Epidemiology of rotator cuff surgery in Italy: regional variation in access to health care. Results from a 14-year nationwide registry.

PURPOSE: Rotator cuff (RC) disease is frequent and represents a common source of shoulder pain. The aim of this study is to analyse geographical differences in RC surgeries from 2001 to 2014 in Italy, a country with universal and free health care for its population. METHODS: An analysis of the Italian National Hospital Discharge records from 2001 to 2014 was performed. These data are anonymous and include patient's age, sex, domicile, region of hospitalization, length of the hospitalization and type of reimbursement (public or private). National and regional population data were obtained from the National Institute for Statistics (ISTAT) for each year. RESULTS: During the 14-year study period, 390,001 RC repairs were performed in Italy, which represented a mean incidence of 62.1 RC procedures for every 100,000 Italian inhabitants. Nevertheless, the incidence was very different if every single regional population is considered individually. Lombardy resulted to have the highest number of surgeries during the 14-year study period, with 27.95% (108,954) of the total national procedures performed in the 2001-2014 time span. More than half the surgeries (52.00%) were performed in only 3 regions of the northern part of Italy. CONCLUSIONS: This study shows the existence of geographical disparities in access to RC surgery and patients' necessity to migrate among regions in order to obtain it. Southern regions of Italy are characterized by a lower number of surgeries compared to the northern part of Italy.

Advances in management of periprosthetic joint infections: an historical prospective study.

OBJECTIVE: The purpose of our study is to assess the incidence of prosthetic joint infection (PJI) after total Knee arthroplasty (TKA), total Hip arthroplasty (THA) and total Shoulder arthroplasty (TSA), to identify risk factors, determine the microbial spectrum and management's outcome. PATIENTS AND METHODS: A case-control, retrospective observational study was performed analyzing patients who developed a PJI after TKA, THA, and TSA from 2000 to 2017 at our hospital. The patient's risk profile was defined extracting from clinical records the following data: sex, age, BMI, type of implant, comorbidity, year of surgery, year of infection, previous intra-articular injection, microbial isolation, medical and surgical management outcome. We include in the "control group" for each "case" at least 3 patients who didn't have a PJI after TJA. RESULTS: 28 patients met all inclusion and exclusion criteria. Comparing the "cases" with "controls" demographics parameters, medical comorbidities and previous intra-articular injection were not associated with an increased risk of PJI. Comparing the "early/delayed group" with "late group", BMI was associated with an increased risk of early/delayed PJI, while demographics parameters, medical comorbidities, and previous intra-articular injection did not significantly increase the risk of PJI. Logistic regression showed that for each BMI unit there was a 20-fold increased risk of early prosthetic infection (OR 1.19, IC 1.03-1.38, p=0.01). Staphylococci were isolated most frequently from pre-operative and intra-operative cultures. Two-stage arthroplasty exchange and surgical debridement resulted in the most performed surgical treatment with a success rate of 88 and 87%. CONCLUSIONS: Obesity is a risk factor for "early/delayed infection" of TJA. Two-stage arthroplasty exchange, debridement, antibiotics, and implant retention in patients are treatments with a high rate of success in terms of reinfection.

Anterior cruciate ligament reconstruction in skeletally immature patients : a systematic review.

AIMS: Different methods of anterior cruciate ligament (ACL) reconstruction have been described for skeletally immature patients before closure of the growth plates. However, the outcome and complications following this treatment remain unclear. The aim of this systematic review was to analyse the outcome and complications of different techniques which may be used for reconstruction of the ACL in these patients. MATERIALS AND METHODS: We performed a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This involved a comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using the following combinations of keywords, "knee", "anterior cruciate ligament", "reconstruction", "injury", "children", "adolescent", "skeletally immature", "open physis" and "surgery". RESULTS: A total of 53 studies met the inclusion criteria and were included for analysis. The overall rate of disturbance of growth after ACL reconstruction was 2.6%, with no statistical difference between transphyseal and physeal-sparing techniques. Physeal-sparing techniques had a lower rate of post-operative complications compared with transphyseal techniques (p = 0.0045). Outcomes assessed were Lysholm score, International Knee Documentation Committee (IKDC) score, the IKDC grade, the Tegner score and the KT-1000. Both techniques had similar clinical outcomes. CONCLUSIONS: This review reveals low rates of disturbance of growth after ACL reconstruction in skeletally immature patients. Although limited, the available evidence did not support any particular surgical technique when considering disturbance of growth or clinical outcome. Further randomised controlled trials are needed to investigate the efficacy of differing surgical techniques on outcomes in skeletally immature patients. Cite this article: Bone Joint J 2017;99-B:1053-60.

