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Background and aim of the work: subcutaneous Achilles tendon lesions are common degenerative tendon tears, often related to sport activities, multiple pharmacotherapies and internal medical comorbidities. Neglect an Achilles tendon lesion can affect walk ability, while neglect a bilateral lesion could really lead to a serious limitation of self-sufficiency in daily living. We report a case of chronic bilateral Achilles tendon lesion successful treated with LARS augmentation, along with some clinical considerations concerning the clinical outcome. Methods: we report a case of a chronic bilateral Achilles tendon lesion in an elderly man with multiple comorbidities, successful treated with LARS reconstruction, along with some considerations concerning possible intraoperative issues and the clinical outcome. Results: good functional result was obtained as documented with pre and postoperative American Orthopedic Foot And Ankle Society Scale and the “Foot And Ankle Disability Index”, without complications. Conclusions: a bilateral Achilles tendon rupture is a very disabling pathology, that needs prompt diagnosis and treatment to prevent further complications. LARS reconstruction could be an effective method in selected patients to avoid some intraoperative issues related to patient comorbidities and ability to follow complex postoperative rehabilitation protocols. (www.actabiomedica.it).

Spontaneous rupture of the digital extensor tendons of the hand has been reported after Kienbocks disease, rheumatoid arthritis, Vaughan-Jackson syndrome, distal radial fracture. Rupture may also occur as a consequence of unrecognized carpal lunate fracture. We present a case report of a man affected with spontaneous rupture of the digital extensor tendons secondary to unrecognized carpal lunate fracture with partial dorsal dislocation. The edges of the tendon were debrided and sutured using a locked modified Kessler suture. A dynamic splinting cast was applied in moderate extension of the wrist. The aim of this case report is to highlight that in absence of a clear etiology for rupture of the extensor tendons of the hand, carpal lunate fracture, though rare, is an important cause of spontaneous extensor tendons rupture.La ruptura espontánea de tendones extensores digitales de la mano ha sido reportado después de la enfermedad de Kienböck, artritis reumatoide, síndrome de Jackson Vaughan, fractura del radio distal. La lesión del tendón también puede ocurrir como consecuencia de la fractura no reconocida de carpal semilunar. En este artículo, se presenta un caso de un hombre que sufre de rotura espontánea del tendón extensor digital secundaria a fractura semilunar no reconocida de los huesos del carpo con luxación dorsal del fragmento parcial. Los bordes del tendón se han limpiado y se sutura usando una sutura de Kessler. Un refuerzo dinámico se aplicó en extensión moderada de la muñeca. El propósito de este caso clínico es poner de relieve que, en ausencia de una etiología clara de la ruptura de los tendones extensores de la mano, una fractura de los huesos del carpo semilunar puede ser una causa importante de la ruptura espontánea de los tendones extensores de la mano.

Increasing evidence indicates that local neurogenic inflammation, possibly in response to different stimuli, may be involved in sensory nerve sensitization, migraine generation and some other precipitating events leading to neuronal dysfunction in the brain. In addition, mast cells generate eicosanoids that are linked to asthma and other inflammatory diseases. Regulated upon activation, normal T-cell expressed and secreted (RANTES) is a small protein and a prototype member of the CC chemokine-beta subfamily with chemoattractant and inflammatory properties. In this study we used the RBL-2H3 cell line to determine whether or not these cells generate prostaglandin D2 (PGD2) after treatment with RANTES. After 4 hours of incubation, RBL-2H3 cells cultured with RANTES at 20 ng/mL released large amounts of PGD2 in a dose-response manner compared to control. Moreover, RBL-treated RANTES generated a large quantity of histamine. Our study confirms once again the proinflammatory action of RANTES, in this case acting on the stimulation of the arachidonic acid cascade product PGD2.

Due to a growing numbers of lateral fragility fractures of the femur and their high social costs the need to work out an effective strategy in order to find a better solution for these patients is warranted. From January 2010 to July 2011, we carried out a prospective randomized clinical study comparing the results of patients with femoral lateral fractures treated by nail and cephalic hydroxyapatite coated screws (study group including 27 patients) compared to the patients with the same fractures treated with nail and head standard screws (control group including 27 patients). We defined the two parts of the femoral neck as ROI 1 (under the head screw) and ROI 2 (above the femoral screw) on the AP view. The bone density of the two areas was calculated using DEXA at T0 (1st day post-surgery), at T1 (40th day post-surgery), at T2 (3 months later), at T3 (1 year later). The clinical-radiography evaluations were based on the Harris Hip Score (HHS), ADL test and x-ray views of the hip. As far as the bone mineral density average of ROI 1 and ROI 2 is concerned, we found a significant statistical increase at T1 and T3 in the study group, while it was not significant in the control group. We could account for this data through the higher mechanical stability of hydroxyapatite coated screws than standard screws. In fact, this material was responsible for improved implant osteointegration. Thanks to a 1 year follow-up we were able to demonstrate the implant utility associated with augmentation and the importance of densitometry exams such as easily repeatable and low cost diagnostics to prevent the onset of complications linked to screw loosening.

