High satisfaction rate and range of motion can be expected in frozen shoulder after awake manipulation with brachial plexus block.

BACKGROUND: Adhesive capsulitis (AC) is a disease of the glenohumeral joint that is characterized by pain and both passive and active global stiffness with a slow and insidious onset. The disease can occur spontaneously (primary AC) or it can be secondary to other comorbidities, surgery, or trauma, such as fracture or dislocation. Multiple treatment approaches have been suggested: intra-articular steroid injection, physical therapy, manipulation under total anesthesia, and arthroscopic or open surgery. Shoulder manipulation under anesthesia is usually proposed to patients that suffer from severe AC and have already undergone several nonoperative treatments without benefit. Different techniques have been proposed. This study presents our manipulation technique and the clinical results we achieved after shoulder mobilization under brachial plexus block in patients with phase III primary AC. MATERIALS AND METHODS: A retrospective cohort study was performed on a sample of 110 patients with phase III AC who were treated with this manipulation and followed up for 1 year. Patients underwent two assessments-before the procedure (T0) and 4 months after it (T1)-based on the Numerical Rating Scale, Simple Shoulder Test, and joint range of motion to assess shoulder pain, function, and joint articulation, respectively. Furthermore, the patients had to express their degree of satisfaction with the procedure and the results achieved. RESULTS: Positive and statistically significant results were recorded in terms of pain reduction (ΔNPRS = - 5.4; p < 0.01) and improved functionality (Simple Shoulder Test Δ = 5; p < 0.01). Passive range of motion was statistically significantly increased for each movement at T1. Large increases were observed in extrarotation range of motion (ROM): R1 (Δ = 77.5°) and R2 (Δ = 70°), whereas little improvements were observed in intrarotation ROM. Patients achieved satisfying functional and articular recovery in all cases. Complications that needed further treatment occurred in three cases: a brachial plexus injury, a glenoid flake fracture, and persistent pain and stiffness. CONCLUSIONS: In this study, we proposed a standardized method of manipulation under brachial plexus block for patients affected by phase III adhesive capsulitis. The technique was applied among a large cohort of patients, who reported a high satisfaction rate and range-of-motion recovery after 4 months. This could represent an alternative treatment to surgery that has a shorter timeline and does not require patient hospitalization. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Custom-made reverse shoulder arthroplasty for severe glenoid bone loss: review of the literature and our preliminary results.

The treatment of severe glenoid bone loss in shoulder arthroplasty represents a challenge, and the results of current prosthetic designs with only glenoid fixation still remain unsatisfactory. In the past decade, customized glenoid prostheses have been developed to address severe glenoid arthritis and in the revision setting. In this review, we analyzed the current surgical options, the classification limits, past literature evidence, and our preliminary results of 6 patients (3 male, 3 female) treated with a reverse implant and custom-made glenoid implant (ProMade; LimaCorporate, Italy). Computer analysis of the residual shape and the amount of glenoid bone stock in association with new classifications could help the surgeon to obtain good clinical and radiological outcomes. The development of navigation systems could improve the adequacy of the implant and, thus, the reliability and longevity of the implant itself.

Clinical comparison of oral administration and viscosupplementation of hyaluronic acid (HA) in early knee osteoarthritis.