Reverse shoulder arthroplasty for massive irreparable rotator cuff tears and cuff tear arthropathy: a systematic review.

PURPOSE: To report the outcomes and complications of reverse shoulder arthroplasty (RSA) in massive irreparable rotator cuff tears (MIRCT) and cuff tear arthropathy (CTA). METHODS: A systematic review of the literature contained in Medline, Cochrane, EMBASE, Google Scholar and Ovid databases was conducted on May 1, 2016, according to PRISMA guidelines. The key words "reverse total shoulder arthroplasty" or "reverse total shoulder prostheses" with "rotator cuff tears"; "failed rotator cuff surgery"; "massive rotator cuff tears"; "irreparable rotator cuff tears"; "cuff tear arthropathy"; "outcomes"; "complications" were matched. All articles reporting outcomes and complications of RSA for the management of MIRCT or CTA were included. The comparison between preoperative and postoperative clinical scores, as well as range of motion (ROM), was performed using the Wilcoxon-Mann-Whitney test. P values lower than 0.05 were considered statistically significant. RESULTS: Seven articles were included in our qualitative synthesis. A statistically significant improvement in all clinical scores and ROM was found comparing the preoperative value with the postoperative value. The degrees of retroversion of the humeral stem of the RSA do not influence the functional outcomes in a statistically significant fashion. There were 17.4% of complications. The most frequent was heterotopic ossification, occurring in 6.6% of patients. Revision surgery was necessary in 7.3% of patients. CONCLUSIONS: RSA restores pain-free ROM and improves function of the shoulder in patients with MIRCT or CTA. However, complications occur in a high percentage of patients. The lack of level I studies limits the real understanding of the potentials and limitations of RSA for the management of MIRCT and CTA.

Deltoid muscle tropism does not influence the outcome of arthroscopic rotator cuff repair.

BACKGROUND: Several different factors have been identified as causes of failure of rotator cuff (RC) repair. However, no studies focused on the role of the deltoid muscle. The aim of this study was to investigate the role of the deltoid tropism in the outcomes of arthroscopic RC repair procedures. MATERIALS AND METHODS: Nine male (45 %) and 11 female (55 %) patients who underwent arthroscopic RC repair were included in the study. The mean age was 63.5 ± 8.1 years (range 50-74 years), and the follow-up averaged 1.9 ± 1.3 years (range 1-5 years) after surgery. Clinical outcomes were assessed using the modified University of California, Los Angeles (UCLA) shoulder rating scale, Wolfgang criteria shoulder score and Oxford shoulder score (OSS). Functional outcomes were evaluated considering active and passive range of motion of the shoulder and muscle strength. The deltoid tropism was measured pre-operatively and post-operatively using T2-weighted transverse MRI images. RESULTS: No statistically significant correlation was found between the thickness of each portion of the deltoid muscle (vD, lD and dD) and the UCLA shoulder rating scale, Wolfgang shoulder score and OSS. At the same time, no statistically significant relationship was detected between the thickness of each portion of the deltoid muscle (vD, lD and dD) and the functional outcomes. CONCLUSIONS: The deltoid tropism does not influence the results of arthroscopic RC repair. Early RC repair may prevent the reduction in the tropism of the deltoid muscle. Nevertheless, further prospective randomized studies with larger samples are necessary to clarify the role of deltoid tropism in the outcomes of arthroscopic RC repair procedures.

Reverse total shoulder arthroplasty for the management of fractures of the proximal humerus: a systematic review.

