[Artículo traducido] Manejo de metástasis sintomáticas de columna: un enfoque multidisciplinario basado en un diagrama de flujo / Management of symptomatic spine metastases: A multidisciplinary approach based flow-chart

Describimos un algoritmo para el manejo de las metástasis espinales en el que la importancia de los parámetros individuales varía dependiendo del momento en el que se contemplan.Cada paciente sigue su propio proceso secuencial «personal» que no necesariamente considera todos los parámetros cada vez, ya que algunos pueden ser irrelevantes a la hora de elegir el tipo de tratamiento para ese individuo. Por ejemplo, un paciente en mal estado general con una puntuación ASA alta generalmente no es candidato para la cirugía, independientemente de la naturaleza del tumor primario o del número de metástasis. Para este paciente, el elemento más importante sería la sensibilidad del tumor al tratamiento adyuvante. Del mismo modo, un paciente con lesión aguda y progresiva de la médula espinal se sometería a descompresión quirúrgica y estabilización sin considerar una intervención más agresiva.(AU)

We described an algorithm for the management of spinal metastases in which the importance of single parameters varies depending on when they are contemplated.Each patient follows his own «personal» sequential process which does not necessarily consider all the parameters each time as some may be irrelevant for the purpose of choosing the type of treatment for that single individual. For instance, a patient in general poor condition with a high ASA score is usually not a candidate for surgery, regardless of the primary tumor nature or the number of metastases. For this patient, the most important element would be the sensitivity of the tumor to adjuvant treatment. Similarly, a patient with acute and progressive spinal cord injury would undergo surgical decompression and stabilization without considering a more strenuous intervention.(AU)

Management of symptomatic spine metastases: A multidisciplinary approach based flow-chart / Manejo de metástasis sintomáticas de columna: un enfoque multidisciplinario basado en un diagrama de flujo

Describimos un algoritmo para el manejo de las metástasis espinales en el que la importancia de los parámetros individuales varía dependiendo del momento en el que se contemplan.Cada paciente sigue su propio proceso secuencial «personal» que no necesariamente considera todos los parámetros cada vez, ya que algunos pueden ser irrelevantes a la hora de elegir el tipo de tratamiento para ese individuo. Por ejemplo, un paciente en mal estado general con una puntuación ASA alta generalmente no es candidato para la cirugía, independientemente de la naturaleza del tumor primario o del número de metástasis. Para este paciente, el elemento más importante sería la sensibilidad del tumor al tratamiento adyuvante. Del mismo modo, un paciente con lesión aguda y progresiva de la médula espinal se sometería a descompresión quirúrgica y estabilización sin considerar una intervención más agresiva.(AU)

We described an algorithm for the management of spinal metastases in which the importance of single parameters varies depending on when they are contemplated.Each patient follows his own «personal» sequential process which does not necessarily consider all the parameters each time as some may be irrelevant for the purpose of choosing the type of treatment for that single individual. For instance, a patient in general poor condition with a high ASA score is usually not a candidate for surgery, regardless of the primary tumor nature or the number of metastases. For this patient, the most important element would be the sensitivity of the tumor to adjuvant treatment. Similarly, a patient with acute and progressive spinal cord injury would undergo surgical decompression and stabilization without considering a more strenuous intervention.(AU)

Management of symptomatic spine metastases: A multidisciplinary approach based flow-chart. / [Artículo traducido] Manejo de metástasis sintomáticas de columna: un enfoque multidisciplinario basado en un diagrama de flujo.

We described an algorithm for the management of spinal metastases in which the importance of single parameters varies depending on when they are contemplated. Each patient follows his own «personal¼ sequential process which does not necessarily consider all the parameters each time as some may be irrelevant for the purpose of choosing the type of treatment for that single individual. For instance, a patient in general poor condition with a high ASA score is usually not a candidate for surgery, regardless of the primary tumor nature or the number of metastases. For this patient, the most important element would be the sensitivity of the tumor to adjuvant treatment. Similarly, a patient with acute and progressive spinal cord injury would undergo surgical decompression and stabilization without considering a more strenuous intervention.

