (p=0.008), and it was higher in those with cemented than with uncemented implants (p=0.01). Only patients with cementless CrCoMo prostheses had levels of GM-CSF similar to those of the control group. The highest GM-CSF concentrations were observed in patients treated with non-steroidal anti-inflammatory drugs (NSAIDs) in the last months before revision (p=0.04). In addition, when massive osteolysis was observed, the level of GM-CSF tended to decrease to that of the control group.

[Proglumetacin: a flexible and broad-spectrum antirheumatic agent]. / Proglumetacina: antireumatico flessibile e ad ampio spettro.

Fifty-five patients with osteoarthritis, rheumatoid arthritis or spondyloarthritis, joint pain and other rheumatic-inflammatory disorders were treated with proglumetacin, at different doses, during 3-60 days. Assessment of therapeutic efficacy indicated 88.9% of good results. Joint pain progressively decreased during the whole period of observation. Tolerance was considered good or very good in 78% of patients.

Lumbar nerve root compression caused by herniated intradiscal gas: description of a clinical case with recurrence.

The authors report a rare case of recurrence of lumbar nerve root compression caused by herniated intradiscal gas treated surgically with resolution of pain symptoms. They describe the possible causes of the formation of gaseous material reported in the literature. They believe that to avoid recurrence it is important to associated removal of the hernia with complete emptying of the disc and resection of the posterior longitudinal ligament.

Transverse fracture of the second sacral vertebra: description of a clinical case.

The authors report a rare case of transverse fracture of the second sacral vertebra that was isolated, with neurologic deficit, and treated conservatively by reduction opposing the trauma mechanism, and immobilization in plaster. After 22 months there was good neurologic recovery, although some perineal sensory disorders persisted, as did sexual deficit. This method is believed to be a valid one as an alternative to surgery, which is difficult, and not without complications.

Snapping hip: etiopathogenesis and surgical treatment.

Snapping hip is a polymorphous pathology the genesis of which is multifactorial, characterized by a snapping sensation which may be painful, and occurring during movement of the hip or during walking. Clinical and instrumental diagnosis for an accurate etiopathogenetic classification is essential to correct surgical treatment, that must be reserved only for cases with painful symptoms and with disorders in walking. The authors provide a classification system of the syndrome, describing four different varieties of the pathology and relative surgical treatment.

Lateral epicondylitis: clinical classification and proposal for treatment.

The authors report their experience in a retrospective study on a sample year (1997) of cases (77 in number) of lateral epicondylitis treated non-surgically at the Rizzoli Orthopaedic Institute. The results for the 63 patients reviewed are very disappointing (healing only in 36.5% of cases). In their opinion, this may be attributed to the lack of an accurate clinical definition of the pathology, and an inadequate treatment protocol. They conclude with the proposal to classify 3 clinical forms for epicondylitis (acute, chronic recurrent, and chronic persistent) and to follow a corresponding treatment protocol, aimed at improving results.

A new fork-shaped condylar and osteotomy plate.

The authors present their experience with a new crossed condylar and osteotomy plate, which is innovative because of the features of its design, and the instrumentation used for its application, as compared to the traditional AO blade plate. The plate is called "fork-shaped" because there are 2 prongs in place of the blade with a "U" profile, and it involves the use of more accurate and less traumatic instrumentation to implant it. The results of a study conducted on a group of 20 patients, who were homogeneous for pathology and surgery, treated by a fork-shaped osteotomy plate, compared with an equal number of patients treated by a blade plate, are reported. The results were better in the group treated with a fork plate because there was a more accurate correspondence with the preoperative planning, and because there were fewer intraoperative complications, and time required for surgery was shorter.

Distal centering in locked intramedullary osteosynthesis of the femur: use of a magnet-resistant probe.

The authors present an original solution for distal screw fixation in locked nail intramedullary osteosynthesis, traditionally carried out with image intensifier. The system includes the determination of an electromagnetic field produced by a microbobbin placed in the hole and, thus, coaxial with it. The study, conducted through a probe equipped with special magnet-resistant sensors capable of picking up electromagnetic variations, is based on the same principle as a compass. In addition to being effective and simple, the method avoids exposure to ionizing radiations required for the search for holes.