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Lorenzo Pradelli,1 Tiziana Sinigaglia,1 Alberto Migliore,2 Giovanni Antonio Checchia,3 Francesco Franceschi,4 Bruno Frediani,5 Florenzo Iannone,6 Emilio Romanini7 1AdRes HE&OR, Torino, Italy; 2Saint Peter Hospital, Rome, Italy; 3Hospital of Monselice, Padua, Italy; 4University Hospital of Rome, Rome, Italy; 5Hospital of Siena, Siena, Italy; 6University of Bari, Bari, Italy; 7RomaPro Center for Hip and Knee Arthroplasty, polo Sanitario San Feliciano, Rome, ItalyCorrespondence: Lorenzo Pradelli Email l.pradelli@adreshe.comAbstract: The aim of this document is to provide a set of indications on the national best practice management of knee osteoarthritis based on an analysis of the existing literature and the contribution of experts in the field. During the first phase of the project, in agreement with the multidisciplinary panel of experts, the main guidelines on the topic were selected. Each guideline was assessed through the AGREEII system to identify their strong/weak points and a summary of the recommendations contained in the various documents was drawn up. The panel drew up a list of therapeutic options to be included in the document and some of these topics were selected for in-depth analysis and review. The search strategy for the required literature reviews was constructed using the PICOS approach. The results obtained from the literature reviews, the in-depth analyses conducted by the members of the scientific societies involved and the analysis of the existing guidelines enabled an initial draft of the consensus document to be elaborated. This document was examined at the consensus conference held on 28 May 2019, in the presence of a multidisciplinary group consisting of members of the various scientific societies involved. Single recommendations were discussed in work groups with a view to combining the indications given by the literature examined with the experience of the specialists involved. The recommendations discussed were then put to the vote in a plenary assembly. The final document contains 26 practice recommendations which leading specialists involved in the management of knee OA in Italy agree upon.Keywords: knee osteoarthritis, conservative management, multidisciplinary consensus, Italy

Background : Proximal humeral fractures (PHFs) are common, especially in the elderly, and account for 4% to 10% of all fractures, with women more often affected than men. Treatments include conservative methods, internal fixation and arthroplasty, with surgical approaches increasingly being used due to technological advancements. This study analyzes the evolution of PHF treatments in Italy from 2001 to 2022, using data from the Italian Hospital Discharge Records (HDRs) Database, and includes a stratified analysis by age and sex. Methods : Using HDR data from 2001 to 2022, records with ICD9-CM codes for proximal humeral fractures (812.0 and 812.1) among diagnoses were selected and categorized into three treatment groups: arthroplasty, fixation and conservative. Time series were analyzed with stratification by sex and age. Results : The extracted data included 486,368 records of PHFs, with 223,742 cases treated surgically (arthroplasty or internal fixation) and 262,626 treated conservatively; the average patient age was 66.6 years, with a higher proportion of women, especially among arthroplasty patients. Over time, the use of fixation and arthroplasty increased from 20% of treatments in 2001 to over 60% in 2022, with fixation becoming the most common treatment method by 2014 and arthroplasty significantly increasing among women, particularly in the 65-74 and 75-84 age groups. Conclusions : The study shows that in Italy, over the past two decades, treatment for PHFs has shifted from conservative methods to a preference for internal fixation and increasingly for arthroplasty, particularly among women and patients aged 65-84, reflecting evolving trends and technological improvements.