Management of symptomatic spine metastases: A multidisciplinary approach based flow-chart.

We described an algorithm for the management of spinal metastases in which the importance of single parameters varies depending on when they are contemplated. Each patient follows his own "personal" sequential process which does not necessarily consider all the parameters each time as some may be irrelevant for the purpose of choosing the type of treatment for that single individual. For instance, a patient in general poor condition with a high "ASA" score is usually not a candidate for surgery, regardless of the primary tumor nature or the number of metastases. For this patient, the most important element would be the sensitivity of the tumor to adjuvant treatment. Similarly, a patient with acute and progressive spinal cord injury would undergo surgical decompression and stabilization without considering a more strenuous intervention.

A high-resolution neutron spectroscopic camera for the SPARC tokamak based on the Jet European Torus deuterium-tritium experience.

Dedicated nuclear diagnostics have been designed, developed, and built within EUROFUSION enhancement programs in the last ten years for installation at the Joint European Torus and capable of operation in high power Deuterium-Tritium (DT) plasmas. The recent DT Experiment campaign, called DTE2, has been successfully carried out in the second half of 2021 and provides a unique opportunity to evaluate the performance of the new nuclear diagnostics and for an understanding of their behavior in the record high 14 MeV neutron yields (up to 4.7 × 1018 n/s) and total number of neutrons (up to 2 × 1019 n) achieved on a tokamak. In this work, we will focus on the 14 MeV high resolution neutron spectrometers based on artificial diamonds which, for the first time, have extensively been used to measure 14 MeV DT neutron spectra with unprecedented energy resolution (Full Width at Half Maximum of ≈1% at 14 MeV). The work will describe their long-term stability and operation over the DTE2 campaign as well as their performance as neutron spectrometers in terms of achieved energy resolution and high rate capability. This important experience will be used to outline the concept of a spectroscopic neutron camera for the SPARC tokamak. The proposed neutron camera will be the first one to feature the dual capability to measure (i) the 2.5 and 14 MeV neutron emissivity profile via the conventional neutron detectors based on liquid or plastics scintillators and (ii) the 14 MeV neutron spectral emission via the use of high-resolution diamond-based spectrometers. The new opportunities opened by the spectroscopic neutron camera to measure plasma parameters will be discussed.

Novel concepts and nanostructured materials for thermionic-based solar and thermal energy converters.

Thermal and concentrated solar solid-state converters are devices with no moving parts, corresponding to long lifetimes, limited necessity of maintenance, and scalability. Among the solid-state converters, the thermionic-based devices are attracting an increasing interest in the specific growing sector of energy conversion performed at high-temperature. During the last 10 years, hybrid thermionic-based concepts, conceived to cover operating temperatures up to 2000 °C, have been intensively developed. In this review, the thermionic-thermoelectric, photon-enhanced thermionic emission, thermionic-photovoltaic energy converters are extensively discussed. The design and development processes as well as the tailoring of the properties of nanostructured materials performed by the authors are comprehensively described and compared with the advances achieved by the international scientific community.

A data-centric approach to generative modelling for 3D-printed steel.

The emergence of additive manufacture (AM) for metallic material enables components of near arbitrary complexity to be produced. This has potential to disrupt traditional engineering approaches. However, metallic AM components exhibit greater levels of variation in their geometric and mechanical properties compared to standard components, which is not yet well understood. This uncertainty poses a fundamental barrier to potential users of the material, since extensive post-manufacture testing is currently required to ensure safety standards are met. Taking an interdisciplinary approach that combines probabilistic mechanics and uncertainty quantification, we demonstrate that intrinsic variation in AM steel can be well described by a generative statistical model that enables the quality of a design to be predicted before manufacture. Specifically, the geometric variation in the material can be described by an anisotropic spatial random field with oscillatory covariance structure, and the mechanical behaviour by a stochastic anisotropic elasto-plastic material model. The fitted generative model is validated on a held-out experimental dataset and our results underscore the need to combine both statistical and physics-based modelling in the characterization of new AM steel products.

