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Literary realism has produced some of the most famous deaths in literary fiction. Psychological insight into the characters’ experiences and the mental states that induced their deaths helps readers to engage the protagonists not as victims of society, martyrs of fate, or wicked characters but, rather, as pathological human beings. Their psychological dualities bring affirmations of identity as well as breakdowns of identity, hence transforming readers’ judgments on their morality with new understanding.

When Oscar Wilde defiantly observed that life is imitation of art, literary criticism had found another role to the complicated relationship between literature and reality. The issue is most central in Cesare Pavese and Sylvia Plath, for their lives seemed to re-enact what their fictional characters in, respectively, Among Women Only and The Bell Jar, had attempted. The conscious manipulation of novelistic material into physical and mental events appears to prove correct Wilde's statement about the power of imitation. However, apart from the work of scholars who wrote on Pavese and Plath as an isolated case, the theory of life as imitation of art was never used to define the authors’ intention. Therefore, further theorization is necessary.

Dino Buzzati's Un Amore has been largely defined as a consequence of the progressive development of the phenomenon of “lolitism,” and a few years before, Nabokov's Lolita had been accused of being an example of pedophilia. While both female characters are archetypes of “nymphet,” defiant, sexually promiscuous, capricious, and, above all, skilled in manipulation, the relationship progresses through a labyrinth of absence and deprivation. However, in order to place the novels in a proper perspective, we must avoid any intrusion into the authors’ private sexuality, and search for the aesthetic phenomenon thereby implied. Written from the male's perspective, women are a riddle but their age offers a key to understanding: youth's artful image can grant the illusion of immortality before death.

Chinese postmodern literature, or post-Mao fiction, comes with disillusionment among the intellectuals and cynicism among the fictional characters. According to this line of thinking, narrative enters a theoretical discourse that leaves aside the former ideological imprint and moves within the frame of realism. As in the experience of the nineteenth century French realism, Su Tong’s and Yu Hua’s fiction describe a process of Bildungsroman that is never accomplished. A crude Darwinian weltanschauung seems to be the key to understanding.

Este artículo contiene 31 páginas, 19 figuras, 3 tablas., The morphological reexamination of specimens previously identified as Laonice bahusiensis Söderström, 1920 from North European and Mediterranean collections, supported by the molecular analysis of freshly collected material, enabled the recognition of four different species in the region: the genuine L. bahusiensis, L. irinae n. sp. from North European waters, and L. grimaldii n. sp. and L. mediterranea n. sp. from the Mediterranean Sea. The morphology of these species is described and illustrated, and their distributions are clarified based on old and new materials. A key for their identification is also provided. The Bayesian analysis of the COI sequences (483 bp) showed that these four species form a clade, namely the L. bahusiensis species complex, morphologically characterized by the continuous dorsal crests on postbranchiate chaetigers in the adults. The genetic p-distances between the species of the complex ranged from 13.27% to 17.99%, while the intraspecific variability ranged from 0.6% to 1.57%. Together with the sister species Laonice cirrata (Sars, 1851), the L. bahusiensis complex formed the Laonice (Laonice) clade, which is morphologically characterized by the prostomium fused with the anterior peristomial margin. However, the monophyly of the L. bahusiensis complex, as well as that of the clade Laonice (Laonice), needs to be further supported through the analysis of a greater set of genes from a larger number of species.

Aphanius fasciatus is a small fish occurring in Mediterranean brackish environments. In Cyprus it is known from three localities separated by long stretches of coast. The genetic diversity of these populations was evaluated using fragments of two mitochondrial genes. A comparison with the other available data showed that Cyprus populations represent a distinct lineage. The other lineages are concentrated in a relatively small area between the Strait of Sicily and the Western Ionian Sea, while all other areas include a subset of these lineages, suggesting that the aforementioned area might have acted as a glacial refugium. Landlocked North-African populations diverge from all other populations, suggesting that they might have originated in the Late Pleistocene, during transgression events of the Mediterranean Sea in North-African inland water bodies. The genetic diversity of A. fasciatus varied across different Cyprus populations, with a pattern mirroring the degree of environmental degradation, which likely affected population genetic variability through demographic reductions. The three Cyprus populations showed genetic uniqueness, suggesting the need of population-based management practices; the low genetic diversity of two populations, and the number of threats affecting them, suggest that the species should be considered endangered at national level and deserves protection measures.

