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Klippel-Trenaunay syndrome is a rare congenital malformation which may be associated with macrodactyly. The main problem is the need for custom-made shoes. We describe the case of a female newborn affected by Klippel-Trenaunay syndrome, with a larger and longer right foot; the difference increased progressively and, at 5 years of age, the right foot was 50% larger and 38% longer than the left one. Due to the progression of the deformity, reduction surgery was advised to reduce the foot's width. Resection of the second ray and 2nd cuneiform was performed. The result was excellent and there were no complications during a 10-year follow-up period with a decrease of width and length difference to 10% and 4%, respectively, in comparison to the contralateral foot. There were no gait anomalies. Abnormal foot width and length represented the main problems and guided the surgical strategy. Second ray resection was effective, without complications and with a good long-term functional outcome. Possibility of wearing fashionable conventional shoes without insoles was achieved to the patient's satisfaction.

Introduction: Assessing the outcomes of Platelet Rich Plasma (PRP) treatment in Achilles Tendinopathy (AT) may prove difficult due to several methodological reasons. For example, given that the simple mean of VISA-A score is just the result of positive, negative or null values, this may provide incomplete information, and therefore the size of individual changes can remain unknown. On the contrary, calculating the score changes in each subject after treatment would allow a more appropriate evaluation of the clinical results. However, this method has been applied only to few small-scale studies. Therefore we performed a retrospective study aiming to determine: (1) are the percentages of positive outcomes of the present research comparable to those of previous studies performed in different settings? (2) Is there a relationship between the size of increase of the clinical score and the patient satisfaction?, Hypotheses: The percentages of positive outcomes of the present research are comparable to those of previous studies performed in different settings., Material and Methods: This is a retrospective observational study. Eighty-four patients submitted to PRP treatment for mid-portion AT were enrolled. Pain and function were evaluated by means of VISA-A scale. Besides the mean, in each subject the pre- and post-treatment difference of VISA-A score was computed and the outcome was defined clinically no detectable, detectable and evident according to the increasing values of the score (0 to 9 points, 10 to 19, and≥20 points change, respectively). The Likert's scale for the patients satisfaction was also used., Results: The mean VISA-A increased significantly after treatment (from 50.1±9.1 at baseline to 63.7±13.8 at 3 months (p=0.00001) and 67.2±14.1 at 6 months (p=0.00001)). At 3 and 6 months the subjects belonging to the prefixed categories were 15, 45, 24 and 19, 36, 29, respectively. Moreover, large discrepancies were observed between the size of increase of the clinical score and patients satisfaction, mainly for intermediate increases of the score., Discussion: The percentages of positive outcomes found in this study are slightly lower than those reported in literature. The different patients expectations about the efficacy of the therapy can explain the discrepancies between the size of increase of the clinical score and the individual satisfaction. In comparison to the simple mean, the individual changes of VISA-A score allow a proper evaluation of the outcomes. The research shows that discrepancies can be present in the percentage of positive clinical outcomes between different studies. The size of increase of the clinical score does not always match patient satisfaction., Level of Proof: IV retrospective study without control group., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objective  Sound experimental data suggest that oxidative stress plays an important role in the pathogenesis of tendinopathies. However, this hypothesis in humans remains speculative given that clinical data are lacking to confirm it. Recently, a new methodology has allowed to quantify the oxidative stress in vivo by measuring the concentration of hydroperoxides of organic compounds, which have been utilized as an oxidative stress-related marker in several pathologic and physiologic conditions. Given the reliability of this test and the lack of information in subjects with tendinopathies, the aim of the present study was to assess the oxidative stress status in elite professional soccer players with and without ultrasonographic features of tendon damage. Methods  In 73 elite players, blood metabolic parameters were evaluated and oxidative stress was measured by means of a specific test (expressed as U-Carr units). Therefore, an ultrasonographic evaluation of the Achilles and patellar tendons was performed. Results  No significant relationships were observed between metabolic parameters and oxidative stress biomarkers. The Achilles and patellar tendons showed a normal echographic pattern in 58 athletes, and sonographic abnormalities in 15. The athletes with ultrasonographic alterations, compared to those with normal US picture, showed significantly higher U-Carr levels ( p  = 0.000), body mass index (BMI) values ( p  = 0.03) and were older ( p  = 0.005). The difference in U-Carr values among the subjects remained significant also after adjustment for age and BMI. Conclusion  The results of the present study support the hypothesis that oxidative substances, also increased at systemic and not only at local level, may favor tendon damage. Level of Evidence  IV (pilot study)., Competing Interests: Conflito de Interesses Os autores não têm conflito de interesses para declarar., (Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: Open tibial fractures are mostly the result of high-energy traumas and often involve severe injuries with extensive bone and soft tissue loss, damage of muscles and neurovascular structures. Over recent- years, - the growth of Ortho-Plastic teams, as a well-coordinated bone, joint and soft tissue treatment, contributed to change the approach to these fractures and to achieve higher successful results in lower limb salvage. Unfortunately, many hospitals cannot benefit of a combined team in emergency, and the orthopedic surgeon is forced to manage personally these kinds of traumas., Methods: We retrospectively reviewed all the open tibial fractures treated at our Orthopaedic Department over the last 10 years, in order to assess the treatments performed (one-stage fixation with Intramedullary Nailing or Open Reduction Internal Fixation - ORIF, versus two/multiple-stage fixation with temporary External Fixation followed by nailing or ORIF) and the differences in the outcome between the different methods., Purpose: Based on our experience and review of the literature, the purpose of this paper is to define what cases can be managed by a single-stage orthopaedic approach, and when the orthopaedist should lay down his arms in favor of other specialties.

