Arthroscopic treatment of ankle multiligamentous injuries provides similar clinical outcomes to the treatment of isolated lateral ligament injury at the 2-year follow-up.

PURPOSE: Rotational ankle instability is a multiligamentous injury defined as an overload injury of the deltoid ligament caused by a long-standing injury of the lateral collateral ligament in patients affected by chronic ankle instability. The purpose of the study was to compare the clinical outcomes of combined arthroscopic repair of lateral and medial ankle ligaments for rotational ankle instability versus isolated arthroscopic lateral ligament repair for lateral ankle instability at 2 years' follow-up. METHODS: Between 2019 and 2021, 108 patients with chronic ankle instability were consecutively treated by arthroscopy. Of this group, 83 patients (77%) [median age: 26 (range, 14-77) years] underwent an isolated all-inside lateral ligament repair for lateral ankle instability (group A). In the remaining 25 patients (23%) [median age: 27 (range, 17-58) years], rotational ankle instability was clinically suspected and confirmed during arthroscopy; thus, a combined all-inside repair of lateral and medial ligaments was performed (group B). The same postoperative protocol was utilised for both groups. Patients were prospectively evaluated before surgery, at 3, 6, 12 and 24 months with Foot Functional Index (FFI) score, visual analogue scale (VAS) and Foot and Ankle Ability Measure-Sports subscale (FAAM-SS). At the latest follow-up, the satisfaction rate and complications were also recorded. RESULTS: In both groups, FFI, VAS and FAAM-SS scores significantly improved compared to preoperative values (p < 0.001). In addition, according to all the scores evaluated, there was no significative difference (n.s) between groups at the final follow-up or at any of the intermediate follow-up. No major complications were observed in both groups. CONCLUSIONS: Arthroscopic ligament repair in case of ankle multiligamentous injuries, such as in rotational ankle instability, provides excellent clinical outcomes and is comparable to isolated lateral ligament repair at 2 years' follow-up. Therefore, when treating ankle instability, arthroscopic repair of each and every ligament that appears injured provides the best potential outcomes and is the recommended treatment. LEVEL OF EVIDENCE: Level II, prospective comparative.

Quantum Molecular Resonance Inhibits NLRP3 Inflammasome/Nitrosative Stress and Promotes M1 to M2 Macrophage Polarization: Potential Therapeutic Effect in Osteoarthritis Model In Vitro.

This study aimed to investigate the anti-inflammatory effects of Quantum Molecular Resonance (QMR) technology in an in vitro model of osteoarthritis-related inflammation. The study used THP-1-derived macrophages stimulated with lipopolysaccharide and hyaluronic acid fragments to induce the expression of inflammatory cytokines and nitrosative stress. QMR treatment inhibited COX-2 and iNOS protein expression and activity and reduced NF-κB activity. Furthermore, QMR treatment led to a significant reduction in peroxynitrite levels, reactive nitrogen species that can form during inflammatory conditions, and restored tyrosine nitration values to those similar to sham-exposed control cells. We also investigated the effect of QMR treatment on inflammasome activation and macrophage polarization in THP-1-derived macrophages. Results showed that QMR treatment significantly decreased NLRP3 and activated caspase-1 protein expression levels and downregulated IL-18 and IL-1ß protein expression and secretion. Finally, our findings indicate that QMR treatment induces a switch in macrophage polarization from the M1 phenotype to the M2 phenotype.

The Role of Platelet-Rich Plasma on the Chondrogenic and Osteogenic Differentiation of Human Amniotic-Fluid-Derived Stem Cells.

