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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.

Fractures of the proximal humerus are relatively common injuries in adults accounting for 5% of fractures. Nowadays the most common technique used is open reduction internal fixation with LCP plates. The risks associated with open reduction internal fixation had led us to develop and apply a "hybrid" system, which is based on external fixation and closed surgery principles. This system is capable of stabilize up to 4 fragment fractures on different planes while conferring a strong enough fixation to maintain fracture reduction while allowing the patient to perform passive and active movement since the first day following the surgery. Our study group started on November 2009 until December 2015 and consisted of 118 patients with a mean age of 68.84±10.52 years for females (76) and 65.62±12.56 for males (44). Patients were classified according to the AO/OTA (Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopedic Trauma association) Classification. In a few patients we performed mini lateral accesses to allow reduction of the humeral head and greater tuberosity. Shoulder mobilization was initiated from the first day following surgery. The external fixator was removed at 5 weeks with successive check-ups at 3, 6, and 12 months. The majority of type B and type C1 fractures had almost a complete functional recovery. Patients also, especially in the elderly, reported a good quality of life without pain during any range of motion. Our group of patients, after removal of the apparatus at 5 weeks following the surgery, had a mean articular range of motion with active abduction of 90 degrees and about 100 degrees with passive abduction. Postoperative CS scores at 12 months follow-up was 75,47±8.02. In addition there was also significant (P

To determine the validity of extracorporeal shock wave therapy (ESWT) in the treatment of bone marrow edema (BME) of the medial condyle of the knee.Retrospective.Orthopedic Surgery outpatient clinic.Symptomatic patients (N=56) affected by BME of the medial condyle of the knee. Patients were equally divided into an ESWT-treated group and a control group, which was managed conservatively.ESWT delivery to the medial condyle of the affected knee.Clinical and functional assessment of the knee was performed with the use of the clinical and functional scores of the Knee Society Score (KSS). Pain was measured with the visual analog scale (VAS). BME area was measured with magnetic resonance imaging (MRI) before treatment and at 4 months' follow-up.Clinical evaluation of patients at final follow-up of 4 months posttreatment showed a significant improvement (P.0001) of symptoms and knee functionality, both for range of motion and strength in both groups. VAS values were significantly improved (P.0001) in both groups, with 3 patients in the ESWT group being pain-free (VAS=0) at 4 months' follow-up. At 4 months, MRI assessments on both sagittal and coronal views showed a significant reduction in BME in the ESWT group compared with the control group.Our findings show that ESWT is a valid nonpharmacologic and noninvasive therapy for spontaneous BME of the medial condyle that improves the affected vascular and metabolic state present in this pathologic disorder through its metabolic mechanisms of action.

Background: Conflicting studies link several conditions and risk factors to Dupuytren’s disease (DD). A questionnaire-based case-control study was set to investigate associated conditions and clinical features of DD in a sample of Italian patients. The main purpose was the identification of predicting factors for: DD development; involvement of multiple rays; involvement of both hands; development of radial DD; development of recurrences and extensions. Methods: A self-administered questionnaire was used to investigate medical and drug histories, working and life habits, DD clinical features, familial history, recurrences and extensions. Binary logistic regression, Mann Whitney U-test and Fisher’s exact test were used for the statistical analysis. Results: A role in DD development was found for male sex, cigarette smoking, diabetes and heavy manual work. The development of aggressive DD has been linked to age, male sex, high alcohol intake, dyslipidemias and positive familial history. Conclusion: Further studies might explain the dual relationship between ischemic heart disease and DD. According to our results, the questionnaire used for this study revealed to be an easy-handling instrument to analyze the conditions associated to DD. Nevertheless, its use in further and larger studies is needed to confirm our results as well as the role of the questionnaire itself as investigation tool for clinical studies.