Background In spite of the proven efficacy of pharmacological prophylaxis of heterotopic ossification followingtotal hip arthroplasty, its routine use is still debated, and nodata are available regarding the adherence to its administration in clinical practice.Materials and methods In this prospective, observational,multicenter study, 480 consecutive patients operated on forprimary total hip arthroplasty during the year 2009 werefollowed radiographically for 12 months after surgery inorder to assess the incidence of periprosthetic heterotopicossification. Surgeons were free to choose whether toadminister pharmacological prophylaxis, and were asked tokeep a record of the duration of the prophylaxis (if used) orthe reasons for not using it. To facilitate the statisticalanalysis, all of the participating centers agreed to use onlyone drug (celecoxib) that had already proven to be effective.Results 368 patients were administered celecoxib and112 patients did not receive any prophylaxis. Reportedreasons for not administering celecoxib prophylaxis werethe surgeon’s opinion that prophylaxis was not needed on aroutine basis (84/112 patients, 75%), previous history ofgastrointestinal bleeding (17.8%), and concomitant cardiorenal pathologies (7.1%). The overall incidence of heterotopic ossification in the celecoxib-treated patients was23% (no cases of Brooker grade 3 or 4 ossifications),compared to 55% in the untreated patients (Brooker grade3 and 4: 8.9%). Multivariate analysis showed that celecoxib prophylaxis was the single most important variablewhen predicting the occurrence of heterotopic ossification.Conclusions This study confirms the efficacy and tolerability of celecoxib for the prophylaxis of heterotopicossification after total hip arthroplasty, and shows how thesurgeon’s belief that routine prevention is not required still plays an important role in the determination of this complication, together with the fear of possible unwanted sideeffects

The link between low density lipoprotein and coronary heart disease has been widely studied. Oxidized LDL damages the artery wall, and a diet rich in vitamins and low in saturated fat and cholesterol may reduce this risk. Not only hypercholesterolemia but also low levels of high density lipoprotein cholesterol are critical risk factors for atherosclerosis and related diseases. It has been reported that high doses of B complex vitamin may be useful in lowering blood cholesterol and triglyceride levels in the body, however the use of this compound has been limited by an annoying flush and concern for toxicity. Niacin is a B-complex vitamin with anti-atherosclerotic properties and is an effective medication for raising high density lipoprotein. The combination of niacin with other lipid-lowering drugs, such as statins, reduces the dynamic of atherosclerosis disease. In addition, vitamin E is one of the most important lipid soluble anti-oxidants in humans, and reduces atherosclerosis plaque, coronary artery diseases and myocardial infarction. Vitamin E protects the integrity of membranes by inhibiting lipid peroxidation. In this study we revisited the interrelationship between cholesterol, low density lipoproteins and vitamins.

Chemokines are cytokines with chemotactic properties on inflammatory cells and other cell types. RANTES, MCP-1 and related molecules, constitute the C-C class of chemokine supergene family and a group of cytokines produced by hematopoietic cells, while IL-8 constitute the C-X-C class. The roles of most of these chemokines are not well known, although members of the chemokine family are inflammatory agents. The C-C chemokine plays a role in regulating Th-cell cytokine production and leukocyte trafficking. In this study we clearly show that RANTES and MCP-1 are mediators of acute inflammatory responses. Our report describes additional biological activities for RANTES, MCP-1, and IL-8, suggesting that these chemokines play a fundamental role in histamine and serotonin generation and cell function in mast cells.