Purpose: Articular fractures of the proximal femur are seldom encountered and there are few studies in literature regarding this topic. To date, only a few large series have adequate follow-up and exhaustive description of treatment and outcome, which, however, often result incomplete and do not allow a comparison. Since there are still uncertainties and debates on which the treatment gold standard should be, the goal of the present study is to carry out a meta-analysis on type I and II Pipkin fracture management to establish the best treatment according to EBM., Methods: Studies regarding acetabular fractures of the femur head were identified from Google Scholar, Cochrane Library, Medline, ScienceDirect and PubMed; gray studies were searched from the included references' literature, and using general search engines and Social media; the query to be temporally extended from 1996 to 2020. Only comparative studies were included; we ruled out case-reports, case series, author's opinion, register databases., Results: Comparing conservative and surgical treatment, we found evidence of a better outcome choosing surgical treatment. We found a significant better outcome with open reduction internal fixation, instead of fragment excision. Comparing failure rate of surgical approaches, we found no statistically significant difference., Conclusion: Our study proves that there is evidence in favor of operative treatment rather than conservative in complete or displaced Pipkin fracture Type I + II; open reduction internal fixation should be preferred rather than fragment excision, whenever possible., Level of Evidence: III. Therapeutic., Competing Interests: Conflict of interestThe authors declare that they have no competing interests., (© Indian Orthopaedics Association 2021.)

Introduction: Intra-articular (i.a.) hyaluronic acid is an accepted conservative therapy for knee osteoarthritis (OA). This study evaluated the safety and efficacy of a single i.a. injection of an innovative formulation of sodium hyaluronate 2.4% plus sodium chondroitin non-sulphated 1.6% of biotechnological origin (HA-SC) for the treatment of patients with radiographically confirmed symptomatic hip OA and moderate-to-severe pain., Methods: In this prospective, multicenter, open-label, pilot study, HA-SC was administered using a standard ultrasound-guided procedure. Adverse events, global/local evaluation of tolerability, and use of rescue analgesics were recorded. Efficacy endpoints included visual analogue scale (VAS) measurement of hip pain, changes in Lequesne's algofunctional Index, and assessment of global status., Results: Treatment was well tolerated; adverse device events of moderate-to-severe intensity, most commonly, injection site pain/localized arthralgia occurred in 20.8% of subjects. Global evaluation of tolerability was rated as excellent or good (75.0%), fair (16.7%), and poor (8.3%) by subjects and 77.1, 14.6, and 8.3%, respectively, by investigators. There was a rapid and significant decrease in hip pain after a single injection; VAS pain score decreased from a mean of 67.5 mm at baseline to 29.3 mm by day 7, with the effects sustained during 6 months of follow-up (P < 0.0001). There were significant improvements in Lequesne's Index for hip OA total scores at all time points during follow-up (P < 0.0001). The majority of subjects reported 'Very much improved' or 'Slightly improved' global improvement at any time point. Use of rescue paracetamol was generally low., Conclusions: A single i.a. injection of an innovative HA-SC formulation was well tolerated, safe, and effective in the treatment of symptomatic hip OA.

Objective: Several symptoms are common to knee osteoarthritis and Baker's cyst. To what extent each condition contributes to the patient's discomfort is still a matter of debate. The aim of the present study was twofold: first, to compare the burden of symptoms in patients with isolated knee osteoarthritis and patients with knee osteoarthritis associated with Baker's cyst; second, to assess the outcomes after conservative treatments., Subject and Methods: Patients suffering from monolateral idiopathic knee osteoarthritis were enrolled. Demographic, anthropometric and clinical data (KOOS scale) were collected. Ultrasound evaluation was performed according to standard protocols. On the basis of the clinical presentation different therapeutic options were used (fluid withdrawal, hyaluronic acid and/or steroids injections)., Results: One-hundred and thirty patients were included in the study (97 with isolated knee osteoarthritis, 33 with knee osteoarthritis and Baker's cyst). In basal conditions, lower scores in KOOS sub-scales were observed in patients with knee osteoarthritis associated with Baker's cyst and in patients with effusion compared with patients without effusion. At 3 months after therapy significant higher scores were observed in both groups. At 6 months the scores were unchanged in the patients without Baker's cyst, but worsened in those with Baker's cyst., Conclusions: The study shows that Baker's cysts associated with knee osteoarthritis contribute to the burden of symptoms. The conservative treatment of both conditions allows significant improvements, but in the medium term (6 months) the efficacy of the therapy declines in patients with knee osteoarthritis associated with Baker's cyst., (© 2021 The Author(s) Published by S. Karger AG, Basel.)