Reverse total shoulder arthroplasty (RTSA) represents a good solution for the management of patients with fracture of the proximal humerus with associated severe osteoporosis and RC dysfunction. A systematic review of the literature according to the PRISMA guidelines was performed matching the following keywords: "reverse total shoulder arthroplasty"; "reverse total shoulder prostheses"; "fractures"; "fracture of the proximal humerus." Medline, EMBASE, Google Scholar, and Ovid database have been screened. Ten studies were considered in the qualitative analysis. No randomized prospective controlled trials have been found. A total of 256 patients received a RTSA for the management of fracture of the proximal humerus. There were 28 males (10.8 %) and 228 females (89.2 %). The mean age of patients was 75.5 ± 2.2 years (range 70-78 years). The mean follow-up period was 27.8 ± 21.8 months range (6-86 months). Overall, the mean Constant score was 56.7 ± 7.6 points (range 44-67.8 points), the mean DASH score was 39.9 ± 6 points (range 31.5-46.8 points), the ASES averaged 70.3 ± 6.8 points (range 65-78 points), and the OSS averaged 28.7 points (range 15-56 points). RTSA restores function and relieves pain in patients with proximal humeral fractures. However, no randomized controlled trials are available to support RTSA versus osteosintesis, anatomical prostheses or hemiarthroprotesis. Further studies are needed to evaluate the effectiveness of RTSA in the management of fracture of the proximal humerus.

Errors of level in spinal surgery: an evidence-based systematic review.

Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery.

Conservative management of patients with an osteoporotic vertebral fracture: a review of the literature.

Osteoporotic vertebral compression fractures (VCFs) are an increasing public health problem. Recently, randomised controlled trials on the use of kyphoplasty and vertebroplasty in the treatment of these fractures have been published, but no definitive conclusions have been reached on the role of these interventions. The major problem encountered when trying to perform a meta-analysis of the available studies for the use of cementoplasty in patients with a VCF is that conservative management has not been standardised. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing. In this review, we report the best evidence available on the conservative care of patients with osteoporotic VCFs and associated back pain, focusing on the role of the most commonly used spinal orthoses. Although orthoses are used for the management of these patients, to date, there has been only one randomised controlled trial published evaluating their value. Until the best conservative management for patients with VCFs is defined and standardised, no conclusions can be drawn on the superiority or otherwise of cementoplasty techniques over conservative management.

Fat pad-derived mesenchymal stem cells as a potential source for cell-based adipose tissue repair strategies.

BACKGROUND: Mesenchymal stem cells are able to undergo adipogenic differentiation and present a possible alternative cell source for regeneration and replacement of adipose tissue. The human infrapatellar fat pad is a promising source of mesenchymal stem cells with many source advantages over from bone marrow. It is important to determine whether a potential mesenchymal stem-cell exhibits tri-lineage differentiation potential and is able to maintain its proliferation potential and cell-surface characterization on expansion in tissue culture. We have previously shown that mesenchymal stem cells derived from the fat pad can undergo chondrogenic and osteogenic differentiation, and we characterized these cells at early passage. In the study described here, proliferation potential and characterization of fat pad-derived mesenchymal stem cells were assessed at higher passages, and cells were allowed to undergo adipogenic differentiation. MATERIALS AND METHODS: Infrapatellar fat pad tissue was obtained from six patients undergoing total knee replacement. Cells isolated were expanded to passage 18 and proliferation rates were measured. Passage 10 and 18 cells were characterized for cell-surface epitopes using a range of markers. Passage 2 cells were allowed to undergo differentiation in adipogenic medium. RESULTS: The cells maintained their population doubling rates up to passage 18. Cells at passage 10 and passage 18 had cell-surface epitope expression similar to other mesenchymal stem cells previously described. By staining it was revealed that they highly expressed CD13, CD29, CD44, CD90 and CD105, and did not express CD34 or CD56, they were also negative for LNGFR and STRO1. 3G5 positive cells were noted in cells from both passages. These fat pad-derived cells had adipogenic differentiation when assessed using gene expression for peroxisome proliferator-activated receptor γ2 and lipoprotein lipase, and oil red O staining. DISCUSSION: These results indicate that the cells maintained their proliferation rate, and continued expressing mesenchymal stem-cell markers and pericyte marker 3G5 at late passages. These results also show that the cells were capable of adipogenic differentiation and thus could be a promising source for regeneration and replacement of adipose tissue in reconstructive surgery.

No correlation between physicians administered elbow rating systems and patient's satisfaction.