An emerging issue for orthopedic surgeons is how to manage patients with active or previous COVID-19 disease, avoiding any major risks for the surgeons and the O.R. personnel. This monocentric prospective observational study aims to assess the prevalence of SARS-CoV-2 viral RT-PCR RNA in cancellous bone samples in patients with active or previous COVID-19 disease. We collected data about 30 consecutive patients from our institution from January 2021 to March 2021 with active or previous COVID-19 disease. The presence of SARS-CoV-2 in the samples was determined using two different PCR-based assays. Eighteen of the thirty patients included in the study had a positive nasopharyngeal swab at the time of surgery. Twelve patients had a negative nasopharyngeal swab with a mean days since negativization of 138 ± 104 days, ranging from 23 to 331 days. Mean days of positivity to the nasal swab were 17 ± 17. Twenty-nine out of thirty (96.7%) samples were negative for the presence of SARS-CoV-2 RNA. In one sample, low SARS-CoV-2 load (Cycle threshold (Ct) 36.6.) was detected but not confirmed using an additional confirmatory assay. The conducted study demonstrates the absence of the viral genome within the analyzed cancellous bone. We think that the use of personal protection equipment (PPE) to only protect from aerosol produced during surgery, both in active and recovered patients, is not strictly necessary. We think that the use of PPE should not be employed by surgeons and the O.R. personnel to protect themselves from aerosols produced from the respiratory tract. Moreover, we think that our results could represent a valid basis for further studies related to the possibility of bone donation in patients that suffered and recovered from COVID-19.

Chinese Avant-garde stands as a literary avalanche at the economic dawning of the Reform Era. The shaping of postmodern texts depoliticized, and fragmented, is somewhere along the line the ontological transaction to a post-ideology literature where the permanent struggle is not anymore between classes, but within the frame of personal identities. The narrative moves from socialist realism to experimental writing, from realism to abstract expressionism, forging a literary paradigm alternative to the dominant one. In this sense, Chinese Avant-garde stands as the narrative re-enchantment of Chinese fiction.

Objective. Herein, we present a case series of patients treated with megaprosthesis who sustained high energy trauma with comminuted articular hip or knee fracture, complex periprosthetic fractures or pathological fractures.Methods. We retrospectively reviewed 15 consecutive patients who sustained knee re- placement/revision (7 patients) and 8 patients who underwent hip replacement/revision with megaprosthesis between 2014 and 2018. In the knee group, there was 1 man and 6 women, while in the hip group there were 3 men and 5 women.In knee group, preoperative indications were: periprosthetic fracture; highly comminuted distal femoral fracture; metastatic localization of distal femur; nonunion of distal femoral fracture in one case.In the hip group, preoperative indications were: subtrochanteric pathological fractures; peri- prosthetic fracture; recurrent infection; recurrent tumoral lesions.Preoperative evaluation included standard radiographs; CT-scan with 3D reconstruction for tailored implant planning; MRI only for pathological localization.Results. Mean clinical follow-up with radiographic control was 44 months (range 23-71). All complications were managed before the patient left the hospital. During the follow-up period, 13 of 15 patients regained walking ability as before surgery. At the end of follow-up, 6 patients had died due to causes not related to the surgery.Conclusions. The use of megaprosthesis offers useful solutions for different pathologies such as tumors, infections, comminu ed fractures, and periprosthetic fractures in the elderly patient with good functional results.