Objective: Femoroacetabular impingement (FAI) is a condition that has been increasingly recognized as a source of hip pain and a possible risk factor to early development of hip osteoarthritis (OA). To our knowledge, the use of HA in the treatment of femoroacetabular FAI has been investigated only by two studies, both using a high molecular weight HA. The aim of this study was to evaluate the efficacy of two weekly injections of an hexadecylamide derivative of HA (HYADD4-G, HYMOVIS, Fidia Farmaceutici) in FAI., Methods: All patients received two weekly intra-articular injections of Hymovis at baseline and after 7 days. Clinical and functional assessments were performed at baseline and was repeated after 1, 3, 6 and 12 months. Functional measures included visual analogue scale (VAS) for pain, Harris Hip score (HHS), Lequesne Index (LI), Tegner activity level scale (TALS) and monthly consumption of nonsteroidal anti-inflammatory drugs (NSAIDs)., Results: Twenty-one hips (19 patients, 2 bilateral cases) were treated. The variables VAS, HHS as well as Lequesne improved significantly from T0 to T4 (at 12 months) with the best improvement between T0 and T1. At the same time, a reduction in NSAIDs monthly intake was registered. On the other hand, a significant improvement in Tegner scale was not observed. No adverse events were registered., Conclusion: This study states that one cycle of HYADD4-G could be a safe and effective treatment in patients with FAI, showing significative results in term of pain control as well as hip functionality and quality of life up to 1 year., (© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

CoViD-19 epidemic started in China in late December 2019, and soon spread, turning into a pandemic. All medical specialties have soon been involved in the management of CoViD-19 patients; the daily Orthopaedic activity has been affected profoundly by this dramatic health emergency. The present paper aims to summarize all the measures and changes that had to be made in order to avoid the healthcare system collapse in the most affected areas, and provides an operative flowchart., Competing Interests: Authors had nothing to disclose about conflict of interest., (© 2020 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

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., (© 2020 Wiley Periodicals LLC.)

Background: The efficacy of platelet-rich plasma in the treatment for Achilles tendinopathy is debated. Therefore, it is important to know which factors, related to the subjects and/or the disease, are associated with positive or negative outcomes. Aim of this study was to evaluate in a large cohort of patients with Achilles mid-portion tendinopathy which variables were independently associated with a positive outcome after platelet-rich plasma treatment., Material and Methods: Eighty-four subjects with Achilles tendinopathy were evaluated by means of VISA-A score and ultrasound and treated with a single platelet-rich plasma injection once a week for 3 weeks. Afterward, a rehabilitation program, based on eccentric training, was implemented. At 3 and 6 months, the relationship between the mean VISA-A score and the following putative predictors was evaluated: sex, age, physical activity, sport, smoking, metabolic risk factors, BMI, symptoms duration, tendon damage, neovessels, adherence to eccentric training. Finally, the percentage of clinically evident positive outcomes (defined as an increase in VISA-A score ≥ 20 points) related to each variable was computed., Results: At final follow-up, using the General Linear Model for Repeated Measures procedure, male sex (0.02), age ≤ 40 (0.05) and adequate eccentric training (0.02) were found to be independently associated with a significant increase in the mean VISA-A score. Moreover, the clinically evident positive outcomes, as previously defined, were significantly associated with male sex (0.01), age ≤ 40 (0.000), BMI ≤ 25 (0.001), symptoms duration ≤ 12 months (0.02) and good adherence to eccentric training (0.004)., Conclusion: Younger age, male sex and good adherence to eccentric training can be considered predictors of better results after platelet-rich plasma therapy in Achilles tendinopathy.

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).

Objective: The purpose of this study was to investigate the potential ability of autologous conditioned serum (ACS) to decrease pain and improve joint functionality in patients affected by knee osteoarthritis (OA). Methods: Fifteen patients with clinical and radiological signs of OA of the knee were recruited for this study. Each patient received 4 injections of ACS (Orthokine; orthogen, Dusseldorf, Germany) at the site of OA once per week for 4 weeks. Clinical and functional evaluation was performed using the VAS scale for pain, WOMAC scale and KSS functional and clinical scores before the first injection, at one week, at two weeks, at three weeks, at one month and at six months. Statistical analysis was done with the Wilcoxon Signed-Rank Test. Results: Our results show an improvement of all the evaluation scales at 6 months follow-up. Particularly, VAS scales among all patients decreased by 35.8% ( p  = .00148), KSS functional scores improved by 38.2% ( p  = .00148), KSS clinical scores improved by 28.9% ( p  = .00236) and WOMAC scores were reduced by 19.8% ( p  = .00188). Few adverse effects were observed in our sample. The most common complaint was pain and swelling in the subsequent days after performing the intra-articular injection. Only one patient reported rigidity following the injection of the ACS. Conclusion: Our results, in conjunction with preexisting studies in the medical literature regarding ACS, demonstrate the viability of this therapy for the treatment of knee OA, showing positive influence on pain and joint function without significant adverse effects., (© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Rationale: Posterior sternoclavicular joint dislocations (PSCJDs) are particularly rare injuries, accounting for 3% to 5% of sternoclavicular joint dislocations. With very few cases reported in the literature, these injuries are often misdiagnosed and imaging is not always clear, thus making physicians often unaware of them. The present case report aims to investigate a rare case involving a clavicular Salter-Harris II fracture with associated posterior displacement of the diaphysis, a term coined a "pseudodislocation.", Patient Concerns: We present a case of a 14-year-old adolescent who sustained a traumatic injury to the shoulder while falling during a soccer match. His main concern was about recovery time and the return to daily life activities., Diagnoses: Multiple imaging studies imaging (X-rays, computed tomography, magnetic resonance imaging) revealed a Salter-Harris II fracture of the right clavicle with posterior displacement of the diaphysis., Interventions: The patient underwent primary surgery to reduce the fracture, using an articular locking compression plate, and secondary surgery to remove the hardware., Outcomes: Following the removal of the hardware at 60 days after the initial surgery and a number of cycles of physiotherapy the patient reported a pain-free range of motion with slight limitation at extremes. Full return to recreational and everyday life activities were achieved at 3 months from the initial surgery., Lessons: The PSCJDs are challenging injuries, as they are surrounded by delicate structures inside the mediastinum. Attention must be taken while diagnosing and treating these injuries as the risk of complications and iatrogenic injuries is high. To the author's knowledge, this case is one of the first of its kind described in the literature where we have a Salter-Harrys type II fracture associated with a posterior pseudodislocation of the lateral clavicle. Given the positive results of the case, we recommend the above-mentioned treatment protocol in PSCJD with associated Salter-Harris II fractures in adolescent patients.