Introduction: The rupture of the plantar fascia is a rare but significant injury that predominantly affects athletes and individuals engaged in high-impact activities. Sudden increases in physical activity, direct trauma, corticosteroid injections, and chronic degeneration from plantar fasciitis can predispose individuals to rupture. It can involve a complete or partial tear of the plantar fascia fibers, leading to a loss of structural integrity and functional support. The tear may occur at the origin, mid-portion, or insertion of the fascia. Spontaneous ruptures of the plantar fascia (occurring without any predisposing factors) are rarely observed in clinical practice. No guidelines or other unequivocal recommendations are available for this pathological condition., Method: A healthy 35-year-old male who works in an office setting and is a recreational cyclist with a silent clinical anamnesis experienced a spontaneous rupture of the plantar fascia of the left foot with no history of trauma. He exhibited significant localized tenderness and swelling in the medial arch of the left foot with difficulty bearing weight on the affected foot. An MRI confirmed a partial rupture of the medial cord of the plantar fascia accompanied by surrounding inflammation. The patient underwent conservative treatment, which included rest, immobilization, physiotherapy (ultrasound therapy, high-power laser therapy, and transcutaneous electrical nerve stimulation), rehabilitation, and a gradual return to activity., Results: At the 12-week follow-up, the patient reported a significant reduction in pain and marked improvement in functional mobility (as confirmed by VAS and Foot Function Index scores). Physical examination showed no tenderness, and the patient could bear full weight on the foot without discomfort. A follow-up ultrasound demonstrated complete resolution of the plantar fascia rupture and no residual inflammation., Discussion: This case underscores the effectiveness of an integrated rehabilitative approach and provides a framework for managing similar cases in clinical practice., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Venosa, Romanini, Vitale and Logroscino.)

Objective This study aimed to assess the quality of online patient educational materials regarding posterior cruciate ligament (PCL) reconstruction. Methods We performed a search of the top-50 results on Google® (terms: "posterior cruciate ligament reconstruction," "PCL reconstruction," "posterior cruciate ligament surgery," and "PCL surgery") and subsequently filtered to rule out duplicated/inaccessible websites or those containing only videos (67 websites included). Readability was assessed using six formulas: Flesch-Kincaid Reading Ease (FRE), Flesch-Kincaid Grade Level (FKG), Gunning Fog Score (GF), Simple Measure of Gobbledygook (SMOG) Index, Coleman-Liau Index (CLI), Automated Readability Index (ARI); quality was assessed using the JAMA benchmark criteria and recording the presence of the HONcode seal. Results The mean FRE was 49.3 (SD 11.2) and the mean FKG level was 8.09. These results were confirmed by the other readability formulae (average: GF 8.9; SMOG Index 7.3; CLI 14.7; ARI 6.5). A HONcode seal was available for 7.4 % of websites. The average JAMA score was 1.3. Conclusion The reading level of online patient materials concerning PCL reconstruction is too high for the average reader, requiring high comprehension skills. Practice implications Online medical information has been shown to influence patient healthcare decision processes. Patient-oriented educational materials should be clear and easy to understand., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Venosa et al.)

Introduction: Total knee arthroplasty is an effective operation. Post-surgery rehabilitation, based on early and intensive progressive exercise programs, plays a substantial role and telerehabilitation can be an effective safe option. This retrospective study aimed to compare traditional in-presence rehabilitation and telerehabilitation for total knee arthroplasty, based on our experience during the Italian COVID-19 lockdown., Materials and Methods: We retrospectively analyzed 164 patients (94 females and 70 males) enrolled in 2020 within 2 weeks after total knee replacement to perform post-operative outpatient rehabilitation. The clinical results of 82 patients (mean age 66.8 ± 10.2 years) performing telerehabilitation with those obtained from a similar cohort of 82 patients (mean age 65.4 ± 11.8 years) performing traditional in-presence outpatient rehabilitation were compared. Clinical outcomes were examined by comparing the gait speed (Time Up and Go-TUG test), the range of motion, the pain intensity (VAS), the functional status (Oxford Knee Score-OKS and Knee injury and Osteoarthritis Outcome Score-KOOS) and the overall satisfaction (Self-administered patient satisfaction scale) 12 weeks after the beginning of the physiotherapeutic protocol., Results: Telerehabilitation was non-inferior to traditional in-presence rehabilitation in all of the investigated areas and no statistical difference in terms of effectiveness was detected at 12 weeks, as confirmed by the respective patient-reported outcome scores such as TUG test (reduced from 20 ± 2 s to 12 ± 1.5 s for the telerehab cohort and from 18 ± 1.5 s to 13.1 ± 2 s for the in-presence rehabilitation one), pain VAS, OKS (improved from 22 ± 1.3 to 36 ± 2.7 for the telerehab cohort and from 23 ± 2.1 to 35.1 ± 4.2 for the in-presence group), KOOS (improved from 46.2 ± 10.2 to 67.4 ± 3.8 for the telerehabilitation cohort and from 48.4 ± 8.4 to 68.3 ± 6.6 for the other group), and the Self-administered patient satisfaction scale (more than two-thirds of patients globally satisfied with the results of their surgery in both groups)., Conclusion: The telerehabilitation program was effective after total knee replacement and yielded clinical outcomes that were not inferior to conventional outpatient protocols.