Amniotic fluid represents a new and promising source of engraftable stem cells. The purpose of this study was to investigate the in vitro effects of platelet-rich plasma (PRP) on amniotic-fluid-derived stem cells (AFSCs) on chondrogenic or osteogenic differentiation potential. Amniotic fluid samples were obtained from women undergoing amniocentesis for prenatal diagnosis at 16-18 weeks of pregnancy. Undifferentiated human AFSCs were cocultured with PRP for 14 days. The study includes two protocols investigating the effects of activated PRP using two different methods: via freeze-thaw cycles and via the addition of calcium gluconate. On the 14th day of culturing, the differentiation potential of the cocultured AFSCs was then compared with undifferentiated AFSCs. Staining with alcian blue solution (ABS) and alizarine red solution (ARS) was performed, and chondrogenic- and osteogenic-associated genes markers were investigated. ABS demonstrated enhanced glycosaminoglycan expression. Cocultured cells expressed chondrocyte-associated genes, determined by real-time polymerase chain reaction (RT-PCR), including type I collagen, type II collagen, COMP, and aggrecan. In regard to the osteogenic markers, osteopontin and bone sialoprotein, there were no changes. In particular, the activation of PRP using the freeze-thaw cycle protocol showed a higher expression of the chondrogenic markers. Our preliminary in vitro results showed that PRP has good potential in the chondrogenic differentiation of AFSCs.

Rat bone healing induced by natural nanocrystalline carbonated hydroxyapatite in combination with human amniotic fluid stem cells (AFSCs).

The present study was aimed at identifying a new scaffold/stem cell combination useful to treat large bone defects. Human amniotic fluid stem cells (AFSCs) were expanded in vitro, labeled with a fluorescent cell-permeable dye (PKH26) and transplanted in vivo in a femoral injured rat model. The femoral defect was left untreated (control rats) or filled with hydroxyapatite (HA; natural nanocrystalline carbonated hydroxyapatite-Orthoss®) scaffold alone or loaded with PKH26-labeled AFSCs. All animals were killed 3 weeks after implantation. Both gross anatomy and histological observations revealed a major bone regenerative response in rat specimens treated with HA scaffold, alone or supplemented with AFSCs. Samples injected with HA plus AFSCs displayed the presence of abundant fibrotic tissue, the formation of periosteal woven bone, and an increased presence of blood vessels in the bone marrow, with still fluorescent AFSCs in close proximity. These observations provide evidence that natural HA plus AFSCs represents a promising alternative therapeutic strategy to autologous bone grafting procedures.

Italian consensus statement (2020) on return to play after lower limb muscle injury in football (soccer).

Return to play (RTP) decisions in football are currently based on expert opinion. No consensus guideline has been published to demonstrate an evidence-based decision-making process in football (soccer). Our aim was to provide a framework for evidence-based decision-making in RTP following lower limb muscle injuries sustained in football. A 1-day consensus meeting was held in Milan, on 31 August 2018, involving 66 national and international experts from various academic backgrounds. A narrative review of the current evidence for RTP decision-making in football was provided to delegates. Assembled experts came to a consensus on the best practice for managing RTP following lower limb muscle injuries via the Delphi process. Consensus was reached on (1) the definitions of 'return to training' and 'return to play' in football. We agreed on 'return to training' and RTP in football, the appropriate use of clinical and imaging assessments, and laboratory and field tests for return to training following lower limb muscle injury, and identified objective criteria for RTP based on global positioning system technology. Level of evidence IV, grade of recommendation D.

Surgical treatment of displaced intraarticular calcaneal fractures by a minimally invasive technique using a locking nail: A preliminary study.

BACKGROUND: The aim of this retrospective study was to evaluate the outcome of patients with intra-articular calcaneal fractures treated using a minimally invasive locking nail (Calcanail®). METHODS: Between January 2016 and April 2017, 15 patients (9 men and 6 women) with a calcaneal fracture were consecutively treated with Calcanail®. The Böhler angle was recorded on standard X-rays pre- and post-operatively. The articular reduction of the posterior facet was evaluated with the Goldzak index in a CT scan 3 months post-operatively. The mean age of the patients was 53 years (range, 24-78). Mean final follow-up was 18 months (range, 12-24). RESULTS: Six fractures were classified as Sanders II, 7 as Sanders III and 2 as Sanders IV. In 13 out of the 15 patients treated, the post-operative Böhler angle was of more than 20°. Goldzak index was deemed as excellent in 73.5% of the cases (11 patients), good in 20% of cases (3 patients), and poor in 6.5% (1 patient). Post-operative mean AOFAS score was 85 (range, 60-96). CONCLUSIONS: The Calcanail® provides good restoration of the subtalar joint and the calcaneal angles with the advantages of a minimally invasive approach. It was effectively used in Sanders types II and III, even in the presence of poor cutaneous conditions.