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., (Copyright © 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Patients affected by coxarthrosis may be treated surgically with total hip arthroplasty (THA). During the surgical intervention, the hip joint capsule can be completely removed, performing a capsulectomy. Otherwise it's possible to perform a capsulotomy, which allows for capsular conservation. Since there is no scientific evidence demonstrating the superiority of one method over the other, the choice whether to remove or conserve the capsule is at the surgeon's discretion and both procedures are actually accepted.The purpose of our study is to evaluate the differences in functional activities and proprioception in patients who underwent THA and capsulotomy with capsular conservation versus patients who underwent THA with capsulectomy., Methods: In order to compare the two surgical techniques of capsulotomy with capsular conservation and capsulectomy, we created a randomized, controlled, double-blind, single-centre, non-pharmacological, interventional, superiority, parallel-group trial. The primary outcome of our study is evaluated using the HOOS scale (Hip disability and Osteoarthritis Outcome Score). Secondary outcomes are: the proprioceptive sensitivity, the postoperative bleeding, the surgical time, the active range of motion, and the ability to walk, sit and stand. The proprioception study is carried out through active and passive repositioning tests. THA is performed through the minimally invasive direct anterior approach. The evaluation tests are carried out in the 15 days preceding the intervention (T0), at 50-day post-operative (T1), and finally at three months after surgery (T2)., Discussion: Considering that the hip joint capsule is innervated by proprioceptive nerve endings, while the psuedocapsule that replaces the native capsule following a THA with capsulectomy doesn't have any active neurophysiological role, we hypothesize that capsulotomy with capsular conservation at the time of primary THA may lead to better proprioception and therefore better functional recovery., Trial Registration: ClinicalTrials.gov identifier: NCT02749058. Date of registration: 04/21/2016., (© 2019 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Objectives: The efficacy of platelet rich plasma in the treatment of Achilles tendinopathy is controversial. Despite positive results observed in open studies, randomized controlled trials failed to show difference against saline or rehabilitation. Aims of this retrospective observational study were to compare the efficacy of platelet-rich plasma and dry needling and to assess possible differences age and sex-related., Methods: Groups of 46 and 38 patients with non-insertional Achilles tendinopathy were treated with platelet-rich plasma and dry needling (once a week for 3 weeks), respectively. At baseline, 3 and 6 months, pain and function scores and the percentage of satisfactory outcomes were evaluated. Sub-group analyses were performed according to age and sex., Results: At 3 and 6 months no differences in terms of pain and function between groups were observed, but the percentage of subjects reporting satisfactory results, at 6 months, was higher in platelet rich plasma group. Better results were observed in younger subjects, with a greater reduction of pain, improvement of function, and accordingly of the percentage of positive outcomes. A trend toward better results was also observed in males., Conclusion: Beneficial effects of platelet rich plasma and dry needling in non-insertional Achilles tendinopathy have been observed only in some subjects, but not in others; platelet rich plasma shows a slight superiority against dry needling, mainly in younger persons; finally, a gender difference in the therapeutic response can be hypothesized.

