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

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

Radial head prosthesis: surgical tips and tricks.

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

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

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

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

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

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

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

Elbow rehabilitation in traumatic pathology.

The elbow, intermediate joint of the upper limb, frequently undergoes to pathological events and is especially prone to stiffness. Rehabilitation plays an important role in recovering functional activities. For the rehabilitation team, this goal always represents a challenge, as the treatment has to be continuously modeled and calibrated on the needs of the individual patient, even many times during the same rehabilitation cycle. Containing the effects of immobilization, avoiding to excessively stress the healing tissues, satisfying specific clinical criteria before moving to the next rehabilitation stage, basing the rehabilitation plan on up-to-date clinical and scientific data that can be adapted to each patient and to his/her needs are the basic principles of the rehabilitation plan, which can be chronologically grouped into four rehabilitation stages. After summarizing the general principles of elbow treatment, the specific principles of rehabilitation after elbow fractures and elbow instability are presented, and then the rehabilitative approach to the most frequent and feared pathological conditions of the elbow, namely stiffness, is described.

Development and validation of a HPLC-ES-MS/MS method for the determination of glucosamine in human synovial fluid.

A new HPLC method for the determination of glucosamine (2-amino-2-deoxy-D-glucose) in human synovial fluid was developed and validated. Synovial fluid samples were analyzed after a simple protein precipitation step with trichloroacetic acid using a polymer-based amino column with a mobile phase composed of 10 mM ammonium acetate (pH 7.5)-acetonitrile (20:80, v/v) at 0.3 mL/min flow rate. D-[1-13C]glucosamine was used as internal standard. Selective detection was performed by tandem mass spectrometry with electrospray source, operating in positive ionization mode and in multiple reaction monitoring acquisition (m/z 180-->72 and 181-->73 for glucosamine and internal standard, respectively). The limit of quantification (injected volume=3 microL) was 0.02 ng, corresponding to 10 ng/mL in synovial fluid. Calibration curves obtained using matrix-matched calibration standards and internal standard at 600 ng/mL were linear up to 2000 ng/mL. Precision values (%R.S.D.) were < or = 14% in the entire analytical range. Accuracy (%bias) ranged from -11% to 10%. The recoveries measured at three concentration levels (50, 800, and 1500 ng/mL) were higher than 89%. The method was successfully applied to measure endogenous glucosamine levels in synovial fluid samples collected from patients with knee osteoarthritis and glucosamine levels after oral administration of glucosamine sulfate (DONA) at the dose of 1500 mg/day for 14 consecutive days (steady-state).

Synovial and plasma glucosamine concentrations in osteoarthritic patients following oral crystalline glucosamine sulphate at therapeutic dose.

OBJECTIVE: We investigated the synovial and plasma glucosamine concentrations in osteoarthritic patients following oral administration of crystalline glucosamine sulphate at the therapeutic dose of 1500mg once-a-day for 14 days. DESIGN: Twelve osteoarthritic patients (six males and six females) received 14 consecutive once-daily oral administrations of crystalline glucosamine sulphate soluble powder (1500mg), in an open fashion. Plasma and synovial fluid were collected simultaneously from the same patient, at baseline and, at steady state (3h after the last dose). Glucosamine was determined in plasma and synovial fluid by liquid chromatography-tandem mass spectrometry. RESULTS: Median endogenous glucosamine concentrations in plasma and synovial fluid were 52.0ng/ml (0.29microM) and 36.5ng/ml (0.21microM), respectively (P=0.001), and varied substantially among patients (41-121ng/ml and <10-67ng/ml, respectively). Three hours after the last dose, glucosamine concentrations resulted increased from baseline in all patients with median increases of 20.5 and 21.5 folds in plasma and synovial fluid, respectively, the difference being not statistically significant (P=0.11). In plasma, the median post-treatment value was 1282ng/ml (7.17microM) and ranged from 600 to 4061ng/ml (3.35-22.7microM). The median post-treatment synovial glucosamine concentration was 777ng/ml (4.34microM), i.e., significantly lower than in plasma (P=0.001), and ranged from 577 to 3248ng/ml (3.22-18.1microM). Plasma and synovial glucosamine concentrations were highly correlated and were in the 10microM range. CONCLUSIONS: Glucosamine is bioavailable both systemically and at the site of action (the joint) after oral administration of crystalline glucosamine sulphate in ostaeoarthritis patients. Steady state glucosamine concentrations in plasma and synovial fluid were correlated and in line with those effective in selected in vitro studies.