The influence of substrate morphology on early stages of fouling development was assessed through submerged experimental substrates with different morphological complexity. The experiment was carried out within commercial and touristic harbours of the port of Livorno (Italy), analysing the communities at three steps of colonization (14, 28, 42 days). We assessed the effect of substrate complexity on recruitment of non-indigenous species (NIS), combined with the influence of port use destinations. NIS were recorded in both use destination areas since the first step of colonization. Substrate morphological complexity significantly affected fouling colonization and particularly NIS assemblages. We found that high-complexity substrates are particularly suitable for NIS establishment in comparison with less complex ones. The touristic harbour exhibited a potential for fouling colonization higher than the commercial harbour. These results contributed to the understanding of factors involved in NIS establishment and spread, as well as in their spatial-temporal dynamics within port environments.

Due to the introduction of the market economy, in the past four decades China has switched from being a “planned country” – planned economy, planned art – into a domestic version of cultural pluralism. Consumerism has refilled the vacuum left by the retreat of Maoist ideology. However, the overwhelming success of mass culture is sided by the progressive marginalization of the intellectuals or elite, featuring a culture that is kitsch in its ideological twist. In China, present-day cultural constructions provide a forum of debate for the identity of the whole nation, no more traditional, and not yet modern. In other words, consumerism and commercialism, triggered by products of market economy, have generated a cultural consumption of redundant bad taste. Kitsch indeed.1

Background: From February 21, the day of hospitalisation in ICU of the first diagnosed case of Covid-19, the social situation and the hospitals’ organisation throughout Italy dramatically changed. Methods: The CIO (Club Italiano dell’Osteosintesi) is an Italian society devoted to the study of traumatology that counts members spread in public and private hospitals throughout the country. Fifteen members of the CIO, Chairmen of 15 Orthopaedic and Trauma Units of level 1 or 2 trauma centres in Italy, have been involved in the study. They were asked to record data about surgical, outpatients clinics and ER activity from the 23rd of February to the 4th of April 2020. The data collected were compared with the data of the same timeframe of the previous year (2019). Results: Comparing with last year, overall outpatient activity reduced up to 75%, overall Emergency Room (ER) trauma consultations up to 71%, elective surgical activity reduced up to 100% within two weeks and trauma surgery excluding femoral neck fractures up to 50%. The surgical treatment of femoral neck fractures showed a stable reduction from 15 to 20% without a significant variation during the timeframe. Conclusions: Covid-19 outbreak showed a tremendous impact on all orthopaedic trauma activities throughout the country except for the surgical treatment of femoral neck fractures, which, although reduced, did not change in percentage within the analysed timeframe.

Beach litter can affect public health and economic activities worldwide forcing local authorities to expensive beach cleaning. Understanding the key mechanisms affecting the accumulation of this waste on beaches, such as sea state and proximity to entry points, is critical to plan effective management strategies. In this one-year study, we estimated the impact of storm events and waterways runoff on litter abundance and local economy using as a model a managed, peri-urban beach facing a north-western sector of the Mediterranean Sea. We also investigated the relationship between litter composition/density and beach proximity to major/closest harbors/rivers at regional scale by combining our data with those on litter density available in literature. Autumn/winter storms caused larger litter depositions than spring/summer ones in the peri-urban beach. No preferential accumulation occurred near to waterway mouths. Litter mainly consisted of plastic, and its composition in terms of micro-categories varied over seasons. In total, 367,070 items were deposited along 4.7 km of beach over one year, and the cost for the removal of this waste amounted to approximately 27,600 euros per km/year. At regional scale, beach litter density was positively correlated to the proximity of major harbors while its composition was related to the proximity to both major harbors and rivers. Results indicate that autumn/winter storms are important drivers of marine litter deposition. They also suggest that beaches in front of the convergence zone of littoral currents and close to major harbors can be particularly subjected to this kind of pollutant. To increase their effectiveness, litter mitigation/cleaning activities should be planned based on predictions of major storm events and performed at spatial scales encompassing at least coastal regional sectors.