Introduction: Running is a very popular modality of physical activity, which may help to lose weight and normalize pathological values of blood parameters in subjects suffering from metabolic disorders. Given that both overuse and metabolic pathologies are responsible for the onset of tendon damage, aim of the present study was to evaluate whether the first group of pathogenetic factors or the latter was more responsible for mid-portion Achilles tendinopathy., Method: Thirty-six and 28 subjects with and without mid-portion Achilles tendinopathy, who were regular runners and started running for metabolic disorders, were enrolled, respectively. Information about body weight and blood parameters at baseline was collected. The characteristics of running practice, dietary habits and anthropometric measures were registered. An ultrasound evaluation of the tendon was performed, and the blood metabolic parameters were evaluated., Results: The amount of running years and mileage was equivalent in both groups. A similar weight loss was observed; the subjects with mid-portion Achilles tendinopathy showed a worse metabolic profile (Hb1aC%, p = 0.008; total cholesterol, p = 0.04; HDL cholesterol, p = 0.003; triglycerides, p = 0.009)., Conclusions: These findings suggest that the subjects with less evident positive effects of running on metabolism are more exposed to the onset of mid-portion Achilles tendinopathy.

Objective: The therapeutic efficacy of platelet-rich plasma in the treatment of Achilles tendinopathy is controversial. Among the variables which can explain the discrepant results, little attention has been paid to the distribution of platelet-rich plasma inside the tendon. The aim of the present study was to evaluate whether this factor is related to the clinical outcome of treatment., Subjects and Methods: Forty patients suffering from mid-portion Achilles tendinopathy were studied. At baseline, pain and function were measured by means of a visual analogue scale and the Victorian Institute of Sport Assessment-Achilles questionnaire. Thereafter, an ultrasound examination was performed, and platelet-rich plasma was injected. Immediately after injection, the plasma distribution was assessed visualizing the material in the tendon. The patients were re-evaluated at 3 and 6 months, computing pain and function values and the percentage of satisfactory outcomes in relation to the distance reached by the plasma from the point of injection., Results: The diffusion inside the tendon was longitudinal in all cases and cross-sectional only in 9. The mean distance from the tip of the needle increased significantly according to the severity of tendon damage. At follow-up, no relationship was found between plasma diffusion and clinical outcomes., Conclusions: Platelet-rich plasma diffusion has no effect on clinical outcome, which mainly depends on the metabolic activation of the whole structure of the tendon., (© 2019 The Author(s) Published by S. Karger AG, Basel.)

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., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Purpose: Platelet rich plasma and high volume image guided injections of saline have been used in the treatment of patellar tendinopathy with positive results. As the different mechanisms of action do not interfere each other, it can be hypothesized that they can be used in combination. Aim of this study was twofold: first, to evaluate the efficacy of these two treatments in the management of patellar tendinopathy; second, to verify whether the combination of these therapies could provide further advantages., Methods: Fifty-four patients suffering from patellar tendinopathy were enrolled. After clinical (VAS and VISA-P) and sonographic evaluation, two ultrasound guided injections (2 weeks apart) of platelet rich plasma, high-volume image-guided injections of saline, or both in association were performed. The VAS and VISA-P scores obtained from the three treatments groups (18 patients in each group) were compared across the different follow-up times (3 and 6 months)., Results: In the short term both treatments showed comparable efficacy, whereas in the medium term the positive effects of high-volume image-guided injections gradually diminished and platelet rich plasma showed greater efficacy. Better results (reduced pain, improved function and increased number of subjects who exhibited optimal recovery [> 20 points in VISA-P score]) were observed when both procedures were associated., Conclusions: The contemporaneous administration of platelet rich plasma and high volume image guided injections of saline treatments, which influence tendon repair by means of different mechanisms, grants a greater improvement for patellar tendinopathy. This finding has clinical relevance, given that this condition has a substantial impact on sports and work performance., Level of Evidence: III.

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., (Copyright © 2016 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Introduction: Overuse, micro-traumas, and impingement, isolated or combined, are the more common etiological factors for rotator cuff tears. Metabolic disorders (diabetes, adiposity, hypercholesterolemia), hypertension, cigarette smoking and a genetic predisposition are considered risk factors. However, no study has compared the prevalence of these risk factors in subjects with bilateral and monolateral tears., Hypothesis: Controlateral tears can be observed in patients with symptomatic monolateral rotator cuff lesions, especially in those with comorbidities., Material and Methods: In patients with symptomatic rotator cuff tear, the controlateral shoulders were evaluated by means of ultrasound imaging. Age, BMI, diabetes, hypercholesterolemia, hypertension, cigarette smoking, work habits were registered. Risk factors in subjects with bilateral tears were compared with those with monolateral lesions., Results: Of the 180 subjects recruited, 69 had a tear in the controlateral shoulder. Higher age and BMI values, heavy repetitive work and diabetes were significantly prevalent in these patients. At multivariate analysis, these factors were independently related to a higher probability to detect bilateral tears., Discussion: Metabolic risk factors are more heavily involved in presence of bilateral rotator cuff tears, in comparison to monolateral., Type of Study: Original study., Level of Proof: IV., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Osteoarthritis (OA) is a progressively degenerative joint disease, with a very high prevalence rate that is expected to increase worldwide with the ageing of the population. Considering that OA requires long-term treatment, therapies with minimal side effects and which can be repeated as needed are warranted. Hyaluronic acid (HA), a natural glycosaminoglycan with viscoelastic properties, is a major component of synovial fluid and the extracellular matrix of the joint cartilage, and plays key roles in maintaining synovial fluid viscosity and the bio-mechanical integrity of healthy cartilage. Intra-articular administration of exogenous HA has therefore been used to successfully improve the viscoelastic properties of the joint to improve lubrication, modulate inflammation and modify the catabolic micro-environment. Sinovial®/GELSYN-3TM is a sterile, non-pyrogenic formulation of highly purified, chemically unmodified HA of bio-fermentative origin, which has been introduced in several different concentrations in clinical use within the European market. This expert opinion reports on the published data regarding the efficacy and tolerability of first and multiple injection series of Sinovial®-based product formulations. The data regarding the tolerability of Sinovial® in patients with knee osteoarthritis were analyzed, showing that this formulation, beside favourable therapeutic effects, has a very good tolerability profile, with only mild, transient, and easily managed, local injection-site reactions and absence of systemic reactions. In particular, repetitive cycles of HA have been shown to yield positive results in terms of both efficacy and safety and therefore should be offered to patients who had undergone a successful first course of therapy when their symptoms reoccur.