BACKGROUND The disorders of the long head of the biceps (LHB) are a common cause of shoulder pain. Among all surgical treatments used to resolve LHB tendon disorders, tenodesis is one of the most frequent.The literature describes many arthroscopic and open surgical techniques, but there is still no general consensus on the standard of care.The purpose of this paper is to describe the clinical and functional outcomes of our totally intra-articular "Needle-Anchor" arthroscopic tenodesis technique applied to isolated LHB tendinopathy. MATERIALS AND METHODS We present a case study of 60 patients with an isolated LHB tendon disorder, treated with our totally intra-articular Needle-Anchor arthroscopic technique between 2011 and 2013.All patients were assessed preoperatively with University of California, Los Angeles (UCLA) and Constant-Murley (CS) shoulder scores and the visual analogue scale (VAS) for subjective pain assessment. Imaging studies were performed through magnetic resonance imaging. Patients were reevaluated with a follow-up at 3 and 12 months with VAS, UCLA, and CS scores.Statistical analysis was performed with the Mann-Whitney score where values of P

Subclavius posticus muscle is a supernumerary anatomical variation of the subclavius muscle. The aim of this study was to show the possible contribution of the posticus muscle in the development of unilateral thoracic outlet syndrome (TOS) in overhead athletes, presenting hypertrophy of the dominant arm due to their sport activity. Reported here are 2 young overhead athletes complaining pain, paresthesia, weakness in the dominant upper limb, although presenting none of the main shoulder and neurological disorders. After developing subclavian vein thrombosis, TOS was suspected and finally diagnosed by dynamic magnetic resonance angiography, which also showed bilateral subclavius posticus muscle in both patients. Despite bilateral subclavius posticus, TOS was only evident in the dominant limb in which the association of hypertrophy of lateral cervical muscles, resulting from the overhead sport activity, to the subclavius posticus likely led to a significant reduction of the upper thoracic outlet space.

Conflicting studies link several conditions and risk factors to Dupuytren's disease (DD). A questionnaire-based case-control study was set to investigate associated conditions and clinical features of DD in a sample of Italian patients. The main purpose was the identification of predicting factors for: DD development; involvement of multiple rays; involvement of both hands; development of radial DD; development of recurrences and extensions.A self-administered questionnaire was used to investigate medical and drug histories, working and life habits, DD clinical features, familial history, recurrences and extensions. Binary logistic regression, Mann Whitney U-test and Fisher's exact test were used for the statistical analysis.A role in DD development was found for male sex, cigarette smoking, diabetes and heavy manual work. The development of aggressive DD has been linked to age, male sex, high alcohol intake, dyslipidemias and positive familial history.Further studies might explain the dual relationship between ischemic heart disease and DD. According to our results, the questionnaire used for this study revealed to be an easy-handling instrument to analyze the conditions associated to DD. Nevertheless, its use in further and larger studies is needed to confirm our results as well as the role of the questionnaire itself as investigation tool for clinical studies.

To show the efficiency and safety of a surgical treatment in both acute and chronic acromio-clavicular junction (ACJ) dislocations.Retrospective.Department of Orthopedics and Traumatology at IRCCS San Raffaele Hospital.This study was performed on 37 subjects classified as Rockwood grade III-V or Tossy III ACJ dislocation.The surgical treatment was carried out by placing a vascular graft (GorePropaten(®)) between the tip of the coracoid process and the mid-lateral side of the clavicle with two temporary percutaneous K-wires positioned in a parallel manner in the AC ligament through the acromion and clavicle for 30 days to improve stability.Outcomes were assessed using the Constant Shoulder (CS) score, DASH score, subjective satisfaction, and stability of AC joint at 24 months. UCLA scores taken preoperatively and at 15-month follow-up were used to perform statistical analysis significance using a control group treated conservatively. Postoperative X-rays were examined to assess joint stability after 24 months.Preoperative CS score was 51 ± 12 in the acute group and 55 ± 15 in the chronic group. Follow-up mean CS score was 88 ± 11 in the acute group and 82 ± 20 in the chronic group at 24 months. Preoperative DASH score was 19 ± 3 in the acute group and 14 ± 5 in the chronic group. Mean DASH score was 3.60 ± 7 in the acute group and 6.42 ± 6 in the chronic group. Preoperative UCLA scores were 14.6 ± 2 and 15 ± 7 in the acute group and chronic group, respectively. At 15-month follow-up, UCLA scores of 28.1 ± 1.9 and 27.7 ± 1 in the acute and chronic group, respectively, showed a significant improvement (p0.05) compared with UCLA scores taken preoperatively and at 15 months in the control group treated conservatively of 15.8 ± 0.9 and 16.2 ± 0.9, respectively. Results were good to excellent in 10 patients from the acute group and 23 patients from the chronic group who presented clinical stability of the AC joint without pain. Postoperative radiography showed anatomical repositioning of the ACJ and joint stability in 35 cases, but only two patients showed a partial re-dislocation at the 24-month X-ray follow-up. No infections, either deep or superficial, or nerve palsies were reported.Given the results obtained during the study and the response of the patients in both acute and chronic groups, the authors found that the employment of a vascular graft combined with temporary percutaneous K-wires is able to improve the patient's clinical outcome following an acromio-clavicular joint dislocation.