Intercalary allograft reconstruction in a patient with large tibial defect: Case report.

A fit 26 year-old-man presented to our Department with an open fracture of the left tibial shaft (AO 42-C3). The fracture was initially treated with an External Fixator, which was replaced by an intramedullary Grosse Kempf nail after 4 months. In the following year he developed an atrophic non-union and we witnessed the increasing bone resorption at the fracture site which led to the nail breakage. An accurate CT pre-operative planning was made and a revision surgery was successfully performed: the broken nail was removed and intercalary allograft reconstruction was made, using a compressible intramedullary nail. Whereas in literature it is well described how intercalary allografts can be used to fill the massive diaphyseal defects after tumor resections, we assumed it could also be an adequate technique to treat a large bone defect at a non-union site.

Italian consensus conference on guidelines for conservative treatment on lower limb muscle injuries in athlete.

Provide the state of the art concerning (1) biology and aetiology, (2) classification, (3) clinical assessment and (4) conservative treatment of lower limb muscle injuries (MI) in athletes. Seventy international experts with different medical backgrounds participated in the consensus conference. They discussed and approved a consensus composed of four sections which are presented in these documents. This paper represents a synthesis of the consensus conference, the following four sections are discussed: (i) The biology and aetiology of MIs. A definition of MI was formulated and some key points concerning physiology and pathogenesis of MIs were discussed. (ii) The MI classification. A classification of MIs was proposed. (iii) The MI clinical assessment, in which were discussed anamnesis, inspection and clinical examination and are provided the relative guidelines. (iv) The MI conservative treatment, in which are provided the guidelines for conservative treatment based on the severity of the lesion. Furthermore, instrumental therapy and pharmacological treatment were discussed. Knowledge of the aetiology and biology of MIs is an essential prerequisite in order to plan and conduct a rehabilitation plan. Another important aspect is the use of a rational MI classification on prognostic values. We propose a classification based on radiological investigations performed by ultrasonography and MRI strongly linked to prognostic factors. Furthermore, the consensus conference results will able to provide fundamental guidelines for diagnostic and rehabilitation practice, also considering instrumental therapy and pharmacological treatment of MI. Expert opinion, level IV.

Open and arthroscopic lateral ligament repair for treatment of chronic ankle instability: A systematic review.

BACKGROUND: Chronic ankle instability is defined by an instability lasting more than 6 months, in those cases where a comprehensive conservative treatment fails a surgical stabilization is required. Several surgical techniques have been proposed for the management of the chronic lateral instability of the ankle and even after 50 years, the Broström-Gould technique is still considered the gold standard for the treatment of this pathology. Recently, many authors have developed completely arthroscopic lateral ligament repair and the use of these procedures is rapidly increasing. The aim of this review is to provide an updated overview of open and new arthroscopic lateral ligament repair techniques in order to summarize and compare the effectiveness of these strategies. METHODS: A systematic literature review using PubMed/Medline databases was performed (July 1972-July 2015). Clinical results, satisfaction rate and complications of both patient populations were recorded and statistically analyzed. RESULTS: The total ankles treated with an open Broström ATFL repair in the 13 studies was 505 with a mean follow up of 73.4 months (range 9 months-27.9 years). Postoperative AOFAS score was reported in 11 studies, with a mean value of 90.1 (range, 60-100), patient's satisfaction rate was 91.7%. Surgery-related complications occurred in 40 (7.92%) out of 505 treated ankles. The total number of ankles treated within the 6 arthroscopic studies was 216 with a mean follow up of 37.2 months (range 6 months-14 years). Five studies reported a mean postoperative AOFAS score of 92.48 (range, 44-100) with a patient's satisfaction rate of 96.4%. Surgery-related complications were observed in 33 (15.27%) cases. CONCLUSIONS: The results of this review show the excellent efficacy of open and arthroscopic surgical procedures in the treatment of the chronic ankle instability. The higher complication rate of arthroscopic procedures respect to the open ones represents the major issue: however, this does not seem to affect the patient's satisfaction. Because of statistical heterogeneity observed no definitive conclusions can be statistically drawn. Finally, to definitively validate the effectiveness of arthroscopic procedures prospective and comparative studies are needed.