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., (© 2017 Elsevier Ltd. All rights reserved.)

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., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

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.

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.

Introduction: local glucocorticoids injections are widely administered for the treatment of tendinopathies. positive results have been observed in some tendinopathies but not in others. moreover, worsening of symptoms, and even spontaneous tendon ruptures has been reported. the characteristics of the tendinopathies, the clinical peculiarities of the patient, and the technique used to administer glucocorticoids, can influence the therapeutic response. Areas covered: After reviewing the pertinent literature on the clinical results, basic information, both on the pathogenesis of tendinopathies and the effects of glucocorticoids on tendons, is reported. The pharmacological properties of glucocorticoids are useful to counteract some pathogenetic mechanisms of tendinopathies. However, several experimental studies suggest that the direct action of glucocorticoids on tendons is detrimental. Loss of collagen organization, impaired viability of fibroblasts, depletion of stem cells pool, and reduced mechanical properties have been observed. Expert opinion: Drawbacks of local glucocorticoids injections could be predicted on an individual basis, after a careful appraisal of patient characteristics and concomitant medications, along with the specific stage of tendon disease.

The combined use of low and high molecular weight hyaluronic acid (HA) has never been reported in the treatment of osteoarthritis (OA). The aim of this paper was to evaluate the efficacy of a new hybrid association of both preparations in patients suffering from hip OA and to compare the results with those obtained retrospectively from a cohort of patients treated with high molecular weight HA. Twenty patients with moderate-severe hip OA (grade II-IV according to Kellgren-Lawrence score) were enrolled in the study group. After clinical and functional evaluation (Visual Analogue Scale [VAS] for pain, Lequesne Index, Harris Hip Score), each participant received an intra-articular ultrasound-guided injection of the new HA compound at baseline and after 40 days. The measures were repeated at three and six months. The data collected were retrospectively compared with those obtained in a cohort of 20 patients, matched for sex, age, and severity of hip OA, treated with high molecular weight hyaluronic acid. The intra-group comparison showed a significant improvement in clinical and functional outcomes at three and six months in both cohorts, while the infra-group comparison showed better results in the patients treated with the study compound at six months (VAS at rest, P <0.04; VAS during activities, P <0.02; Harris Hip Score, P <0.001). The present study is the first which demonstrates that a combination of low and high molecular weight HA is effective and safe in the management of patients suffering from hip OA and provides better therapeutic results in comparison to high molecular weight HA. We may infer that both HA preparations work synergically, enhancing their positive activities.

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., (© 2015 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd.)

Objective: 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., Materials and Methods: In this review, we analyzed anatomy, pathophysiology and existing classifications of posterior tibial tendon dysfunction., Results: 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., Conclusions: 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.

Objective: Skeletal diseases, both degenerative and secondary to trauma, infections or tumors, represent an ideal target for regenerative medicine and in the last years, stem cells have been considered as good candidates for in vitro and in vivo bone regeneration. To date, several stem cell sources, such as adult mesenchymal stem cells, embryonic stem cells (ESCs) and induced pluripotent stem cells (iPSCs), have shown significant osteogenic potential., Materials and Methods: In this narrative review, we analyze the possible advantages of the use of AFSCs in the treatment of skeletal diseases, especially through the application of tissue engineering and biomaterials., Results: Among the different sources of stem cells, great attention has been recently devoted to amniotic fluid-derived stem cells (AFSC) characterized by high renewal capacity and ability to differentiate along several different lineages., Conclusions: Due to these features, AFSCs represent an interesting model for regenerative medicine, also considering their low immunogenicity and the absence of tumor formation after transplantation in nude mice.

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.