Background The aim of our study was to evaluate the effectiveness of both clinical and functional benefits after the surgical repair of the rotator cuff in irreparable lesions using a synthetic patch with augmentation of the long head of the biceps (LHB) tendon. Methods This is a retrospective study analysis of a randomized series of 60 patients (45 women and 15 men; average age 66 y) who underwent open repair of irreparable rotator cuff tear with synthetic patch using LHB tendon augmentation between 1999 and 2008.The inclusion criteria were: patients painful symptomatology, presenting a deficit in elevation, who are not responsive to physiotherapy, irreparable tear size, minimum follow-up of 36 months after surgery, and active and motivated patients. We used a control group of 60 patients treated without employment of the synthetic patch and LHB tendon augmentation.Patients were evaluated preoperatively and after 36 months with a Visual Analog Scale (VAS) and the University of California, Los Angeles (UCLA) shoulder rating scale and by measuring elevation of the scapular plane and strength with a dynamometer. All the patients were assessed preoperatively also with plain radiographs (anteroposterior and axillary views), ultrasound, and NMRI of the shoulder. The VAS and UCLA scores were also obtained 3 months postoperatively. Tendon integrity was assessed after 1 year by NMRI. Statistical analysis was conducted by 1-way analysis of variance between groups of treatment, with Dunnett post hoc correction for multiple comparisons. P-values ≤ 0.05 were considered as statistically significant. This surgical technique consisted in a short deltoid splitting, irreparable lesion evaluation, and, after tenodesis, the proximal segment of the LHB tendon was sutured to the remaining cuff tendons to fill the gap of the corresponding lesion. To shield the repaired rotator cuff we inserted a synthetic patch. Results Satisfactory results were achieved in 52 of the patients treated with this procedure; after 3 months the mean VAS was 6.85 ± 1.11 versus 4.9 ± 0.9, whereas the mean UCLA was 11.28 ± 1.43 versus 20.85 ± 1.27, respectively, for control and prolene group. After 36 months the mean VAS was 3.7 ± 1.01 versus 3.23 ± 1.07, whereas the mean UCLA was 14.73 ± 1.96 versus 24.6 ± 3.3, respectively, for control and prolene group. In addition, after 36 months elevation on the scapular plane was 140.75 ± 10.48 degrees versus 174.75 ± 8.1 degrees and abduction strength was 8.57 kg ± 0.63 versus 13.61 kg ± 0.84, respectively, for control and prolene group (P-value = 0.005). Re-tear rate after 12 months was 40% (24/60) in the control group and 15% (9/60) in the prolene group. No adverse side effects (infection, rejection, allergy) were reported during the study period. Conclusions The results of our study suggest that employing this surgical technique in patients (appropriately selected) with an irreparable rotator cuff tear can lead to pain relief and improved clinical outcome.

The imbalance between osteogenesis and adipogenesis, which naturally accompanies bone marrow senescence, may contribute to the development of bone-associated diseases, like osteoporosis. In the present study, using primary human mesenchymal stromal cells (hMSCs) isolated from trabecular bone, we assessed the possible effect of GH on hMSC differentiation potential into adipocytes. GH (5 ng/ml) significantly inhibited the lipid accumulation in hMSCs cultured for 14 days in lipogenic medium. GH decreased the expression of the adipogenic genes, CCAAT/enhancer-binding protein alpha (C/EBPα) and adiponectin (ADN) as well as the expression of two lipogenesis-related enzymes, lipoprotein lipase (LPL) and acethylCoA carboxylase (ACACA). In parallel, GH induced an increase in the gene expression and protein levels of osterix (OSX) and osteoprotegerin (OPG). These effects were ascribed to enhanced Wnt signaling as GH significantly reduced Wnt inhibitors, Dickkopf 1 (DKK1) and the secreted frizzled protein 2 (SFRP2), and increased the expression of an activator of Wnt, Wnt3. Accordingly, the expression of β-catenin and its nuclear levels were raised. Wnt involvement in GH anti-adipogenic effect was further confirmed by the silencing of β-catenin. In silenced hMSC, both the inhibitory effect of GH on the expression of the adipogenic genes, ADN and C/EBPα and the lipogenesis enzymes LPL and ACACA, were prevented together with the stimulatory effect of GH on the osteogenic genes OSX and OPG. The present study supports the hypothesis that when GH secretion declines as in aging, the fat in the bone-marrow cavities increases and the osteogenic capacity of the MSC pool is reduced due to a decrease in Wnt signaling.