AIM: The aim of this study was to assess the functional outcome of patients who had undergone elbow arthroscopy, evaluating the correlation between three elbow scoring systems and the patients' subjective perception of satisfaction METHODS: Fourteen patients who had undergone elbow arthroscopy were retrospective reviewed to evaluate the correlation between three elbow scoring systems and the patients' subjective perception of satisfaction at a mean follow-up time of 24 months (range 12-64 months). Two independent orthopedic surgeons evaluated all patients using three elbow scoring systems, a simple satisfaction question and a visual analogue scale. RESULTS: The three scoring systems showed significant correlation with each other (P<0.05). There was no correlation between the results of the three scoring systems and patients' satisfaction: patients with the same level of satisfaction could perform differently at the scoring systems. CONCLUSION: Although the three scoring systems used to evaluate the patients showed significant correlation with each other, they failed to correlate to patients' satisfaction. In reporting the results of arthroscopic elbow procedures, emphasis should be placed on individual variables, rather than on global elbow ratings. Further studies are needed to develop a single outcome evaluation system which is reliable, valid and sensitive to changes of clinical importance, which takes into account both patients' and physicians perspective, and which is short and practical to use.

[Surgical treatment of Achilles tendon rupture]. / Operative Behandlung der Achillessehnenruptur.

The open tendon suture is the most commonly used method of treatment for Achilles tendon rupture in Germany. Over the last decade the therapeutic spectrum of operative methods has been further enlarged by the development of new minimally invasive surgical techniques. Important criteria for planning treatment are the location and age of the rupture and comorbidities. For recent Achilles tendon ruptures minimally invasive suturing is indicated but for older ruptures a reconstruction often has to be carried out. The decisive disadvantage of an open tendon suture is the relatively high risk of infection. Using minimally invasive surgical techniques the frequency of postoperative infection could be significantly reduced. The suture methods without opening the ruptured region can be collectively grouped under the term percutaneous suture techniques and the minimally invasive methods with opening of the rupture region as combined open percutaneous techniques. Documented problems with the Ma-Griffith technique, such as injury of the sural nerve, low stability of the suture and insufficient adaption of the tendon stumps have been minimized by new minimally invasive operation techniques. Achilles tendon ruptures which nearly always arise without any external influence or accidents can have substantial psychological consequences regarding the integrity of one's own body especially for people actively engaged in sport. This aspect should be considered and accepted in particular during postoperative treatment.

[Surgical treatment for pain syndromes of the Achilles tendon]. / Operative Behandlung der Schmerzsyndrome der Achillessehne.

Pain syndromes of the Achilles tendon (AT) include both insertional and non-insertional tendinopathy, two distinct disorders with different underlying pathophysiologies and management options, characterized by pain, impaired performance and swelling in and around the tendon. This article gives an overview of the operative treatment of pain syndromes of the Achilles tendon, including both insertional tendinopathy of the AT and tendinopathy of the main body of the AT. New minimally invasive techniques for the management of this condition, including endoscopy are also reported.

Long-term health outcomes of youth sports injuries.

Injuries can counter the beneficial effects of sports participation at a young age if a child or adolescent is unable to continue to participate because of residual effects of injury. This paper reviews current knowledge in the field of long-term health outcomes of youth sports injuries to evaluate the evidence regarding children dropping out of sport due to injury, physeal injuries and growth disturbance, studies of injuries affecting the spine and knee of young and former athletes and surgical outcome of anterior cruciate ligament (ACL) reconstruction in children. Studies of dropping out of sport due to injury are limited primarily to gymnasts and implicate such injuries as ACL rupture and osteochondritis dissecans of the elbow joint in the early retirement of young athletes. Although most physeal injuries resolve with treatment and rest, there is evidence of disturbed physeal growth as a result of injury. Radiological findings implicate the effects of intense physical loading and injury in the development of spinal pathology and back pain during the growth of youth athletes; however, long-term effects are unclear. Follow-up studies of young athletes and adults indicate a high risk of osteoarthritis after meniscus or ACL injury. Prospective cohort studies with a follow-up into adulthood are needed to clarify the long-term health outcomes of youth sports injuries. Important to this research is meticulous documentation of injuries on injury report forms that include age-appropriate designations of the type of injury and accurate determination of exposure-based injury rates.

Triglycerides and total serum cholesterol in rotator cuff tears: do they matter?