To assess the exposure of beachgoers to viruses, a study on seawater, sand, and beach-stranded material was carried out, searching for human viruses, fecal indicator organisms, and total fungi. Moreover, for the first time, the genome persistence and infectivity of two model viruses was studied in laboratory-spiked sand and seawater samples during a one-week experiment. Viral genome was detected in 13.6 % of the environmental samples, but it was not infectious (Human Adenovirus - HAdV, and enterovirus). Norovirus and SARS-CoV-2 were not detected. The most contaminated samples were from sand and close to riverine discharges. In lab-scale experiments, the infectivity of HAdV5 decreased by ~1.5-Log

Loyal to the path spotted by the avant-garde and in contrast to the aesthetics of socialist realism, Chinese female literary production in the post-Mao era is iconoclast in its intentions. Having the ideological truth being stripped away from the text, the shaking reality writers draw up their ideas is staged on the individual's impressions and experiences. However, considering this literature as all-encompassing realism would be misjudging the reality of postmodern China. The object of the present study is to define the literary experience of Chinese postmodernism from the perspective of four ontologically different female writers.

The cryptic diversity in the polychaete Syllis gracilis Grube, 1840, in the Mediterranean Sea was examined with an integrative morpho-molecular approach. Individuals of S.gracilis were collected at eleven Mediterranean localities to provide an insight into the role of brackish environments in inducing cryptic speciation. The examination of morphological features combined with a molecular genetic analysis based on a partial sequence of the 16S rRNA gene highlighted discrepancies between morphological and molecular diversity. Morphological data allowed to identify a morphotype with short appendages occurring in coralline algae communities and another one with long appendages observed in brackish-water environments and Sabellaria reefs. Multivariate analyses showed that sampling localities were the greatest source of morphological divergence, suggesting that phenotypic plasticity may play a role in local adaptations of S.gracilis populations. Molecular data showed the occurrence of four divergent lineages not corresponding to morphological clusters. Different species delimitation tests gave conflicting results, retrieving, however, at least four separated entities. Some lineages occurred in sympatry and were equally distributed in marine and brackish-water environments, excluding a biogeographic or ecological explanation of the observed pattern and suggesting instead ancient separation between lineages and secondary contact. The co-occurrence of different lineages hindered the identification of the lineage corresponding to S.gracilis sensu stricto. The discrepancy between morphological and molecular diversity suggests that different environmental and biogeographic features may interact in a complex and unpredictable way in shaping diversity patterns. An integrative approach is needed to provide a satisfactory insight on evolutionary processes in marine invertebrates.

The dialectic between transitory pleasure and permanent values, between the nature of life and the ideal, finds one of its representations in the experience of unfulfilled loves. Cyrano de Bergerac and Baudelaire’s poem A une passante have already received extensive scholarly attention but never as a theory of desire. Can a love still be real if it cannot be undertaken and experienced? The texts in analysis re-think the role of the object of love, and therefore the metaphysics of love, through the dynamic of lack and desire. Desire needs to replicate itself in order to exist, thus the object of love must remain unattainable.

While Western thinking is a linear belief system set in motion by Christianity, Chinese reasoning conceives changes within a circular process that holds together repetition and transformation. Making sense of this is simply to recognize that depending on how we consider the nature of history, we will also partake in a different imprint on society as a whole. The transition from socialist to post-socialist China is also the drift from the stability guaranteed by Chinese philosophy to the individualism offered by the logic of marketization. Over the sociological implosion of Chinese cyclicity, China places its quest for a new identity.

This manuscript stages the West and China as civilizations rooted in contrasting myths. The Western leading paradigm is the Faustian Man whose ambition created modernity and the tragedy of progress. It is a tragedy already condemned by history but, being Faust’s construction site unfinished, it is a tragedy that everyone seems keen to re-enact. On the other hand, China conceived the concept of stability, rather than competition, the key for a durable success. Behind Zheng He’s voyages and the Ming Dynasty’s choice to go westbound, rather than eastbound, lies an anti-Faustian attitude, the essence of Chinese philosophy, to be read not as anti-modernity but the attempt to shape an alternative modernity.