Hematopoietic stem and progenitor cells (HSPC) reside in the bone marrow (BM) niche and serve as a reservoir for mature blood cells throughout life. Aging in the BM is characterized by low‐grade chronic inflammation that could contribute to the reduced functionality of aged HSPC. Mesenchymal stromal cells (MSC) in the BM support HSPC self‐renewal. However, changes in MSC function with age and the crosstalk between MSC and HSPC remain understudied. Here, we conducted an extensive characterization of senescence features in BM‐derived MSC from young and aged healthy donors. Aged MSC displayed an enlarged senescent‐like morphology, a delayed clonogenic potential and reduced proliferation ability when compared to younger counterparts. Of note, the observed proliferation delay was associated with increased levels of SA‐β‐galactosidase (SA‐β‐Gal) and lipofuscin in aged MSC at early passages and a modest but consistent accumulation of physical DNA damage and DNA damage response (DDR) activation. Consistent with the establishment of a senescence‐like state in aged MSC, we detected an increase in pro‐inflammatory senescence‐associated secretory phenotype (SASP) factors, both at the transcript and protein levels. Conversely, the immunomodulatory properties of aged MSC were significantly reduced. Importantly, exposure of young HSPC to factors secreted by aged MSC induced pro‐inflammatory genes in HSPC and impaired HSPC clonogenic potential in a SASP‐dependent manner. Altogether, our results reveal that BM‐derived MSC from aged healthy donors display features of senescence and that, during aging, MSC‐associated secretomes contribute to activate an inflammatory transcriptional program in HSPC that may ultimately impair their functionality.

Background:Rotator cuff repair typically results in a satisfactory, although variable, clinical outcome. However, anatomic failure of the repaired tendon often occurs.Hypothesis:Patch augmentation can improve the results of open rotator cuff repair by supporting the healing process, protecting the suture, and reducing friction in the subacromial space.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 152 patients with a posterosuperior massive rotator cuff tear were treated by open repair only (control group; n = 51; mean age, 67.06 ± 4.42 years), open repair together with collagen patch augmentation (collagen group; n = 49; mean age, 66.53 ± 5.17 years), or open repair together with polypropylene patch augmentation (polypropylene group; n = 52; mean age, 66.17 ± 5.44 years) and were retrospectively studied. Patients were evaluated preoperatively and after 36 months with a visual analog scale (VAS) and the University of California, Los Angeles (UCLA) shoulder rating scale and by measuring elevation of the scapular plane and strength with a dynamometer. The VAS and UCLA scores were also obtained 2 months postoperatively. Tendon integrity was assessed after 1 year by ultrasound. Patients were homogeneous as per the preoperative assessment.Results:After 2 months, results (mean ± standard deviation) for the control, collagen, and polypropylene groups, respectively, were as follows: VAS scores were 6.96 ± 1.11, 6.46 ± 1.02, and 4.92 ± 0.90, while UCLA scores were 11.29 ± 1.46, 11.40 ± 1.51, and 19.15 ± 1.99. After 36 months, the mean scores for the respective groups were 3.66 ± 1.05, 4.06 ± 1.02, and 3.28 ± 1.10 for the VAS and 14.88 ± 1.98, 14.69 ± 1.99, and 24.61 ± 3.22 for the UCLA scale. In addition, after 36 months, elevation on the scapular plane was 140.68° ± 9.84°, 140.61° ± 12.48°, and 174.71° ± 8.18°, and abduction strength was 8.73 ± 0.54 kg, 9.03 ± 0.60 kg, and 13.79 ± 0.64 kg for the control, collagen, and polypropylene groups, respectively. The retear rate after 12 months was 41% (21/51) for the control group, 51% (25/49) for the collagen group, and 17% (9/52) for the polypropylene group. In particular, the reduced 12-month retear rate and the increased UCLA scores, abduction strength, and elevation at 3-year follow-up were statistically significant for patients treated with a polypropylene patch compared with those treated with repair only or with a collagen patch.Conclusion:Polypropylene patch augmentation of rotator cuff repair was demonstrated to significantly improve the 36-month outcome in terms of function, strength, and retear rate.