Carbon Ion Radiotherapy for sacral chordoma: a systematic review of the literature.

The aim of the present study is to describe the clinical outcomes and the incidence of complications related to Carbon Ion Radiotherapy (CIRT) in the treatment of sacral chordoma. Through a systematic review of published investigations on CIRT, we collected the local control rates (LC), the overall survival rates (OS) and the post-CIRT adverse effects. Afterwards, we calculated their weighted average, to have a broader perspective. PubMed/Medline and Google Scholar databases were searched to identify studies on Carbon Ion Radiotherapy as a treatment for sacral chordoma. We used Medical Subject Heading (MeSh) terms and keywords. We based our systematic review on the PRISMA guidelines. No data limitations were applied in the search on Pubmed/ Medline database; data limitation (from 2000 to 2019) was applied in the search on Google Scholar. Six studies were included in our review. Local control proportions reported in individual studies ranged between 77% and 96% (95% confidence interval), with respect to a 5-years follow-up. Overall survival rates ranged from 52% to 86% (95% confidence interval), with respect to a 5-years follow-up. Adverse CIRT-related events involving bone occurred in 7% of patients. Neurological and skin toxicities affected 20% and 5% of patients, respectively. Nowadays the gold standard of treatment for sacral chordoma is the surgical resection with wide margins. Whenever adequate oncological margins could not be achieved or could be achieved only by sacrificing neurological structures with consequent functional impairment, CIRT is an effective alternative which has been demonstrated to reach optimal local control and overall survival rate. The caregiver, anyway, should be aware of the potential adverse events and complications related to this kind of treatment.

The impact of SARS-CoV-2 pandemic on Oncologic and Degenerative Spine Surgery Department activity: the experience of Rizzoli Orthopaedic Institute under COVID-19 lockdown.

OBJECTIVE: Experience of Department of Oncologic and Degenerative Spine Surgery of Rizzoli Orthopaedic Institute during SARS-CoV-2 pandemic lockdown. PATIENTS AND METHODS: Retrospective observational study of surgically treated patients from 09th March 2020 to 04th May 2020. DATA COLLECTED: age, sex, type of disease, neurological status, days of hospitalization, complications and type of discharge. A comparison analysis with same period of the last year was performed in order to evaluate the impact of COVID-19 spreading on daily surgical activity. RESULTS: A total of 107 surgical procedures in 102 patients were performed from 09th March 2020 to 04th May 2020. Analysis showed a statistically significant difference in age, sex, ASIA class and type of treated disease compared to the same period of the last year (p=0.042, 0.006, 0.022 and 0.007, respectively). No statistically significant differences were observed in type of discharge, length of hospitalization and complications (p= 0.447, 0.261 and 0.127, respectively). 3 COVID-19 infections have been identified in hospitalized patients. 1 COVID-19 patient wad admitted from Emergency Department and was managed according to a dedicated path. CONCLUSIONS: Surgical activity was paradoxically increased during SARS-CoV-2 pandemic lockdown through the management of urgent and non-deferrable spinal disease with a low rate (3,9%) of COVID-19 infections.

Is minimally-invasive spinal surgery a reliable treatment option in symptomatic spinal metastasis?