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

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

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

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

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

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

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

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

The echo-guided treatment of calcific tendinitis of the shoulder.

The authors report the results of percutaneous mini-invasive treatment of chronic calcific tendinitis of the rotator cuffs. A total of 39 patients have been treated by echo-guided injection under local anaesthesia since June 2000 with a follow-up of about 2 years. Considerable reduction in symptoms was obtained in 34 patients within a few days of treatment; improvement was moderate in 5 cases, there were no complications in any of the cases. Complete regression of calcification was observed in 21 patients, there was a more than 60% reduction in calcific deposits in 11 patients, there was little reduction in 5, and the calcification remained unchanged in 2. The method, based on our experience, proved to be simple to execute, low-cost and easily repeatable, offering good results from a symptomatological point of view as well. It is the purpose of this study to determine and maximize mini-invasive treatment that will allow for the elimination or reduction of calcifications by means of percutaneous and echo-guided access.

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

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

Phalangeal ultrasonography in forearm fracture discrimination.

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

Ion release in patients with metal-on-metal hip bearings in total joint replacement: a comparison with metal-on-polyethylene bearings.

Polyethylene (PE) wear has been shown to be a problem in long-term joint replacement using metal-on-PE bearing. The use of metallic heads articulating with metallic cups could solve this problem: success will be enhanced if wear and corrosion of the articulating surfaces are maintained at a low level. New models with metal-on-metal bearing have been proposed, to be used mainly for young subjects: such coupling seems to have a reduced release, but it is unclear yet if the medium-term corrosion rate is really negligible or, on the contrary, it is significantly higher than in the metal-on-PE bearing. Aim of our study was the comparison of ion release in the serum of two groups of patients who had the same type of stable cementless prosthesis, but different bearing: twenty-six patients with metal-on-metal (Group A) and fifteen patients with metal-on-PE bearing (Group B) were examined. The follow-up was 14-38 months for group A and 18-34 months for group B. The serum concentration of chromium (Cr), cobalt (Co) and molybdenum (Mo) was measured. Twenty-two patients before surgery were used for comparison (Group C). The reference values were obtained from a population of twenty-two healthy subjects (Group D). Our findings indicate that metal-on-metal bearings produce a significantly higher systemic release of cobalt and chromium (ng/ml) when compared with levels found in metal-on-PE, pre-surgery and reference groups. Such a high release should induce to improve the bearing materials or, at least, to study the biologic fate of metal ions and consequently their long-term effects. In such a way a risk-to-benefit ratio for the patient could be established.

The surgical treatment of Rockwood grade III acromioclavicular dislocations.

The conservative or surgical treatment of Rockwood grade III acromioclavicular dislocations continues to be a controversial subject. Thus, the authors report their experience with 52 cases; long-term follow-up was obtained for 40 of these, paying close attention to the preoperative clinical and radiographic evaluation and to the results obtained in order to ascertain whether or not surgical repair is required. The results of surgical treatment, however satisfactory (90% excellent or very good), are nearly the same as those obtained when non surgical treatment is used as reported in the international literature. The authors conclude that the use of surgical treatment must be limited to carefully selected cases, should prolonged conservative treatment fail. Of the three surgical techniques used, temporary stabilization of the acromioclavicular joint using AO wires associated with restoration of the coracoclavicular connections has proven to be more effective than Dall-Miles metal wiring and tangential resection, with a lower incidence of complication.

Experimental study on rotator cuff repair.

It was the purpose of the experimental study to use laboratory experience to verify the effectiveness of different methods used to repair the rotator cuff. The sheep was used as an animal model because its infraspinous tendon is the most similar to that in the human. Three static trials were conducted using Instron machines, comparing the repair systems used most by the same authors in their clinical work, the hold of the suturing wires with two different threading procedures in the bone tunnels and two types of knotting, and the breakage loading of the suturing wires in the two different miniplate systems. The authors conclude that tendinous anchoring must be entrusted to reinforced suturing systems (modified SCOI and Mason Allen), the threading of wires in pairs in a single bone tunnel makes surgery easier and shortens the amount of time required, with threading of wires similar to or better than threading with a single wire. There are no differences in breakage loading of the wire at the level of the holes in the two miniplates considered in this study.

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

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