Introduction: Tibial spine avulsion injury, tibial eminence injury, tibial spine fracture, and anterior cruciate ligament (ACL) avulsion are multiple terms that express the same pathological condition. It can be encountered both in the pediatric and adult population. A wide array of surgical techniques have been proposed to manage displaced tibial spine avulsions. Anyway, insufficient evidence is currently available to prefer one fixation technique over another, and a gold-standard arthroscopy-based technique is still missing. In this article, we describe a mini-invasive, safe and user-friendly technique for arthroscopic reduction and internal fixation of displaced tibial eminence fractures., Materials and Methods: Standard and patient-specific accessory arthroscopic portals allow for full access to knee visualization and management of concomitant intraarticular lesions. After performing the debridement of the inflammatory tissue and the release of eventual interposed tissues in the fracture site, the tibial eminence avulsion can be reduced by using a less-invasive bone impactor. With the knee flexed to 90°, the fracture fragments are then synthesized (under fluoroscopic control) with three thin Kirschner wires inserted in a proximal-distal direction in a cross-shaped geometry., Results: This technique allows a fast surgical and hospitalization time, a punctiform arthrotomy, proximal tibial physis preservation, and an early rehabilitation program., Conclusions: This novel technique seems attractive and very promising since it is respectful of the epiphyseal growth plates and is thus suitable for children and adolescents.

Surgical site infections are a major complication for patients undergoing surgical treatment and a significant cause of mortality and morbidity. Many international guidelines suggest measures for the prevention of surgical site infections (SSI) in perioperative processes and the decontamination of surgical devices and instruments. This document proposes guidelines for improving the perioperative setting in view of the devices and instrumentation required for surgical procedures, aiming to reduce contamination rates and improve clinical performance and management for patients undergoing surgical treatment. This document is intended for doctors, nurses and other practitioners involved in operating theatre procedures, resource management and clinical risk assessment processes, and the procurement, organisation, sterilisation and reprocessing of surgical instruments., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Calò, Catena, Corsaro, Costantini, Falez, Moretti, Parrinello, Romanini, Spinarelli, Venneri, Vaccaro and Scientific Technical Committee.)

Italian grape ale (IGA) beers have been categorized by the Beer Judge Certification Program as a sub-category of fruit beers in which grape, or grape must, is added during the brewing process to provide additional characteristics to the final beer. In the present work, IGA beers have been produced with must and pomace of the Malvasia di Candia Aromatica (MaCA) grape variety, which were added before fermentation at two different percentages (10% and 20%). The (poly)phenolic profile of IGA beers have been characterized with HPLC-MS/MS and compared to a golden ale control beer (produced in the same conditions without the addition of grape-derived ingredients). A series of sub-samples have been collected to monitor the (poly)phenol profile at time 0 and during the different phases of the fermentation process (1, 3, 5, 7 30, 65 days). Results demonstrated how the addition of pomace allowed to significantly enrich ( p < 0.05) final beers in total (poly)phenols detected by MS, while must addition did not influence that amount if compared to the control sample. However, a PCA cluster analysis identified strong similarities among IGA beers and differentiated them to control beer samples. This study underlined how the addition of must and pomace from the MaCA grape variety improved the (poly)phenolic profile of beer from both a qualitative and quantitative point of view.