OBJECTIVE: Up to 70% of patients with cancer are likely to develop spine metastasis. Radiation therapy is the standard of care for painful spinal metastases in absence of unstable or impending fractures. More frequently these patients require open palliative surgery for pain, vertebral collapse and neurological deficits. Minimally Invasive Spine Surgery (MISS) techniques using percutaneous pedicle screw fixation may be considered as an alternative to open surgery in selected cases. MISS techniques are thought to be associated with fewer tissues damages resulting in early pain relief,  they also allow for early mobilization and optimization of function. PATIENTS AND METHODS: From 2011 to 2018, 52 patients affected by spinal metastasis were treated with MISS techniques in Rizzoli Orthopaedic Institute of Bologna and in Cisanello Hospital of Pisa, Italy. All patients underwent percutaneous pedicle screw fixations (PPSF) coupled with mini-decompressions in case it was required by spinal cord compressions. All patients were evaluated pre and post-operatively by Frenkel classification and VAS scores. RESULTS: Mean follow-up time was 19,4 months. Preoperatively, Frankel scores were E in 37 patients, D3 in 6 patients, D2 in 3 cases, D1 in 3 patients, B in one patient and C in two. The Frankel score improved in 10 patients, remained stable in 40 patients and worsened in two patients. Preoperatively, the mean VAS score in 29 patients treated with PPSF procedure with spinal decompression was 7, while postoperatively, it became 5. In 23 patients who underwent only PPSF procedure without spinal decompression mean VAS score was 5, postoperatively it became 3. CONCLUSIONS: In selected cases, MISS surgeries may be considered as a valid alternative to open surgery. Although the efficacy of PPSF has been well documented in trauma or degenerative spine surgery, there is not sufficient literature about MISS techniques in spinal metastasis and further studies are needed to elucidate the most appropriate patient in which this approach could represent the gold standard of treatment.

Percutaneous vertebroplasty and balloon kyphoplasty in the treatment of osteoporotic vertebral fractures: a prospective randomized comparison.

PURPOSE: The purpose of this study is to compare the efficacy and safety of percutaneous vertebroplasty (PVP) and balloon kyphoplasty (BKP) in the treatment of osteoporotic vertebral compression fractures. MATERIALS AND METHODS: Patients with osteoporotic vertebral body fractures (T4-L5) were randomized and not blinded to kyphoplasty (n = 69) or vertebroplasty (n = 70). The postoperative pain score (VAS) at 12 months was the primary end point. The radiographic results were evaluated in relation to the resolution of the fracture and the possible onset of further osteoporotic fractures during follow-up. RESULTS: A total of one hundred and thirty-nine patients were eligible for randomization (n = 70 for PVP group and n = 69 for BKP), and twenty-six patients (twenty in the BKP group and six in the PVP group) were excluded. The mean average age of patients was 73 years, and 82% of the patients were females. VAS pain score was significantly reduced after surgery in both groups, and there were no significant differences between the two groups in postoperative VAS score. There was a significant reduction in kyphotic wedge angle and improvement of the sagittal index in both groups, but there was no significant difference between the two groups. There was a significant higher risk incidence of adjacent level fractures in the vertebroplasty group. CONCLUSIONS: In terms of clinical outcomes, there were no differences between the two groups. Both showed a significant clinical improvement, vertebral body height restoration and reduction in the kyphotic angle. There was a significant higher risk of adjacent level fractures in the vertebroplasty group.

Spinal tuberculosis: proposed spinal infection multidisciplinary management project (SIMP) flow chart revision.

OBJECTIVE: We propose a revised flow chart of spinal infection multidisciplinary management project (SIMP) aimed to standardize the diagnostic process and management of spinal tuberculosis (TB). MATERIALS AND METHODS: We reviewed data from all TB cases with osteoarticular involvement treated at a large tertiary teaching hospital in Bologna, Northern Italy, from January 2013 to December 2017. We cross-linked notified osteoarticular TB cases with SIMP database and we analysed clinical, diagnostic, and treatment data of all cases managed by SIMP. RESULTS: Osteoarticular TB accounted for the 7.8% (n=40) of all TB cases notified between 2013 and 2017 (N=513). Among the identified cases, 52% (n=21/40) had spine involvement: all were enrolled and evaluated by SIMP multidisciplinary group. Females accounted for 57% (12/21) of patients, the median age was 52 years (range 24-82). In the 67% (n=14/21) of cases, the major clinical symptom of spinal TB was back pain reported for a median of 4.5 months (range 1-12 months) before hospital admission. The interferon gamma release assay was positive in 75% (n=16/21) of patients. All patients performed MRI with gadolinium, which indicated spondylodiscitis in 90%. 18F-FDG-PET/CT revealed average maximum standardized uptake value (SUV max) of 12.54 (range 5.3-22) in 17/19 (89.5%). Bacteriological confirmation of TB was obtained in 86% of cases (n=18/21). One-third of patients (7/21) underwent surgery and 95% successfully completed the anti-TB treatment. CONCLUSIONS: Our data reveal that a multidisciplinary approach to spine tuberculosis facilitates early and accurate diagnosis and can improve medical and surgical management of this disease.