Wnt signaling, a major regulator of bone formation and homeostasis, might be involved in the bone loss of osteoporotic patients and the consequent impaired response to fracture. Therefore we analyzed Wnt-related, osteogenic, and adipogenic genes in bone tissue of elderly postmenopausal women undergoing hip replacement for either femoral fracture or osteoarthritis. Bone specimens derived from the intertrochanteric region of the femurs of 25 women with fracture (F) and 29 with osteoarthritis without fracture (OA) were analyzed. Specific miRNAs were analyzed in bone and in matched blood samples. RUNX2, BGP, and OPG showed lower expression in F than in OA samples, while OSX, OPN, BSP, and RANKL were not different. Inhibitory genes of Wnt pathway were lower in F versus OA.β-Catenin protein levels were higher in F versus OA, whereas its cotranscriptional regulator (Lef1) was lower in F group. miR-204, which targets RUNX2, and miR-130a, which inhibits PPARγ, were lower and higher, respectively, in F versus OA serum samples. The present study showed an inefficient Wnt signal transduction in F group despite higherβ-catenin protein levels, consistent with the expected overall postfracture systemic activation towards osteogenesis. This transcriptional inefficiency could contribute to the osteoporotic bone fragility.

The aim of this study was to investigate the in vitro effect of different concentrations of blood on the morphological and biochemical properties of engineered cartilage. Previous studies have demonstrated a negative effect of blood on native cartilage; however, the effect of the contact of blood on engineered cartilage is unclear. Articular chondrocytes were isolated from swine joints, expanded in monolayer culture, and seeded onto collagen membranes. The seeded membranes were cultured for 3 days in the presence of different concentrations of peripheral blood. Some samples were retrieved at the end of the blood contact, others after 21 additional days of standard culture conditions, in order to investigate the “long-term effect” of the blood contact. All seeded samples showed an increase in the weight and an evident cartilage-like matrix production. A concentration-dependent reduction in the mitochondrial activity due to blood contact was shown at the earlier culture time, followed by a partial recover at the longer culture time. A blood contact of 3 days affected the chondrocytes’ activity and determined a delay in the maturation of the engineered cartilage. These findings have clinical relevance, as autologous chondrocytes seeded onto biological scaffolds has become an established surgical method for articular cartilage repair. Therefore, further investigation into material sciences should be encouraged for the development of scaffold protecting the reparative cells from the blood insult.

Menisci represent fundamental structures for the maintenance of knee homeostasis, playing a key role in knee biomechanics. However, their intrinsic regenerative potential is poor. As a consequence, when a lesion occurs and the meniscus is partially removed by surgery, knee mechanics is subject to dramatic changes. These have been demonstrated to lead often to the development of early osteoarthritis. Therefore, menisci should be repaired whenever possible. In the last decades, tissue engineering approaches have been advocated to improve the reparative processes of joint tissues. In this study, the bonding capacity of an articular chondrocytes-fibrin glue hydrogel was tested as a biologic glue to improve the bonding between two swine meniscal slices in a nude mouse model. The composites were wrapped with acellular fibrin glue and implanted in subcutaneous pouches of nude mice for 4 weeks. Upon retrieval, a firm gross bonding was observed in the experimental samples while none of the control samples, prepared with acellular fibrin glue at the interface, presented any sign of bonding. This was consistent with the histological and scanning electron microscope findings. In particular, a fibrocartilaginous tissue was found at the interface between the meniscal slices, partially penetrating the native meniscus tissue. In order to overcome the lack of regenerative properties of the meniscus, the rationale of using cellular fibrin glue is that fibrin provides immediate stability while carrying cells in the site of lesion. Moreover, fibrin gel is recognized as an optimal scaffold for cell embedding and for promoting fibrocartilaginous differentiation of the cells which synthesize matrix having healing property. These results demonstrated the potential of this model for improving the meniscal bonding. However, further orthotopic studies in a large animal model are needed to evaluate its potential for clinical application.