In this article, we provide an extensive review of the recent literature of the signaling pathways modulated by Pulsed Electromagnetic Fields (PEMFs) and PEMFs clinical application. A review of the literature was performed on two medical electronic databases (PubMed and Embase) from 3 to 5 March 2021. Three authors performed the evaluation of the studies and the data extraction. All studies for this review were selected following these inclusion criteria: studies written in English, studies available in full text and studies published in peer-reviewed journal. Molecular biology, identifying cell membrane receptors and pathways involved in bone healing, and studying PEMFs target of action are giving a solid basis for clinical applications of PEMFs. However, further biology studies and clinical trials with clear and standardized parameters (intensity, frequency, dose, duration, type of coil) are required to clarify the precise dose-response relationship and to understand the real applications in clinical practice of PEMFs.

Fouling communities were studied in three port systems of Northern Tyrrhenian Sea (Western Mediterranean), focusing on the occurrence of non-indigenous species (NIS). For each port system two harbour types (large port and recreational marina) were sampled and, within each large port, fouling samples were collected considering two use destinations (commercial and touristic harbour). Among the 431 taxa identified, forty-two were alien or cryptogenic, four of which were new records for the study area. Harbour type and use destination shaped fouling communities and NIS assemblages, with their relative influence varying among different port systems. High fouling variability was detected within port environments and between different marinas. NIS showed the highest occurrence in large ports, in which the touristic harbour generally hosted the greatest amount. Therefore, the touristic harbours within large ports were identified as susceptible areas for NIS establishment and their possible subsequent spread at local scale through recreational maritime traffic.

La evaluación de la vulnerabilidad sísmica de puentes permite identificar aquellas estructuras sísmicamente deficientes y establecer prioridades y pautas relacionadas con la necesidad de su rehabilitación, refuerzo o reemplazo. Al respecto, en Argentina no existe ninguna metodología establecida. El objetivo es presentar un método de avanzada aplicado a dos puentes típicos ubicados en zonas caracterizadas como de elevada y muy elevada peligrosidad sísmica del territorio nacional a fin de verificar su nivel de desempeño estructural. Se utiliza análisis dinámico no lineal, método considerado como el de mayor rigurosidad. Los modelos 3D utilizados se construyeron con la plataforma de elementos finitos OpenSees. Se verificó el mejor comportamiento sismorresistente del puente que presenta mayor rigidez del sistema suelo de relleno-pilotes en los estribos y con mayor número y robustez de las pilas. Ambos puentes cumplen con los niveles de desempeño exigidos, acorde a la vida útil remanente de cada uno de ellos.

A molecular phylogeny of the family Paraonidae was reconstructed on the basis of 16S rDNA, COI and 18S rDNA sequences obtained from 66 individuals belonging to 38 nominal species and subspecies. In agreement with previous findings, Paraonidae represent a monophyletic group, closely related to Sternaspidae. The topology obtained by the Bayesian and Maximum Likelihood analyses on the combined dataset was not consistent with the traditional view on Paraonidae evolution, nor with a recent cladistic analysis. According to our results, Paraonidae are divided in five clades. The earliest branching clade (Clade I) included five species of the genera Cirrophorus and Paradoneis, whereas the remaining species of these genera were included in the Clade II. The genus Levinsenia is monophyletic and represents the sister group of a highly supported clade including some morphologically homogeneous species previously assigned to the genus Aricidea, which is here described as Blakeia n. gen. The remaining species of Aricidea clustered in a clade that included Paraonis as well. Paraonis can be interpreted as a pedomorphic form of Aricidea, accounting for the strong morphological divergence between the two genera. For priority rules, Aricidea should be considered a junior synonym of Paraonis. None of the subgenera traditionally recognised within Aricidea were monophyletic; in addition, the shallow molecular divergence identified among species, in particular for 18S rDNA sequences, suggests that the adaptive radiation of the genus Aricidea is relatively recent. Phylogenetic relationships suggested that the median antenna is an ancestral character, which has been independently lost several times, though a long, cirriform antenna only occurs in the genus Aricidea. The ancestral number of pre-branchial chaetigers is most likely three, even though arrangements with a higher number of chaetigers have been probably achieved at least twice independently. Notopodial modified chaetae appear to be a plesiomorphy of Paraonidae and they have been lost subsequently, whereas neuropodial modified chaetae have been acquired at least thrice independently through the evolutionary history of the family. Paraonidae show a strikingly high occurrence of cryptic and pseudocryptic species; results of the present work suggest that environmental features play a crucial role in the diversification of this family, whereas the influence of geographical distance appears less pronounced. Lastly, despite their importance in deep-water environments, Paraonidae probably are a primarily shallow-water family, that radiated in the deep sea secondarily.