PURPOSE: Osteoarthritis (OA) is a progressive, chronic and degenerative joint disease characterized by a loss of articular cartilage. Treatment of OA is largely palliative based on nonsteroidal anti-inflammatory drugs, opioids and injections of steroids. Regarding conservative treatment, intra-articular injections of hyaluronic acid (HA) can play a role in early symptomatic knee OA. MATERIALS AND METHODS: Between August 2015 and September 2015, sixty patients (32 males and 28 females) between 40 and 70 years old were randomly allocated into two groups: Half were treated with three weekly intra-articular injections of hyaluronic acid 1.6 % (group A), while the others were treated with Syalox 300 Plus® (hyaluronic acid 300 mg + Boswellia serrata extract 100 mg) 1 tab/die for 20 days and afterward Syalox 150® (hyaluronic acid 150 mg) 1 tab/die for other 20 days (group B). All patients were evaluated clinically with American Knee Society Score (AKSS) and visual analogue scale (VAS) for the pain before the treatment and after 3 months. RESULTS: AKSS of the patients in both groups was significantly increased by the treatment, and VAS score was significantly reduced. In both groups, two subgroups were created with patients older than 60 years and patients younger than 60 years. Better results are reported in younger patients of group A and older subjects in group B. CONCLUSIONS: Despite several limitations, the results of the study have shown that HA injection and oral administration may have beneficial therapeutic effects on patients with early osteoarthritis. Different outcomes in younger and older subject suggested a combined therapy first with local infiltrations and then with oral composition.

Chromium-induced diffuse dermatitis with lymph node involvement resulting from Langerhans cell histiocytosis after metal-on-metal hip resurfacing.

Total hip arthroplasty (THA) is a highly effective surgical treatment for severe joint involvement. However, due to the release of metal ions in the blood, the patients who undergo hip replacement with metal-on-metal (MOM) bearings may develop signs of allergic skin disease. We report a case of a 60-year-old man who had received MOM hip resurfacing 5 years earlier for osteoarthritis. He presented with a 3-year history of diffuse dermatitis that did not respond to antihistamines and corticosteroids and also had elevated serum levels of chromium and cobalt. A patch test revealed chromium-sulfate hypersensitivity. A skin biopsy showed nonspecific perivascular lymphocytic infiltrate associated with histiocytes. A biopsy of an inguinal lymph node demonstrated large aggregates of Langerhans cells, suggesting type IV delayed-type hypersensitivity. The prosthesis was replaced using ceramic-on-ceramic bearings and the dermatitis resolved after 3 months. The lymph nodes decreased in volume and the serum chromium levels normalized within 24 months of revision surgery. The high levels of serum ions associated with the metal debris from MOM-THAs may induce sensitization and type IV hypersensitivity reactions. Replacing the prosthesis using alternative coupling surfaces is the only approach that has the capacity to resolve these symptoms. Physicians who are not familiar with this issue may misdiagnose systemic symptoms and provide inadequate treatment.

The treatment of proximal humeral fractures with a "Polarus" intramedullary nail.

Proximal humeral fractures are complex lesions with difficult management problems; therefore, they pose a challenge for orthopaedic surgeons. In the literature, numerous treatment techniques have been proposed for these kinds of fractures. In our study we reviewed 30 patients with a mean age of 75 years presenting a proximal humeral fracture (Neer 2-3) and treated at our clinic with a Polarus nail, with a mean follow-up of 7 years. We obtained 73.3% of good and excellent results in line with literature. Complications were recorded in 6 of the patients (20%) recruited in our study. In particular, 3 cases of proximal screw pull-out, 1 case of deep infection and 2 cases of acromio-clavicular joint impingement syndrome. The aim of our study was to review our case histories and compare them with the literature analysing this complex type fracture and treatment options.

Femoroacetabular impingement: biomechanical and dynamic considerations.

Femoroacetabular impingement (F.A.I.) is a pathologic process caused by an abnormal shape of the acetabulum, of the femoral head, or both. F.A.I., often referred to as idiopathic, may be secondary to slipped capital femoral epiphysis, congenital hypoplasia of the femur, Legg-Calvé Perthes disease, post-traumatic mal-union and protrusio acetabuli. From 2009 to 2012 we studied 21 patients (14 males), with a mean age of 52 (33 y - 75 y), affected by idiopathic F.A.I. Every patient underwent pelvic and hip joint X-rays and CT scan with 3D reconstructions, in order to evaluate the morphology of the pelvis and the hip joint and the torsion of the lower limbs (Femoroacetabular ante-retroversion). Our results show an average femoral ante-version angle of 12,4° (15°-20° physiological range) in patients affected by CAM impingement and an average acetabular ante-version angle of 13,5° (15°-20° physiological range) for those with PINCER impingement. These values, in patients affected by F.A.I., are probably related to morphologic and biomechanical features that may lead to the onset of idiopathic femoroacetabular impingement. In the literature, other studies partially support our findings, suggesting a more critical approach to a patient with idiopathic F.A.I. extending evaluations to nearby articulations.