Carbon ions therapy as single treatment in chordoma of the sacrum. Histologic and metabolic outcome studies.

OBJECTIVE: Even though carbon ions treatment (CIRT) of sacral chordoma (SC) substantially reduces tumor mass, tumor remnants are observed in most patients. Differentiating tumor remnants from necrosis is challenging, expensive in terms of imaging and time-consuming. So far, there has not been a systematic histological and metabolic analysis of post-CIRT lesions. We designed a prospective study aiming to histologically a metabolically differentiate between viable tumor and foci of necrosis and of fibrosclerosis after CIRT and correlate these findings to clinical outcome in patients with SC. PATIENTS AND METHODS: Between January 2013 and December 2016 18 patients, 12 males and 6 females, with histological confirmation of sacral chordoma, underwent CIRT. The total dose was 70.4 GyE, with a daily fraction of 4.4 GyE, for 4 weeks. MRI was performed every three months after treatment. FDG PET-CT scan and CT-guided needle biopsy were performed 6-12 months after CIRT. The incidence of complications (intraoperative and postoperative), local control (LC), overall survival (OS) and progression-free survival (PFS), changes in neurological status, clinical outcomes and toxicity were considered. RESULTS: All histological analysis but 2 reported signs of necrosis and of fibrosclerosis after CIRT. One of these 2 patients turned into a dedifferentiated chordoma. Radiological partial response (PR) was observed in 10 patients (56.3%) and stable disease (SD) in 5 patients (28.3). Two patients (11%) had a local relapse. The overall survival rate was 100% at 24 months. FDG PET CT after CIRT showed uptake decreasing compared with the baseline exam in all but one patient. CONCLUSIONS: The histological presence of necrosis and of fibrosclerosis after CIRT at the histological analysis supports the previous clinical evidence on the efficacy of CIRT. Volumetric stability of the residual mass should be considered as a success of treatment. In cases of a volumetric increase of the mass, a CT needle biopsy should always be performed. In our series, during the follow-up, the FDG-PET was able to promptly detect an increased uptake in the case which later was histologically defined as dedifferentiated chordoma.

Isthmic spondylolisthesis and interspinous process device. Hype, hope, or contraindication?

OBJECTIVE: The aim of this study is to investigate, through the analysis of a case report and the literature review, indications and contraindications of Interspinous Process Device (IPD) in the surgical treatment of Lumbar Isthmic Spondylolisthesis (LIS). PATIENTS AND METHODS: A 37-years-old male with L5-S1 grade 2 LIS, treated with IPD at another center, referred to us eight months later with a worsening of back and leg pain. A revision surgery was performed with IPD removal and a L5-S1 TLIF. RESULTS: Clinical evaluation highlighted an improvement of pain, functionality, and quality of life scores at six months (VAS 4; ODI 30; EQ-5D 70) and twelve months follow-up (VAS 1; ODI 20; EQ-5D 90). CT scan was performed at six months and one-year follow-up to evaluate the fusion rate and stability of the implant. CONCLUSIONS: Given the pathologic anatomy and the biomechanics of LIS, IPD is ineffective in preventing further vertebral body slippage resulting in segmental kyphosis, because of the lack of connection between the posterior arch and the vertebral body due to the isthmic lesion.

Stochastic modelling of urban structure.