Knowledge of the diversity of deep-sea polychaetes in the Mediterranean Sea is still scarce and fragmentary, due to the absence of comprehensive taxonomic revisions of several families, with the majority of recent works relying on higher level taxonomy. In the present work samples were collected with a box-corer along the Sardinian Slope, a bathyal escarpment area located in the western Mediterranean Sea, at seven depth levels separated from each other by a 300 m interval, ranging from 600 to 2400 m. Samples were sifted with a 0.3 mm mesh, and polychaetes were identified at the lowest taxonomic level and characterised from the biogeographic and tropho-functional point of view. Ninety-seven taxa were recorded, 60 of which identified at the species level; eight taxa are likely to be undescribed species, possibly endemic to the Mediterranean Sea, whereas another seven are reported for the first time for the Mediterranean Sea. The majority of taxa shows an Atlantic-Mediterranean or strictly Mediterranean distribution, thus confirming the similarity between Atlantic and Mediterranean deep-sea assemblages, but also the unicity of the latter. Conversely, cosmopolitan taxa, usually considered common in deep-sea assemblages, represented a minor component. The trophic guild composition of the assemblage varied along the slope, with shallower assemblages (600–900 m) including a relatively high percentage of predators and microphagous omnivores, while deeper assemblages (1500–1800 m) showed a > 90% percentage of deposit- and filter-feeders, with the 1200 m assemblage characterised by intermediate features. This outcome suggests that in the presently investigated area, the environmental conditions of shallower samples allow the stable occurrence of at least two trophic levels, whereas deeper assemblages depend mainly on organic matter coming from shallower levels and from the water column. The examined polychaete assemblages are characterised by low density and a complete absence of dominance, with the evenness index J’ ranging from 0.72 to 1; the wide ranges of the H’ index (0.50–2.67) and of Hill's N1 (1.65–14.65) suggest a high variability at low spatial scale. If compared to Atlantic deep-sea polychaete assemblages the assemblage studied shows an almost ten-fold lower organism abundance, but species diversity is only two- to four-fold lower, suggesting that biodiversity in Mediterranean deep-sea environments is possibly underestimated. Diversity of polychaete assemblages in the deep Mediterranean Sea is likely to be underestimated due to their low density, and adequate sampling strategies should be planned to have a better insight into the functioning and diversity of these communities.