Interleukin 12 (IL 12) p35/p40 is a heterodimeric cytokine which plays a critical role in inflammation, immunity and tissue proliferation, and also plays a relevant function in T helper (Th) cell polarization and Th1 T-cell differentiation. IL-12 family members, IL-12p70, IL-23, IL-27 and IL-35, play an important role in influencing helper T-cell differentiation. EBV-induced gene 3 can be associated with the p35 subunit of IL-12 to form the EBI3/p35 heterodimer, also called IL-35. It has been shown that IL-35 has biological activity and able to expand CD4+CD25+ Treg cells, suppress the proliferation of CD4+CD25- effector cells and inhibit Th17 cell polarization. IL-35 has been shown to be constitutively expressed by regulatory T (Treg) cells CD4(+)CD25(+)Foxp3(+) and suggested to contribute to their suppressive activity. IL-35 is a crucial mediator which provokes CD4+CD25+ T cell proliferation and IL-10 generation, another well-known anti-inflammatory cytokine, along with TGFbeta cytokine. These studies suggest that IL-35, together with other successfully discovered cytokine inhibitors, represents a new potential therapeutic cytokine for chronic inflammation, autoimmunity and other immunological disorders.

Cytokines are immunomodulatory and infammatory compounds produced by many different cell types. The IL-1 family consists of at least eleven cytokines including IL-18 and IL-13 and are essential to the host defence against severe infections and mediate infammation. IL-18 also enhances tumour rejection and has high capacity to augment the cytotoxicity of NK cells and T cells. IL-33 stimulates basophils and mast cells to produce cytokines and histamine independently of IgE. Mast cells play a crucial role in the development of allergy through the cross-linking of their surface receptors for IgE leading to degranulation and infammation. Activated mast cells induce the generation of PGD2, detectable in 2-15 minutes after challenge, and LTC4. Here we review the interrelationship between PGD2, IL-1 family members and mast cells.

Monteggia fracture-dislocation is a complex injury of the superior arm, both because it usually interests growing individuals with difficulties in the choice of treatment and because its frequent complications in the elbow articulation. Chronic anterior dislocation of the radial head is a frequent complication after a Monteggia's fracture. The present study describes a 20-year-old boy who previously had a Monteggia fracture-dislocation treated with Kirshner wire ostheosynthesis. He underwent surgery 20 days after plaster-cast removal, because of irreducible radial head dislocation. An open reduction and a reconstruction of the anular ligament was performed using the Mitek suture anchor Spiralok and an Orthocord wire. The patient was radiographically and clinically investigated three and six months after surgery, with good results, even if a longer follow-up is advisable to judge objectively the results. Suture anchors are good devices, largely accepted in arthroscopic surgery. This versatile device is really useful to solve problems also in osteoarticular traumatology treated in an open manner, and many other applications of suture anchors could be discovered in the future.

Much evidence suggests a cross-talking between nerve fibers and the immunity system. The immunomodulation by substance P includes cell activation and proliferation of human cells, with cytokine and chemokine generation and release. Substance P was first isolated by Leeman et al. as an undecapeptide with important neurotransmitter-neuromodulator effects. In addition, substance P was shown to induce and mediate inflammation, angiogenesis, infections, intestinal mucosal immunity and stress. Substance P is able to activate several immune cells, such as CD4+ and CD8+ T lymphocytes, mast cells, NK cells and macrophages. In recent studies we have shown that substance P can activate interleukin-8, a CXC chemokine, demonstrating its involvement in immune cell chemoattraction. We believe that substance P is important in understanding the pathophysiology of inflammation.

Chemokines are inflammatory proteins acting via G-protein coupled chemokine receptors that trigger different signaling pathways. Monocyte chemoattractant protein-1 (CCL2/MCP-1) and regulated on activation, normal T expressed and secreted (CCL5/RANTES) are the two major members of the CC chemokine beta subfamily. The roles of RANTES and MCP-1 are emerging in regulating the recruitment of inflammatory cells into tissue during inflammation. The inhibition of MCP-1 and RANTES with corresponding antibodies or other inhibitors may provide benefits in different clinical scenarios including cancer, inflammation, CNS disorders, parasitic disease, autoimmune and heart diseases. RANTES and MCP-1 may represent targets for diagnostic procedures and therapeutic intervention, and may be useful as a prognostic factor in the above diseases.

In the last years there has been a notable improvement in cruciate ligaments reconstructions, due to an evolution of the surgical technique arthroscopic assisted, to a gain of fixation system, to a better choice of the tendons and to an improvement of the operative technique to harvest them. In our experience alternatives are three and the choice depends on the patient peculiarities and on the surgeon habit: 1) Bone - Patellar Tendon - Bone (BPTB); 2) Doubled Gracilis and Semitendinosus Tendons (DGST); 3) Quadriceps Tendon (QT). Our preference, considering the different indications, is for the first two; nevertheless we use the central third of the quadriceps tendon only in particular cases (other techniques failures, revisions, necessity to use more harvests for associated multiple injuries). We describe the harvesting of the grafts that we perform in different surgical phases depending on the tendon choice: the BPTB harvest is done after a diagnostic arthroscopy to confirm the instability and after the tunnel drillings, otherwise the hamstring harvest is done immediately after the diagnostic phase to have more time to tension it, on the mastergraft (workstation).