The aim of this study is to evaluate the functional performance after total knee replacement (TKR). Two groups of patients, one with mobile (n=9) and one with fixed bearing (n=8) total knee prosthesis, were compared by means of motion analysis. A group of healthy subjects (n=8), matched by age, were used as controls. Kinematics, kinetics and electromyography data were collected during physiological daily activities such as walking and squatting. During walking, both groups of patients showed a speed of progression, a maximum knee extension moment (stance phase) and a maximum knee flexion (swing phase) significantly lower than the control group. Moreover, during the swing phase a co-contraction of the antagonistic muscles of the inferior limb was present. During squatting, both groups of patients showed a peak of knee flexion significantly lower than the control group. Motion pattern after TKR is unphysiological but the abnormalities seem to be independent from the differences in the implant designs.

Meniscus repair is a current clinical challenge. Menisci play a fundamental role in knee biomechanics, but they lack intrinsic regenerative properties. Conse quently, when a tear occurs and the meniscus is removed surgically, even partially, crucial changes in knee homeostasis take place, often leading to the development of early osteoarthritis. In recent decades tissue engineering approaches have been advocated to improve the reparative processes of joint tissues. In this study, the bonding capacity of isolated chondrocytes was analysed in a nude mouse meniscus repair model: a swine chondrocyte-fibrin glue suspension was utilised as a biologic glue to improve bonding between two meniscal slices obtained from swine menisci. The composites were wrapped with acellular fibrin glue and implanted in subcutaneous pouches of nude mice for four weeks. Upon retrieval, a firm gross bonding was observed. This was consistent with the histological findings. In particular, a fibrocartilaginous tissue was found at the interface between the meniscal slices, having some penetration buds arising from the neo-tissue. These results demonstrated the potential of this model for improving meniscal bonding. However, further orthotopic studies in a large animal model are needed to evaluate its feasibility in clinical practice.

Fracture of the humerus represents a common problem among the young and elderly populations. Although humerus fractures usually heal uneventfully, nonunions can sometimes occur. We present a case of humeral nonunion managed with shock wave therapy in the outpatient setting. A 62-year-old woman with a closed comminuted fracture of the proximal third of the humerus came to our attention 6 months after the trauma with a hypertrophic nonunion. Radiographs showed a hypertrophic callus with a fracture gap of 4 mm. We performed ten shock wave treatments in the outpatient department, with an interval of 60 days between each single treatment. Each session consisted of 2000 impulses at 0.86 mJ/mm2 applied in two planes. No anesthesia was given during the treatment. The patient received a sling to support the treated arm during the first days following each treatment. Follow-up assessment by radiographic and physical examination, performed after 4 weeks and at 3, 6, 12, 18 and 24 months, showed complete bony union and cortical bridging, achieved at the end of the treatment. We believe that this method is a safe and effective alternative to surgery for the treatment of chronic hypertrophic nonunions. Moreover, in case such treatment is unsuccessful, subsequent surgery is not precluded.

One of the main topics of regenerative medicine and tissue engineering is to address the problem of lesions involving articular cartilage. In fact, these lesions do not heal spontaneously and often lead to osteoarthritis, which causes chronic pain and worsens quality of life. Moreover, the only available treatment for osteoarthritis is symptomatic therapy and prosthetic replacement, with far from satisfactory results. A more conservative approach that restores the articular surface and function with a biologic tissue is desirable. Several strategies for regenerating articular cartilage have been proposed and applied in clinical practice but a gold standard has not yet been identified. Biphasic composites are the latest products of tissue engineering applied to articular cartilage and they seem to permit a more efficient integration of the engineered neo-tissue with the host. We present an in vitro tissue engineered model for osteochondral repair based on a composite of chondrocytes-fibrin glue gel and a calciumphosphate scaffold. This composite showed a gross integration of the two components and a cartilage-like quality of the newly formed matrix. Further studies are planned to quantify the adherence between the scaffold and the cellular fibrin glue.