Purpose: Cervical pain is very frequent in the general population. In clinical practice, plain X-ray and, in selected cases, computed tomography or magnetic resonance imaging, are performed. However, the feasibility and utility of ultrasound examination have been poorly investigated. Aim of the present study was to evaluate whether ultrasound could be useful in the diagnosis of localized cervical pain., Methods: Subjects suffering from posterior cervical pain without irradiation to surrounding tissues were enrolled. After clinical and functional evaluation (demographic and anthropometric data, VAS at rest and during neck movements, symptoms duration, and characteristics of pain onset [atraumatic or traumatic]), an ultrasound exam of the cervical spine was performed according to standard protocols., Results: The anatomic structures of the neck district were visualized in 124/127 enrolled patients and pathological features were observed in 58. Significant ultrasound differences were registered between the patients with traumatic and atraumatic onset of neck pain. In the first group, articular effusion, capsular bulging, disalignment and avulsion of the articular apex were observed, whereas in the latter cortical irregularities, osteophytosis, and articular ankylosis were prevalent., Conclusions: Ultrasound examination can be used as diagnostic tool in the evaluation of selected patients suffering from localized cervical pain, particularly in cases of pain due to traumatic injuries., Competing Interests: The authors declare no potential conflicts of interests with respect to the authorship and/or publication of this article. They do not have a financial relationship with the organization that sponsored the research. The authors have full control of all primary data and agree to allow the journal to review their data if requested. Ethical approval The experiments comply with the current laws of the country in which they were performed. All procedures performed in study involving human participants were in accordance with the ethical standards of the institutional and/or national committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent Informed written consent was obtained from all the subjects.

Background: Exercise is an important therapeutic tool in the management of diabetes in older people. Aim of this study was to assess the relationship among type II diabetes, sport, overweight, and symptomatic Achilles tendinopathy in elderly subjects., Methods: Thirty-eight patients suffering from Achilles tendinopathy and thirty-eight controls were enrolled. The prevalence of diabetes and sport practice as well as BMI and Glycated Hemoglobin (HbA1c) values were registered. An ultrasound evaluation of Achilles tendon was performed., Results: Patients showed an increased prevalence of diabetes (42 vs. 13.1 %, p = 0.004), and practice of sport (60.5 vs. 28.9 %, p = 0.0001), and higher BMI values (26.8 ± 3 vs. 24.8 ± 2.3, p = 0.001). Sonographic abnormalities, being diagnostic criteria, were present in all the patients with Achilles tendinopathy, but signs of degeneration were also found in 36.8 % of asymptomatic controls. Symptomatic subjects with diabetes, compared to those without, showed a higher prevalence of severe degeneration (75 vs. 36.3 %, p = 0.01). HbA1c values were significantly lower in sport practitioners, both diabetics and non-diabetics. Moreover, patients practicing sport showed a trend towards lower BMI values, compared to the sedentary counterpart., Conclusions: Sport practice in elderly diabetics provides relevant metabolic advantages, reducing HbA1c and BMI. However, some sport activities (e.g., speed walking, jogging or tennis) can expose to the risk of Achilles tendinopathy. So, sport practice should be encouraged, but practitioners should follow individual training programs and be submitted to periodic sonographic controls.

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., Competing Interests: The authors have no conflicts of interest to declare.

Background: sonoelastography helps in the detection of abnormalities not yet evident on B-mode exam., Methods: in this observational study, we report a collection of cases of symptomatic patients without alterations at ultrasound imaging but with evidence of pathological findings at sonoelastography. Patients, with clinical history suggestive for tendinopathies or surgically treated, and negative at the ultrasound exam, were submitted to sonoelastography. Out of 846, 632 patients with positive ultrasound exam were excluded. Sonoelastography was therefore performed in the remaining 214., Results: the examination was positive in 168 cases: 78 patients were affected with shoulder diseases, while elbow pathology was observed in 31 subjects; patellar, Achilles and plantar fascia disorders were reported in 19, 27, and 13 patients, respectively., Conclusion: sonoelastography can reveal tendon abnormalities of clinical relevance in a high percentage of cases, where the ultrasound exam was negative, making the method a complementary tool to ultrasound evaluation.

Background: Hormones can modify tendon homeostasis, some of them leading to tendon damage, while others are essentials for healing. This narrative review summarizes the current knowledge on the topic, focusing on the hormones normally secreted by endocrine glands., Methods: A search in PubMed, Web of Knowledge and EMBASE, using the terms tendinopathy or tendon, combined with estrogens, testosterone, thyroid and parathyroid hormones, glucocorticoids and growth hormone, independently, was performed. Relevant articles focusing on the correlation between hormones and tendons, and their therapeutic use in tendinopathies, were selected., Results: Tendon abnormalities observed in subjects with hyperparathyroidism, hypercortisolism and acromegaly are described. At present, experimental studies and preliminary observations in humans suggest that parathyroid and growth hormones, locally administered, are promising therapeutic tools in specific tendon disorders. Local injections of glucocorticoids are useful in several tendinopathies, exploiting their anti-inflammatory and anti-proliferative properties, but carry the risk of further tendon degeneration and ruptures, due to the detrimental direct effect of glucocorticoids on the tendon structure., Conclusion: Because tendons injuries are frequent, often with long lasting sequels, it is important to improve our understanding concerning the therapeutic potential of hormones on healing., Level of Evidence: IV., Competing Interests: Conflict of interest All the Authors have no disclosure.

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., Competing Interests: Conflict of interest The Authors declare that they have no conflict of interest related to the publication of this manuscript.