Aim. The aim of this study is to analyze our experience on 30 patients with TUBS (Traumatic, Unidirectional, Bankart, Surgery), treated with arthroscopic capsulo-plasty using anchors Bioknotless according to Thai's Technique. Methods. From January 2001 to December 2003 we arthroscopically treated 30 patients with post-traumatic instability of the shoulder. The intervention foresees the following steps: evaluation of the capsular lesion; decortication of the anterior glenoid surface; execution of 3 holes; anchors introduction; application of an immobilizzation for 4 weeks. Results. We clinically appraised the patients through the Constant test with a minimum of 12 to a maximum of 24-month follow-up (average 18 months). The middle value of the Constant score was of 85 compared to the pre-operative value of 55.5. Only one case of relapse was observed. Conclusions. Over the time, thanks to the refinement of surgical techniques, to better knowledge of the role of the propioception in the mechanism of shoulder joint feedback, to a greater knowledge of the articular pathology and to the increased confidence of the surgeons with the arthroscopic technique, many authors are underlining the superimposing role of inherent data of recurrences between arthroscopic and open treatment. We believe that a careful preoperative and intraoperative selection of the patient can sensitively reduce the risks of arthroscopic capsulo-plasty recurrences; excluding patients with bony-Bankart> of 25% and with glenoid inverted pear. We can conclude that the use of these anchors, that do not foresee the execution of the knot, allows a reduction of surgical time, and above all, a good anchorage and capsular shift. Despite the facility of such technique in comparison to others described in Literature, we believe that a long learning curve is essential.

In the wiev of the profound and continuous ethical changes tha have occurred in the doctor-patient relation and with special focus on the self-determination of treatment, the authors suggest a methodological approach to the problem of professional responsibility of arthroscopy specialist. In addition, stress is also laid on the professional responsibility in artroscopic treatment, considering deontologic and technical aspects, analysing the matters regarding the definition of the nature of the juridical shop related to this professional performance and estimating its civil implications. The authors discuss this liability, analysing the matters regarding the definition of the nature of the "specialistic error" related to this professional performance. They also, highlight the importance of informed consence, offering hints for discussion on the preliminary information given to the patient in order to acquire a correct consent and to obtain his ivolvement in the decision-making process: the patient conscious of his rights, is always more involved in therapeutic decisions. In addition the authors define the necessary and correct parameters of informations to obtain a valid and complete consent as to justify a specialistic treatement as arthroscopy. Against this backgroud, on the basic aspects taken from medical-legal and specialised literature, they suggest indications for a correct professional practice.

IL-18 is produced by many cell types, such as Kupffer cells, keratinocytes, macrophages, dendritic cells, and activated T cells stimulated by LPS. It is an important regulator of both innate and acquired immune responses. IL-18 plays a central role in rheumatoid arthritis since the T cells and macrophages that invade the synovial. These finding support a role for IL-18 in inflammation, allergy and immune diseases.

Interleukin-36 (IL-36) is a pro-inflammatory cytokine which plays an important role in innate and adaptive immunity. IL-36 activates MAPK and NF-kB pathways and is produced by many different cells. This cytokine is a family member of interleukin-1 (IL-1) and plays an important role in the pathophysiology of several diseases. Here we summarise and review the new aspects of this important pro-inflammatory cytokine.

Adult acquired flatfoot deformity is generally associated with a collapsing medial longitudinal arch and a progressive loss of strength of the posterior tibial tendon (PTT). This condition is commonly associated with PTT dysfunction or rupture, which can have an arthritic or a traumatic etiology. Several causes have been proposed to explain the clinical evidence of tendon degeneration observed at the time of surgery including trauma, anatomical, mechanical, inflammatory and ischemic factors.In this review, we analyzed anatomy, pathophysiology and existing classifications of posterior tibial tendon dysfunction.Anatomical features, and in particular vascularization, expose PTT to major degenerative disorders until rupture. A literature overview showed that a low blood supply of the gliding part of the tendon is linked to a dysfunction and/or a rupture of the PTT in the region located behind the medial malleolus.PTT low blood supply causes a dysfunction resulting in an abnormal loading of the foot's medial structures. This may be the reason why PTT dysfunction leads to an acquired flatfoot deformity. Conversely, flatfoot deformity may be a predisposing factor for the onset of PTT dysfunction.