The building of mathematical and computer models of cities has a long history. The core elements are models of flows (spatial interaction) and the dynamics of structural evolution. In this article, we develop a stochastic model of urban structure to formally account for uncertainty arising from less predictable events. Standard practice has been to calibrate the spatial interaction models independently and to explore the dynamics through simulation. We present two significant results that will be transformative for both elements. First, we represent the structural variables through a single potential function and develop stochastic differential equations to model the evolution. Second, we show that the parameters of the spatial interaction model can be estimated from the structure alone, independently of flow data, using the Bayesian inferential framework. The posterior distribution is doubly intractable and poses significant computational challenges that we overcome using Markov chain Monte Carlo methods. We demonstrate our methodology with a case study on the London, UK, retail system.

Biomaterials as bone graft substitutes for spine surgery: from preclinical results to clinical study.

Vertebral fusion is performed in order to stabilize the spine in the presence of degenerative, traumatic or oncological pathologies that alter its stability. The autologous bone, harvested from the patient's iliac crest or from the lamina during surgery, is still considered the "gold standard" for spine fusion due to its osteogenic, osteoinductive and osteoconductive properties. However, several biological and synthetic bone substitutes have been introduced as alternatives for regenerating bone tissue. We have studied in particular the use of ceramic biomaterials prepared from hydroxypatite (HA), starting from in vitro analysis, through an in vivo study on ovine animal model and a post-market surveillance analysis, to finally design and perform a clinical study, which is ongoing in our Department. In the first step, HA-derived biomaterials were tested in vitro in the presence of bone marrow-derived human mesenchymal stem cells (hMSCs) and evaluated for their ability to activate precursor cells. In the second step, the biomimetic bone graft substitute SintLife® putty (MgHA) was evaluated in vivo. A posterolateral fusion procedure was applied on 18 sheep, where a fusion level was treated with MgHA, while the other level was treated with autologous bone. Microtomography and histological/histomorphometric analysis were performed six months of after surgery. In the third step, we reported the results of a post-market surveillance study conducted on 4 independent cohorts of patients (total 115 patients), in which HA-derived biomaterials were used as bone graft substitutes or extenders. Finally, a clinical study has been designed and approved by the Ethics Committee of our Institute and is currently ongoing. This study aims to evaluate the efficacy of the ceramic biomaterial SintLife® putty for bone replacement in patients treated by posterolateral fusion for degenerative spine disorders. HA biomaterials were effective in promoting the in vitro growth of hMSCs and their osteogenic differentiation. In the animal model, SintLife® putty has been effective in generating neo-formed bone tissue with morphological and structural features similar to those of the pre-existing bone. The post-market surveillance analysis has not reported any intra-operative nor early or late post-operative adverse events. Seven patients are currently recruited for the clinical trial designed to evaluate Sintlife efficacy for spine fusion (FU range: 1-7 months). No adverse events have been recorded. The first CT analysis performed at 6 months FU showed a good spine fusion. The study is ongoing. Our results, obtained from in vitro, preclinical and clinical studies, suggest that biomaterials derived from hydroxyapatite could be a valid alternative to autologous bone graft for vertebral fusion. This would potentially avoid or reduce the need of autologous bone harvesting and therefore, the risk of drawback-related side effects.

First neutron spectroscopy measurements with a pixelated diamond detector at JET.

A prototype Single crystal Diamond Detector (SDD) was installed at the Joint European Torus (JET) in 2013 along an oblique line of sight and demonstrated the possibility to carry out neutron spectroscopy measurements with good energy resolution and detector stability in discharges heated by neutral beam injection and radio-frequency waves. Starting from these positive results, within the Vertical Neutron Spectrometer project of the Joint European Torus, we have developed a pixelated instrument consisting of a matrix of 12 independent SDDs, called the Diamond Vertical Neutron Spectrometer (DVNS), which boosts the detection efficiency of a single SDD by an order of magnitude. In this paper we describe the main features of the DVNS, including the detector design, energy resolution, and data acquisition system for on-line processing. Preliminary spectroscopy measurements of 2.5 MeV neutrons from the present deuterium plasma at JET are finally presented.

Past and present of interposition arthroplasties for joint repair with special tribute to the contribution by Vittorio Putti.