The finding of USP9X variants in females has been associated with female-restricted X-linked mental retardation (MRXS99F), a rare syndrome featured by developmental delay and distinct congenital anomalies. Here, we report a female fetus with MRXS99F due to a novel frameshift variant, c.6679&#95;6685delAAATTATinsTCCTG (p.Lys2227SerfsTer2) in USP9X, which was present in a mosaic state in the amniocytes and in the peripheral blood after birth (14% and 30%, respectively). The X methylation status analysis displayed a partially skewed X-inactivation with 80% of inactive paternal X. The first signs of the MRXS99F were prenatally detected at 20 weeks, with an enlarged posterior cranial fossa, an upward rotation of the cerebellar vermis and partial corpus callosum agenesis, together with a cardiac septal defect and a single umbilical artery. After birth and during postnatal follow-up the anal anteriorization and the presence of a bilateral membranous choanal atresia were noted, whereas the MRI revealed the hypo/aplasia of the olfactory bulbs, a widening of the subarachnoid spaces and a delay in the myelinisation. During the 18-months follow-up a severe growth and global developmental delay, together with a bilateral moderate deafness with a threshold at 40 dB, dental enamel erosions and an initial scoliosis were observed. We report the prenatal and postnatal features of a classical MRXS99F phenotype and a mosaic USP9X frameshift variant with a partially skewed X inactivation and discuss genotype/phenotype correlations in view of the published studies so far., Competing Interests: Declaration of competing interest The authors report no conflict of interest., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

The emphasis on value-based payment models for primary total hip replacement (THA) results in a greater need for orthopaedic surgeons and hospitals to better understand actual costs and resource use. Time-Driven Activity-Based Costing (TDABC) is an innovative approach to measure expenses more accurately and address cost challenges. It estimates the quantity of time and the cost per unit of time of each resource (e.g., equipment and personnel) used across an episode of care. Our goal is to understand the true cost of a THA using the TDABC in an Italian public hospital and to comprehend how the adoption of this method might enhance the process of providing healthcare from an organizational and financial standpoint. During 2019, the main activities required for total hip replacement surgery, the operators involved, and the intraoperative consumables were identified. A process map was produced to identify the patient's concrete path during hospitalization and the length of stay was also recorded. The total inpatient cost of THA, net of all indirect costs normally included in a DRG-based reimbursement, was about EUR 6000. The observation of a total of 90 patients identified 2 main expense items: the prosthetic device alone represents 50.4% of the total cost, followed by the hospitalization, which constitutes 41.5%. TDABC has proven to be a precise method for determining the cost of the healthcare delivery process for THA, considering facilities, equipment, and staff employed. The process map made it possible to identify waste and redundancies. Surgeons should be aware that the choice of prosthetic device and that a lack of pre-planning for discharge can exponentially alter the hospital expenditure for a patient undergoing primary THA.

Background: This study aims to compare the effects of platelet-rich plasma (PRP) alone or in combination with adipose-derived mesenchymal stem cells (AD-MSCs) in patients affected by cartilage defects, undergoing knee arthroscopic microfracture., Methods: Thirty-eight patients diagnosed with a knee monocompartmental cartilage defect (Outerbridge grade IV) on the MRI, underwent an arthroscopic procedure. After the confirmation of the lesion, they all received the same bone marrow stimulation technique (microfracture) and were randomized into two groups: the first one had additional PRP injection (group A), while the second received PRP and AD-MSC injection (group B). Knee assessment and pain score were documented with Knee Injury Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score, Short-Form (SF) 12, and Visual Analogue Scale (VAS) before the treatment and at 1, 3, 6, and 12 months of follow-up postoperatively. An additional arthroscopic procedure, performed in four patients for a subsequent meniscal lesion, let us evaluate cartilage evolution by performing a macro/microscopical assessment on cartilage biopsy specimens., Results: At the 12-month follow-up, both groups showed a comparable functional improvement. The scores on the IKDC form, KOOS, pain VAS, and SF-12 significantly improved from baseline ( p < 0.05) to 12 months postoperatively in both treatment groups. The four second-look arthroscopies showed a complete repair of the articular defects by smooth solid cartilage layer, with a good chondrocytic population, in both groups. A thick smooth hyaline-like cartilage with a predominantly viable cell population and normal mineralization (a form closely resembling native tissue) was observed in group B., Conclusions: Modern regenerative medicine techniques, such as PRP and AD-MSC, associated with traditional arthroscopic bone marrow stimulating techniques, seem to enhance cartilage restoration ability. The preliminary results of this pilot study encourage the synergic use of these regenerative modulating systems to improve the quality of the regenerated cartilage., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 Michele Venosa et al.)