Sports and Recreational Activities following Total Ankle Replacement.

Purpose In literature, there is a controversy regarding whether patients who have undergone total ankle replacement (TAR) can participate in sports and recreational activities. The purpose of this study was to report change in sports activity level after TAR. Methods A retrospective study was performed, enrolling 76 patients with symptomatic end-stage ankle arthritis who underwent TAR from May 2011 to October 2014. Patients were mainly males (44/76; 58%) and 56 years old on average (range: 22.3-79.6 years) at the time of surgery. They were treated with mobile-bearing prosthesis implanted with an anterior approach. Patients were evaluated preoperatively and 12 months postoperatively. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, the visual analog scale (VAS) pain score, and the 12-Item Short Form Health Survey (SF-12) - physical component summary (PCS) and mental component summary (MCS). Activity level was assessed with the University of California at Los Angeles (UCLA) activity scale. Results At 12 months postoperatively, statistically significant increase was reported for AOFAS scores (from 32.8 ± 12.7 preoperatively to 72.6 ± 13.3; p < 0.001), SF-12 PCS (from 34.3 ± 5.1 preoperatively to 45.4 ± 6.4; p < 0.001), and SF-12 MCS (from 39.8 ± 7.5 preoperatively to 51.4 ± 6.1; p < 0.001). A statistically significant decrease was detected in VAS pain score (from 8.7 ± 1.6 preoperatively to 2.2 ± 1.6; p < 0.001). The UCLA activity levels increased significantly from 2.4 ± 0.8 to 6.3 ± 2.3 ( p < 0.001). Conclusion Pain and function significantly improved in patients affected by ankle osteoarthritis, who underwent TAR, at 1-year follow-up. In addition, activity level showed a significant increase respect to preoperative condition. Level of Evidence Level IV, retrospective case series.

Corpectomy and expandable cage replacement versus third generation percutaneous augmentation system in case of vertebra plana: rationale and recommendations.

BACKGROUND: To evaluate the role of third generation percutaneous vertebral augmentation systems (Spine Jack®) as alternative to the corpectomies and expandable cages replacement (X-Core® Adjustable VBR System) in the treatment of vertebra plana (VP) as complication of the osteoporosis vertebral fracture (OVF). METHODS: Spine Jack® is a new device for mechanical kyphoplasty (MK). It is a titanium implant designed to restore the height of the vertebral body in OVF, primary or secondary bone tumors, or traumatic fractures. The X-Core® adjustable VBR System is a vertebral body replacement device indicated for use in the thoracolumbar spine (T1 to L5). The preoperative radiographic exams, computed tomography (CT), and magnetic resonance imaging (MRI) were performed in all cases. Clinical outcome measures included preoperative and postoperative Oswestry Disability Index (ODI), Visual Analog Scale pain score (VAS), neurologic examination, complications, estimated blood loss, and operating time. Postoperative radiographic evaluations were made at 1, 6, and 12 months. RESULTS: The anterior and middle column reconstruction by Spine Jack represents a valid alternative to the corpectomy in the patients affected by VP, especially in case elderly and/or high operative risk. In case of Spine Jack use, the correct indications must be respected: the hyperintense signal in STIR MRI sequences to the level of the fractures must be present. The eventual posterior spinal cord compression represents a relative contraindication. In case it would be superior to 1/3 and 2/3 respectively in case of fractures level above and below the spinal cord, a direct posterior spinal cord decompression must be performed. CONCLUSIONS: Avoiding the corpectomy, it is possible to reduce the operating time and the associated risks, as well as reducing blood loss.

Double plating for bicolumnar distal humerus fractures in the elderly.