Background: Musculoskeletal disorders (MSKDs) are the most common class of complaints among patients presenting for care in the Emergency Department (ED). There is a non-urgent patient population with musculoskeletal complaints attending ED services that creates a burgeoning waiting list and contributes to overcrowding in Emergency Departments (EDs), which is a major concern worldwide. The recent (Coronavirus disease-19) COVID-19 pandemic is an unprecedented challenge that is revealing the structural and situational strengths and weaknesses of healthcare systems. Methods: This study retrospectively and prospectively assessed patients presenting to the Emergency Department before and after the COVID-19 outbreak (from 21 February 2019 to 3 May 2019 and from 21 February 2020 to 3 May 2020) with non-traumatic or low-severity musculoskeletal conditions to test the hypothesis that these patients should have access to care outside the ED and that the COVID-19 outbreak has changed patients’ care and health perception. Results: A total of 613 patients were identified, and 542 of them (87.56%) participated in a personalized survey. From this number, 81.73% of the total accesses took place in 2019, and only 18.27% of the accesses took place during the first outbreak and lockdown. More than 90% of patients admitted to the ED accessed care during the day shift in both periods. A total of 87.30% of patients presenting to the ED with a MSKD followed their general practitioner’s (GP) advice/referral in 2019, and 73.87% did so in 2020. The differences in the means of transport to the ED was statistically significant (p-value 0.002). Conclusions: The outbreak and lockdown period confirmed that there is an inappropriate use of the ED related to patients with MSKD. However, the ED appears to be the only available solution for these patients. New services and pathways are therefore needed to enhance MSKD management and reduce ED crowding. Additional observational studies shall be developed to confirm and compare our findings with those of various EDs. The main limit of the inferential part of the study is probably due to the small sample of patients in 2020.

A pilot study, using the dataset from the research network ‘FLT Med Net’, which regularly monitors transborder regions in the Mediterranean Sea using ferries as platform for systematic surveys, was undertaken to assess common bottlenose dolphin range and population trends within the Natura 2000 EU marine site “Tutela del Tursiops truncatus”. The site was recently designated by the Tuscany Region (Italy) within the requirement of the EU Habitats Directive. In order to evaluate the conservation status of bottlenose dolphin according to the surveillance scheme of the Directive, two six-year periods (2007-2012; 2013-2018) were compared to assess trends in distribution-occurrence (range); Sightings Per Unit of Effort and Density (population). In total, 18146 NM were surveyed along two fixed transects, recording 90 sightings of Tursiops truncatus and a total of 268 specimens. Between the two periods, slight but not statistically significant differences were assessed, with decreasing trend in range and population of the species; no variation was detected in mean group sizes. Travelling was the most common behaviour, and juveniles were present in 20% of the sightings, concentrated during spring and summer. The consistent FLT Med Net dataset was found to be appropriate to evaluate important parameters for the assessment of trends in the conservation status of Tursiops truncatus at the Natura2000 site scale.

Purpose This study aimed to highlight short- and medium-term outcomes of combined medial patello-femoral ligament (MPFL) reconstruction and anterior tibial tuberosity (ATT) transposition surgery in patients with recurrent patellar instability and different degrees of trochlear dysplasia. Methods Between January 2014 and May 2019, 25 patients with patellar instability underwent a surgical procedure combining the lowering/transposition of the ATT and the MPFL reconstruction. Each patient were preoperative assessed by Kujala score, International Knee Documentation Committee (IKDC), Tegner activity level scale. The assessment of instability predisposing factors was carried out with patellar height, tibial tuberosity-trochlear groove (TT-TG) distance, trochlear dysplasia, sulcus angle, patellar tilt and MPFL injuries. Functional outcomes were evaluated with Kujala, IKDC and Tegner scores at 3, 6 and 12 months after surgery. Results The average age of the patients was 20 years (range 13–43 years). Pre- operative Caton–Deschamps index was pathological in 10 (40%). Sulcus angle was elevated in 13 patients (52%) and TT-TG distance was irregular in 17 patients (68%). Trochlear dysplasia was present in 13 patients (9 type A, 3 type B, 1 type C according to Dejour’s Classification). No re-dislocation occurred during the follow-up. There was a significant increase in the Kujala, IKDC and Lysholm scores after 3, 6 and 12 months, and the results were compared for the different follow-up times and patient’s trochlear dysplasia degree. Conclusion This prospective observational longitudinal study identified good clinical outcomes in patients who underwent MPFL reconstruction and ATT transposition for patellar instability. Finally, the different risk factors for patellar instability examined, particularly the presence of trochlear dysplasia, did not significantly influence the final functional results, which range from good to excellent without re-dislocation episodes.