Objective: Regenerative medicine is experiencing a strong expansion worldwide, including the treatment of some common orthopedic pathologies, with an increase in physicians adopting these technologies. This growing interest has been associated with an equally significant spread of websites dedicated to public information on this topic, often lacking scientific bases. This study aims to evaluate the quality of information on the World Wide Web about stem cells for cartilage disorders in orthopedic practice., Design: On February 19, 2021 we performed a search on Google using as keywords "cartilage stem cells," considering only the freely accessible sites in Italian, English, French, and Spanish. We selected the first 50 valid results for each language and evaluated them using the DISCERN scale., Results: A total of 249 sites were observed, of which 49 were discarded as duplicates (8) or not relevant to the topic (41). Of the 200 sites surveyed, 47 were affiliated to a singular surgeon (23.5%), 31 to private stakeholders (15.5%), 73 to information sites (36.5%), 8 to public hospitals (4%), 13 to universities (6.5%), and 28 referred to international scientific journals (14%). Only 76 sites (38%) were rated as fair or better, while the remaining 124 (62%) were classified as poor or very poor., Conclusions: The quality of the information promoted for stem cells in orthopedics is generally low, although a significant minority of the sites offers good quality information. A greater commitment on the part of surgeons and other stakeholders is desirable to promote information on regenerative medicine through scientific criteria supported by adequate literature.

Background and purpose - The main purpose of arthroplasty registries is to collect information on patients, techniques, and devices to monitor and improve the outcome of the specific procedure. This study analyses the role played by registries in the orthopedic research community and describes publication trends, characteristics, and patterns of this field of research.Patients and methods - A descriptive-bibliometric review was conducted. Scopus was the database used for the research. All articles published from 1991 to December 2020 containing keywords related to registries and arthroplasty were considered. In particular, the following dimensions were analyzed in detail: (i) papers/year; (ii) journals; (iii) countries; (iv) research growth rate; (v) collaboration among countries. VOSviewer software was used to perform the bibliometric analysis. Finally, the 50 most cited papers of the last 10 years were briefly analyzed.Results - 3,933 articles were identified. There has been growing interest in the topic since 2010. Acta Orthopaedica ranked first for the number of articles published. The country with the largest number of articles citing registries was the United States, followed by the United Kingdom and Sweden. The relative number of articles per 100,000 inhabitants is 0.60 for Europe and 0.38 for the United States. The literature in this research area has an average yearly growth rate of 28%.Interpretation - The publication rate in the field of arthroplasty registries is constantly growing with a noteworthy impact in the evolution of this research and clinical area. The growth rate is significantly higher than that of arthroplasty literature (28% vs. 10%) and the collaboration among countries is strong and increasing with time.

Traumatic dislocation of the pisiform bone (PB) is a rare injury of the carpal bones, especially in pediatric patients. A few cases were reported, and there is no consensus about the treatment. Each author supports his own method, such as an open reduction internal fixation (ORIF) approach or a closed reduction. However, failures of both techniques with recurrent dislocation of the PB have been reported in the literature. In this article, a fracture dislocation of the PB was treated with ORIF in an 11-year-old boy with a greenstick radial fracture. In addition, a review of the literature about pisiform fracture dislocation in children has been made., Competing Interests: Conflict of Interest None declared., (Society of Indian Hand Surgery & Microsurgeons. All rights reserved.)