Augmentation of unstable pertrochanteric fractures in the osteoporotic elderly patient: operative technique for 1 or 2 head screw systems.

The incidence of proximal femoral fractures has substantially risen in the elderly. This rise has been attributed to an increase in their life span and the underlying poor bone stock and osteoporosis. One of the main reasons for revision surgery, reported to be as high as 19%, is the cut-out of the fixation device at the apex of the femoral head. Augmentation, facilitated by injecting cement (PMMA) around the apex of the proximal screw of the fixation device is considered a useful method with regards to the increased purchase between the bone and implant interface. The aim of this study is the description of the cement Augmentation operative technique for unstable osteoporotic pertrochanteric fractures with 1-2 femoral head screw devices.

Tibial plateau fractures: compared outcomes between ARIF and ORIF.

The purpose of this study is to compare arthroscopic assisted reduction internal fixation (ARIF) treatment with open reduction internal fixation (ORIF) treatment in patients with tibial plateau fractures. We studied 100 patients with tibial plateau fractures (54 men and 46 women) examined by X-rays and CT scans, divided into 2 groups. Group A with associated meniscus tear was treated by ARIF technique, while in group B ORIF technique was used. The follow-up period ranged from 12 to 116 months. The patients were evaluated both clinically and radiologically according to the Rasmussen and HSS (The Hospital for Special Surgery knee-rating) scores. In group A, the average Rasmussen clinical score is 27.62 ± 2.60 (range, 19-30), while in group B is 26.81 ± 2.65 (range, 21-30). HSS score in group A was 76.36 ± 14.19 (range, 38-91) as the average clinical result, while in group B was 73.12 ± 14.55 (range, 45-91). According to Rasmussen radiological results, the average score for group A was 16.56 ± 2.66 (range, 8-18), while in group B was 15.88 ± 2.71 (range, 10-18). Sixty-nine of 100 patients in our study had associated intra-articular lesions. We had 5 early complications and 36 late complications. The study suggests that there are no differences between ARIF and ORIF treatment in Schatzker type I fractures. ARIF technique may increase the clinical outcome in Schatzker type II-III-IV fractures. In Schatzker type V and VI fractures, ARIF and ORIF techniques have both poor medium- and long-term results but ARIF treatment, when indicated, is the best choice for the lower rate of infections.

Three-dimensional matrix-induced autologous chondrocytes implantation for osteochondral lesions of the talus: midterm results.

Introduction. We evaluate the midterm results of thirty patients who underwent autologous chondrocytes implantation for talus osteochondral lesions treatment. Materials and Methods. From 2002 to 2009, 30 ankles with a mean lesion size of 2,36 cm(2) were treated. We evaluated patients using American Orthopaedic Foot and Ankle Surgery and Coughlin score, Van Dijk scale, recovering time, and Musculoskeletal Outcomes Data Evaluation and Management System. Results. The mean AOFAS score varied from 36.9 to 83.9 at follow-up. Average of Van Dijk scale was 141.1. Coughlin score was excellent/good in 24 patients. MOCART score varied from 6.3 to 3.8. Discussion. This matrix is easy to handle conformable to the lesion and apply by arthroscopy. No correlation between MRI imaging and clinical results is found. Conclusions. Our results, compared with those reported in literature with other surgical procedures, show no superiority evidence for our technique compared to the others regarding the size of the lesions.