OBJECTIVE: In this study, the serum triglycerides and total serum cholesterol levels in patients with rotator cuff tear were determined. DESIGN: Frequency-matched case-control study. Setting University teaching hospital. PARTICIPANTS: 240 individuals who were operated on at our institution were included in the study. 120 patients (45 men and 75 women; mean age 64.86 years, range 40 to 83 years) who underwent arthroscopic repair of a rotator cuff tear were included in group 1. 120 patients (45 men and 75 women; mean age 63.91 years, range 38 to 78 years) who underwent arthroscopic meniscectomy for a meniscal tear and had no evidence of shoulder pathology were included in group 2 (control group). These patients were frequency-matched by age (within 3 years) and sex with patients of group 1. MAIN OUTCOME MEASURES: Measurement of serum triglyceride and total cholesterol concentrations. RESULTS: When comparing the two groups, there was no difference either in serum triglyceride concentration or total serum cholesterol concentration. CONCLUSIONS: There appears to be no association between serum triglyceride concentration and total serum cholesterol concentration in rotator cuff tears.

Osteoid osteoma mimicking overuse syndromes in athletes.

This article reports the clinical features, findings at imaging, management and outcome of five athletes who presented with osteoid osteoma. The diagnosis was missed initially in all the athletes, who were managed for an overuse syndrome for many months before receiving a correct diagnosis. Osteoid osteoma can cause atypical pain, and therefore lead to delay in diagnosis and inappropriate management. Each injured athlete must be fully evaluated by history, physical examination and appropriate imaging investigations to minimize the rate of misdiagnosis and underestimation, unnecessary procedures, and delayed management.

Higher fasting plasma glucose levels within the normoglycaemic range and rotator cuff tears.

OBJECTIVE: To determine the plasma glucose levels in non-diabetic patients with rotator cuff tear. DESIGN: Frequency-matched case-control study. SETTING: University Teaching Hospital. PARTICIPANTS: The study included 194 subjects who were operated on at our institution. Group 1 included 97 consecutive patients (36 men and 61 women; mean age: 62.9 years, range 37 to 82) who underwent arthroscopic repair of a rotator cuff tear in 2007 and 2008. Group 2 (control group) included 97 patients (36 men and 61 women; mean age: 61.6 years, range 36 to 80) who underwent arthroscopic meniscectomy for a meniscal tear in the same period, and had no evidence of shoulder pathology. These patients were frequency-matched by age (within 3 years) and gender with patients of Group 1. MAIN OUTCOME MEASURE: Measurement of fasting plasma glucose levels. RESULTS: Patients with rotator cuff tears (Group 1) showed statistically significantly higher fasting plasma glucose levels within the normoglycaemic range (p = 0.007) than patients with meniscal tear (Group 2). CONCLUSIONS: The present study suggests that normal, but in the high range of normal, increasing plasma glucose levels may be a risk factor for rotator cuff tear. An enhanced understanding of these factors holds the promise of new approaches to the prevention and management of rotator cuff tears.

Characteristics at haematoxylin and eosin staining of ruptures of the long head of the biceps tendon.

OBJECTIVE: To examine the relative prevalence of histological changes that have been found to be associated with the process of tendinopathy in lesions of the tendon of the long head of the biceps brachii and to evaluate the reliability of histopathological evaluation of tendon tissue in lesions of the tendon of the long head of the biceps. DESIGN: Tendon samples were taken from 51 patients (31 men, 20 women; mean age 63.2 years) who underwent arthroscopic release of the long head of the biceps tendon because of refractory biceps tendinopathy and from 5 male patients who died of cardiovascular events (mean age 69.6 years). Histological examination was performed using haematoxylin and eosin staining of sections, which were interpreted using a semiquantitative grading scale assessing fibre structure and arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen staining and hyalinisation. RESULTS: The mean (SD) pathological sum score of ruptured tendons was greater than that of control tendons (15.76 (3.11) vs 3.4 (1.9), p<0.001). Within each specific category of tendon abnormalities, the chi(2) test showed significant differences between the control and ruptured tendons; all the variables were significantly different (Mann-Whitney U test 0.05, p<0.001). Using the kappa statistic, the agreement between the two readings ranged from 0.53 to 0.85. CONCLUSIONS: Unruptured tendons of the long head of the biceps, even at an advanced age and ruptured tendons of the long head of the biceps are clearly part of two distinct populations.