Several techniques have been proposed to restore the compromised function of a joint. These include the arthroplasty by placing various tissues or materials between the articular surfaces. An important contribution to the diffusion of arthroplasty techniques was made by Vittorio Putti, head of the Rizzoli Orthopedic Institute in Bologna from 1912 to 1940. Interposition arthroplasty is still used for some non-weight-bearing joints, such as wrist and elbow, and gives good results. This type of surgery has been further developed by the improvement in biomaterials, biomechanical studies and the regenerative medicine. This paper describes the development starting from a historical survey particularly focused on Putti's contribution and ending with the state of the art of regenerative medicine in the treatment of joint diseases. Level of evidence V.

A diamond based neutron spectrometer for diagnostics of deuterium-tritium fusion plasmas.

Single crystal Diamond Detectors (SDD) are being increasingly exploited for neutron diagnostics in high power fusion devices, given their significant radiation hardness and high energy resolution capabilities. The geometrical efficiency of SDDs is limited by the size of commercially available crystals, which is often smaller than the dimension of neutron beams along collimated lines of sight in tokamak devices. In this work, we present the design and fabrication of a 14 MeV neutron spectrometer consisting of 12 diamond pixels arranged in a matrix, so to achieve an improved geometrical efficiency. Each pixel is equipped with an independent high voltage supply and read-out electronics optimized to combine high energy resolution and fast signals (<30 ns), which are essential to enable high counting rate (>1 MHz) spectroscopy. The response function of a prototype SDD to 14 MeV neutrons has been measured at the Frascati Neutron Generator by observation of the 8.3 MeV peak from the (12)C(n, α)(9)Be reaction occurring between neutrons and (12)C nuclei in the detector. The measured energy resolution (2.5% FWHM) meets the requirements for neutron spectroscopy applications in deuterium-tritium plasmas.

Long term results of acute Achilles repair with triple-bundle technique and early rehabilitation protocol.

BACKGROUND: The best treatment for acute rupture of the Achilles tendon is still under debate. Our purpose was to evaluate surgical triple-bundle technique in selected patients with full subcutaneous rupture of Achilles tendon. METHODS: Sixty-six consecutive patients (56 men, 10 women; age range 20-61 years) with full unilateral rupture of the Achilles tendon were surgically treated by the triple-bundle technique. Seventy-four percent of the lesions occurred during sport activity. Each patient was assessed by: (1) The American Orthopaedic Foot and Ankle Society (AOFAS) score; (2) the Leppilahti score; (3) the range of movement measurement of ankle joint; (4) ipsilateral thigh, calf, and ankle circumferences compared to the contralateral limb; (5) functional evaluation with isokinetic dynamometry of both limbs. RESULTS: 80.3% of the patients were fully satisfied (AOFAS ≥90) with treatment and resumed their previous level of sport. Concerning the outcomes, (1) the mean AOFAS score at 36 months was 93.9; (2) the mean Leppilahti score at 36 months was 91.8; (3) the mean difference in dorsiflexion and plantarflexion between the healthy side and the operated side was 4.3° and 6.9°, respectively. We observed calf muscle hypotrophy in two cases and scar complication in one. No re-ruptures occurred. Isokinetic tests performed 36 months after surgery showed a good restoration of plantarflexion. At univariate analysis AOFAS was influenced by age and difference between the healthy side and the operated side in dorsiflexion, plantarflexion, and circumference at all three levels and strenght at 60°/s. At univariate analysis, Leppilahti score confirmed the significant parameters of the AOFAS with the exception of age and difference of thigh circumference. The only predictive parameters in multivariate analysis were dorsiflexion difference (O.R. = 0.831; 95% C.I. 0.694-0.995; p = 0.044) and plantarflexion difference (O.R. = 0.777; 95% C.I. 0.631-0.958; p = 0.018). CONCLUSION: In this case series the triple-bundle technique showed a low rate of complications and good functional restore tested with isokinetic tests. For these reasons afforded by biomechanical strength test reported in literature, this technique has to be considered a valid choice for the treatment of Achilles tendon rupture in young patients with a high level of sport activity.