Several epidemiological and clinical observations have definitely demonstrated that obesity has harmful effects on tendons. The pathogenesis of tendon damage is multi-factorial. In addition to overload, attributable to the increased body weight, which significantly affects load-bearing tendons, systemic factors play a relevant role. Several bioactive peptides (chemerin, leptin, adiponectin and others) are released by adipocytes, and influence tendon structure by means of negative activities on mesenchymal cells. The ensuing systemic state of chronic, sub-clinic, low-grade inflammation can damage tendon structure. Metabolic disorders (diabetes, impaired glucose tolerance, and dislipidemia), frequently associated with visceral adiposity, are concurrent pathogenetic factors. Indeed, high glucose levels increase the formation of Advanced Glycation End-products, which in turn form stable covalent cross-links within collagen fibers, modifying their structure and functionality.Sport activities, so useful for preventing important cardiovascular complications, may be detrimental for tendons if they are submitted to intense acute or chronic overload. Therefore, two caution rules are mandatory: first, to engage in personalized soft training program, and secondly to follow regular check-up for tendon pathology.

Congenital metabolic disorders are consequence of defects involving single genes that code for enzymes. Blocking metabolic pathways, the defect leads to the shortage of essential compounds, and/or to the accumulation of huge quantities of precursors, which interfere with normal functions. Only few of these diseases are characterized by a clinically significant tendon involvement.Heterozygous Familial Hypercholesterolaemia results from the inheritance of a mutant low-density lipoprotein receptor gene; patients show high cholesterol levels, precocious coronary artery disease, and may develop tendon xanthomata (mainly in Achilles tendon). The detection of xanthomata is important, because it allows an early diagnosis and treatment of the disorder. Cerebrotendinous Xanthomatosis is a rare genetic metabolic disorder of cholesterol and bile acid metabolism, characterized by accumulation of cholestanol in brain and tendons. Tendon abnormalities are similar to those reported in Heterozygous Familial Hypercholesterolaemia. Alkaptonuria is caused by a deficiency of the enzyme homogentisic acid oxidase. Due to the accumulation of the homogentisic acid, tendons and ligaments are characterized by a typical ochre/yellow pigmentation (ochronosis), with ensuing inflammation, calcification and rupture. In Congenital Hypergalactosemia an increased tendon collagen cross-linking by non-enzymatic galactosylation can be observed. Finally, Congenital Hypophosphatasia may be associated to deposition of hydroxyapatite crystals in rotator cuff, elbow, and Achilles tendons.

Purpose: Recently, the Zimmer Trabecular Metal Total Ankle Replacement (Zimmer TM TAR) was developed to be used through a lateral transfibular approach. The purpose of this paper is to describe the surgical technique and early outcomes of the TAR via the lateral approach using the Zimmer TM TARs., Methods: Sixty-seven patients underwent primary TAR using the Zimmer TM TAR between May 2013 and May 2015. Patients were clinically evaluated preoperatively and postoperatively at six and twelve months and annually using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot scores, visual analogue scale (VAS) pain score, and the Short Form Health Survey (SF-12) questionnaire. The minimum follow-up was 12 months., Results: The mean AOFAS hindfoot score increased from 32.8 preoperatively to 85.0 at the latest follow-up (p-value < 0.001). The mean VAS pain score decreased from 8.0 to 2.0 at the latest follow-up (p-value < 0.001). The Physical and Mental Health Composite Scale scores (PCS and MCS) of the SF-12 passed from a mean value of 30.2 preoperatively to 43.1 (p-value < 0.001) and from a mean value of 44.6 to 53.5 at the latest follow-up (p-value < 0.001), respectively., Conclusions: We present our surgical tips and the early results of this prosthetic design which are encouraging. They could be useful as an adjunct to the manufacturer's surgical technique guidance for surgeons who utilize these implants., (© The Authors, published by EDP Sciences, 2016.)

Background: Platelet Rich Plasma (PRP) has shown positive and long-lasting effects in patients with tendinopathies. However, information about age-related differences in the clinical outcome is limited. Aim of this retrospective study was to compare the efficacy of PRP therapy in young and elderly subjects suffering for Achilles tendinopathy., Materials and Method: Patients with recalcitrant non-insertional Achilles tendinopathy were enrolled. Clinical (VISA-A) and instrumental (ultrasonography) data were collected at baseline and after 1, 3, 6, and 12 months. PRP injections (once a week for 3 weeks) were performed in sterile conditions and under ultrasound (US) control., Results: Forty-four subjects (29 young: mean age 39.5 ± 6.9; 15 elderly: mean age 61.5 ± 5.3) were retrospectively evaluated. At baseline, no significant differences were observed in the clinical and US parameters. Throughout the whole length of the study, a significant increase of VISA-A score was seen in both groups (from 50.3 ± 8.8 to 76.1 ± 6.6 in the young group, and from 48.7 ± 7.6 to 61.1 ± 9.4 in the elderly group); however, the infra-groups comparison showed better results in young patients, compared to the aged counterpart., Conclusion: Our results show that PRP is less effective in aged people. This finding can be ascribed to several biochemical and biomechanical differences documented in tendons of young and elderly subjects (reduced number and functionality of tenocytes and tenoblasts), which becomes more evident in the long-term tissue healing. However, prospective trials, using different PRP preparations and enrolling a larger number of subjects, are needed to draw more sound and definitive conclusions.