Distal humerus fractures are uncommon injuries requiring specific clinical and radiographic analysis in order to plan the optimal therapeutic strategy. In particular, bicolumnar distal humerus fractures (Type A2, A3 and C) are complex fractures. In the last years, double plating fixation became the standard treatment: this procedure helped surgeons to obtain a stable and anatomical fixation and an early mobilization, which is the main outcome for obtaining valuable functional results. In this retrospective study, we evaluated the use of open bicolumnar 90-90 plating for fixation of acute fragility fractures of the distal humerus in elderly patients, using the olecranon osteotomy as surgical approach.

Identifying the learning curve for total ankle replacement using a mobile bearing prosthesis.

BACKGROUND: Total ankle arthroplasty remains a technically demanding surgery highly influenced by the operator experience. However, no consensus exists regarding the ideal number of cases that need to be performed before a surgeon is considered proficient. The aim of this study was to identify the learning curve of a specific replacement system with regards to intraoperative and postoperative outcomes. METHODS: The first 31 patients undergoing total ankle arthroplasty were examined. No additional procedures were performed at the time of the TAA. Intraoperative characteristics, postoperative complications, as well as clinical and radiologic outcomes were assessed with 24-month follow-up. Learning curves, examining the relationship between surgeon experience and patient outcomes, were determined using the Moving Average Method. RESULTS: The operatory time, and the risk of intraoperative fractures decreased with increasing surgeon experience with the learning curve stabilizing after the 14th and 24th patient, respectively. Furthermore, there appeared to be a learning curve associated with most of the important clinical and radiological outcomes. The number of patients required to stabilize the learning curve for the VAS, ROM, and AOFAS was 11, 14 and 28, respectively. Radiographically, there appeared to be a learning curve of 22 patients required to stabilize the tibio-talar ratio. There was no learning curve associated with the SF-12 PCS and MCS as well as the α-, ß-, and γ-angle. CONCLUSION: This study demonstrates that a surgical learning curve does indeed exist when performing TAA. Most of the operative variables as well as clinical and radiological outcomes stabilize after a surgeon has performed 28 cases.

Spontaneous corpectomy and anterior arthrodesis in lumbar spine: how Ankylosing Spondylitis can resolve a vertebral fracture.

Between the 80% and 90% of vertebral fractures in over 65 years people are due to osteoporosis. Over the 30% of patients affected by vertebral osteoporosis fractures needs of surgical treatment and the 12% presents complications requiring an invasive surgical approach. We report an unusual case of spontaneous corpectomy and anterior arthrodesis occurred in a patient suffering from Ankylosing Spondylitis. This event invites us to reflect about the magnitude of the biological power of the bone healing, even in adverse conditions.

Hyaluronic acid in knee osteoarthritis: preliminary results using a four months administration schedule.

AIM: To evaluate the therapeutic trajectory of intra-articular injections of hyaluronic acid at high concentration (2%) performed at 4-month intervals. METHODS: Subjects with knee osteoarthritis received, after a weekly injection of 32 mg/2 mL hyaluronic acid for 3 weeks, a single injection of 50 mg/2.5 mL hyaluronic acid (not cross-linked, molecular weight 800-1200 kDa) at 4-month interval (4, 8 and 12 months). Clinical assessment (visual analogic scale [VAS] for pain at rest and during activities, Lequesne Index [LI], Knee Injury and Osteoarthritis Outcome Score (KOOS), and monthly non-steroidal anti-inflammatory drug consumption) was performed at baseline, and after 1, 4, 6, 8, 12 and 14 months. RESULTS: In the 15 knees treated, pain decreased (baseline vs. 14 months: VAS at rest, 3.7 ± 1.7 vs. 1 ± 0.7 [P < 0.000]; VAS activities, 6.2 ± 1.7 vs. 2.6 ± 1.3 [P < 0.000]) and function improved (baseline vs. 14 months: KOOS, 51.9 ± 15.3 vs. 70.2 ± 13.7 [P < 0.000]; LI, 10 ± 3.8 vs. 5.4 ± 2.4 [P < 0.000]) significantly. CONCLUSIONS: This schedule provides persistent positive results in terms of reduced pain and improved function, optimizing the protective properties of the hyaluronic acid used.