SummaryBackground and objective: This prospective, randomized study was conducted to compare unilateral spinal block using small doses of hyperbaric bupivacaine and single-agent anaesthesia with sevoflurane in elderly patients undergoing hip surgery.Methods: Thirty patients (>65 yr) undergoing hip fracture repair were randomly allocated to receive unilateral spinal anaesthesia with hyperbaric bupivacaine 7.5 mg 0.5% (Group Spinal, n = 15) or volatile induction and maintenance anaesthesia with sevoflurane (Group SEVO, n = 15). General anaesthesia was induced by increasing the inspired concentration to 5%. A laryngeal mask airway was placed without muscle relaxants, and the end-tidal concentrations of sevoflurane were adjusted to maintain cardiovascular stability. Hypotension (decrease in systolic arterial pressure >20% from baseline), hypertension or bradycardia (heart rate < 50 beats min−1) requiring treatment, and the length of stay in the postanaesthesia care unit was recorded. Cognitive functions were evaluated the previous day, and 1 and 7 days after surgery with the Mini Mental State Examination test.Results: Hypotension occurred in seven patients of Group Spinal (46%) and in 12 patients of Group SEVO (80%) (P = 0.05). Phenylephrine was required to control hypotension in three spinal patients (21%) and four SEVO patients (26%) (n.s.). SEVO patients had lower heart rates than spinal patients from 15 to 60 min after anaesthesia induction (P = 0.01). Bradycardia was observed in three SEVO patients (22%). Discharge from the postanaesthesia care unit required 15 (range 5–30) min in Group Spinal and 55 (15–80) min in Group SEVO (P = 0.0005). Eight patients in Group Spinal (53%) and nine patients in Group SEVO (60%) showed cognitive decline (Mini Mental State Examination test decreased ≥ 2 points from baseline) 24 h after surgery (n.s.). Seven days after surgery, confusion was still present in one patient of Group Spinal (6%) and in three patients of Group SEVO (20%) (n.s.).Conclusions: In elderly patients undergoing hemiarthroplasty of the hip, induction and maintenance with sevoflurane provide a rapid emergence from anaesthesia without more depression of postoperative cognitive function compared with unilateral spinal anaesthesia. This technique represents an attractive option when patient refusal, lack of adequate co-operation or concomitant anticoagulant therapy contraindicate the use of spinal anaesthesia.

UNLABELLED We compared the onset time and quality of interscalene brachial plexus block produced with levobupivacaine and ropivacaine in 50 patients undergoing open shoulder surgery randomly allocated to receive 30 mL of 0.5% levobupivacaine (n = 25) or 0.5% ropivacaine (n = 25) injected through a 20-gauge catheter placed into the interscalene sheath using a 18-gauge insulated and stimulating Tuohy introducer. The block was also prolonged after surgery using a patient-controlled interscalene analgesia with 0.125% levobupivacaine or 0.2% ropivacaine, respectively (basal infusion rate, 6 mL/h; bolus, 2 mL; lockout period, 15 min; maximum boluses per hour, three). Three patients (two with levobupivacaine [8%] and one with ropivacaine [4%]) failed to achieve surgical block within 45 min after the injection and were excluded. The onset time of surgical block was 20 min (10-40 min) with levobupivacaine and 20 min (5-45 min) with ropivacaine (P = 0.53). Rescue intraoperative analgesia (0.1 mg of fentanyl IV) was required in eight patients in each group (34%) (P = 0.99). Forty-two patients completed the 24-h postoperative infusion (22 with levobupivacaine and 20 with ropivacaine). Postoperative analgesia was similarly effective in both groups. Total consumption of local anesthetic infused during the first 24 h was 147 mL (144-196 mL) with levobupivacaine and 162 mL (144-248 mL) with ropivacaine (P = 0.019), with a ratio between boluses received and requested of 0.8 (0.4-1.0) and 0.7 (0.4-1.0), respectively (P = 0.004). The degree of motor block of the operated limb was deeper with levobupivacaine than ropivacaine when starting postoperative analgesia; however, no further differences in degree of motor function were observed between the two groups. We conclude that 30 mL of levobupivacaine 0.5% induces an interscalene brachial plexus anesthesia of similar onset and intensity as the one produced by the same volume and concentration of ropivacaine. Postoperative interscalene analgesia with 0.125% levobupivacaine results in similar pain relief and recovery of motor function with less volume of local anesthetic than with 0.2% ropivacaine. IMPLICATIONS This prospective, randomized, double-blinded study demonstrates that 30 mL of 0.5% levobupivacaine produces an interscalene brachial plexus block of similar onset and quality as the one produced by the same volume of 0.5% ropivacaine. When prolonging the block after surgery, 0.125% levobupivacaine provides adequate pain relief and recovery of motor function after open shoulder surgery, with less volume infused during the first 24 h after surgery than 0.2% ropivacaine.