Third-generation percutaneous vertebral augmentation systems.

Currently, there is no general consensus about the management of osteoporotic vertebral fractures (OVF). In the past, conservative treatment for at least one month was deemed appropriate for the majority of vertebral fractures. When pain persisted after conservative treatment, it was necessary to consider surgical interventions including: vertebroplasty for vertebral fractures with less than 30% loss of height of the affected vertebral body and kyphoplasty for vertebral fractures with greater than 30% loss of height. Currently, this type of treatment is not feasible. Herein we review the characteristics and methods of operation of three of the most common percutaneous vertebral augmentation systems (PVAS) for the treatment of OVF: Vertebral Body Stenting(®) (VBS), OsseoFix(®) and Spine Jack(®). VBS is a titanium device accompanied by a hydraulic (as opposed to mechanical) working system which allows a partial and not immediate possibility to control the opening of the device. On the other hand, OsseoFix(®) and Spine Jack(®) are accompanied by a mechanical working system which allows a progressive and controlled reduction of the vertebral fracture. Another important aspect to consider is the vertebral body height recovery. OsseoFix(®) has an indirect mechanism of action: the compaction of the trabecular bone causes an increase in the vertebral body height. Unlike the Vertebral Body Stenting(®) and Spine Jack(®), the OsseoFix(®) has no direct lift mechanism. Therefore, for these characteristics and for the force that this device is able to provide. In our opinion, Spine Jack(®) is the only device also suitable for the treatment OVF, traumatic fracture (recent, old or inveterate) and primary or secondary bone tumors.

Amniotic Fluid Stem Cells: A Novel Source for Modeling of Human Genetic Diseases.

In recent years, great interest has been devoted to the use of Induced Pluripotent Stem cells (iPS) for modeling of human genetic diseases, due to the possibility of reprogramming somatic cells of affected patients into pluripotent cells, enabling differentiation into several cell types, and allowing investigations into the molecular mechanisms of the disease. However, the protocol of iPS generation still suffers from technical limitations, showing low efficiency, being expensive and time consuming. Amniotic Fluid Stem cells (AFS) represent a potential alternative novel source of stem cells for modeling of human genetic diseases. In fact, by means of prenatal diagnosis, a number of fetuses affected by chromosomal or Mendelian diseases can be identified, and the amniotic fluid collected for genetic testing can be used, after diagnosis, for the isolation, culture and differentiation of AFS cells. This can provide a useful stem cell model for the investigation of the molecular basis of the diagnosed disease without the necessity of producing iPS, since AFS cells show some features of pluripotency and are able to differentiate in cells derived from all three germ layers "in vitro". In this article, we describe the potential benefits provided by using AFS cells in the modeling of human genetic diseases.

Arthroscopic treatment of shoulder instability in professional athletes.

BACKGROUND: Post-traumatic shoulder instability is a common disease, especially in sportsmen. If inadequately or late treated, it may be responsible for an articular biomechanics alteration, with serious problems. This is much more obvious for professionals athletes, because corporate and market needs force them to a premature return to sport. The purpose of this retrospective study is to evaluate if arthroscopic approach may be better than the open one and allowing a shoulder function rapid recovery, with fast return to sport. MATERIALS AND METHODS: From January 2003 to January 2014, 46 professional athletes underwent surgical treatment for post traumatic shoulder instability. Two groups were made: 25 athletes treated arthroscopically and 21 treated with open approach. Patients were followed up from 36 to 92 months, according to Rowe Score for Instability and VAS scoring system. RESULTS: Patients in the open group returned later than the first one to sport. Moreover, pain in postoperative period and during rehabilitation, was lower in the arthroscopic group. There was only one recurrence in the open group. CONCLUSIONS: Arthroscopic surgical approach appears to be excellent in shoulder instability management, reducing recovery time, allowing a faster return to sport, with less pain, if compared with open surgery. LEVEL OF EVIDENCE: III, a case control-study.