Recent evidence demonstrated an interplay between estrogens and growth hormone (GH) at cellular level. To investigate the possible mechanism/s involved, we studied the effect of 17β-estradiol (E2) on GH signaling pathways in primary culture of human osteoblasts (hOBs). Exposure of hOBs to E2 (10(-8) M) 60 min before GH (5 ng/ml) significantly increased phosphorylated STAT5 (P-STAT5) levels compared with GH alone. E2 per se had no effect on P-STAT5. E2-enhanced GH signaling was effective in increasing osteopontin, bone-sialoprotein, and IGF II mRNA expression to a greater extent than GH alone. We then studied the effect of E2 on the protein levels of the negative regulator of GH signaling, suppressor of cytokine signaling-2 (SOCS2). E2 (10(-11) M-10(-7) M) reduced dose-dependently SOCS2 protein levels without modifying its mRNA expression. The silencing of SOCS2 gene prevented E2 positive effect on GH induced P-STAT5 and on GH induced bone-sialoprotein and osteopontin mRNA expression. Treatment with the inhibitor of DNA-dependent RNA synthesis, actinomycin-D, did not prevent E2 induced decrease of SOCS2, thus suggesting a non-genomic effect. E2 promoted an increase in SOCS2 ubiquitination. To determine if increased ubiquitination of SOCS2 by E2 led to degradation by proteasome, hOBs were pretreated with the proteasome inhibitor MG132 (5 μM) which blocked E2 reduction of SOCS2. These findings demonstrate for the first time that E2 can amplify GH intracellular signaling in hOBs with an essential role played by the reduction of the SOCS2 mediated feedback loop.

One of the crucial points for a successful tissue-engineering approach for cartilage repair is represented by the level of in vitro maturation of the engineered tissue before implantation. The purpose of this work was to evaluate the effect of the level of in vitro maturation of engineered cartilaginous samples on the tissue quality after in vivo implantation. Samples were obtained from isolated swine articular chondrocytes embedded in fibrin glue. The cell-fibrin composites were either cultured in vitro or directly implanted in vivo for 1, 5, and 9 weeks. Other experimental samples were precultured for either 1 or 5 weeks in vitro and then implanted in vivo for 4 additional weeks. All the samples were analyzed by histology, immunohistochemistry, biochemistry, and gene expression. The results strongly suggest that the in vivo culture in this model promoted a better tissue maturation than that obtained in the in vitro condition, and that 1 week in vitro preculture resulted in the primary structuring of the engineered composites and their subsequent maturation in vivo, without affecting the cell viability and activity, while a prolonged in vitro preculture caused a cell and matrix degeneration that could not be rescued in vivo.

Summary Osteoarthritis is linked to a reduced risk of femoral fracture despite osteoporosis. Different bone distribution in the femoral neck in osteoarthritis and fracture was revealed using a peripheral quantitative computed tomography (pQCT) comparative analysis. Our findings sustain the presence of an adaptive mechanism of bone structure providing fracture protection in osteoarthritis. Introduction Although osteoarthritis is associated with reduced femoral fracture risk, it does not protect from bone loss. We investigated whether adaptive mechanisms are present at the arthritic joint, leading to reduced fracture risk, despite the presence of low bone mass density. Methods We performed pQCT comparative analyses of human femoral neck specimens derived from 32 postmenopausal women who received hip prostheses for osteoarthritis (n=19) or femoral fracture (n=13) by applying an in-house automated software to extract bone structure descriptors, characterize trabecular and cortical bone distribution, and evaluate their mutual relationships. Results The cortical bone volume and trabecular thickness were significantly (p

"Thoracic outlet syndrome is an often misdiagnosed syndrome which consists of a neurovascular compression at the upper thoracic outlet. The clinical presentation can be variable, ranging from mild symptoms to venous thrombosis and muscle atrophy. Many aetiologies, both congenital and acquired, related either to bony or soft tissue anomalies, have been associated with this syndrome. As a consequence, the diagnosis is often challenging and sometimes it can be obtained only with surgical exploration. Additionally, no specific clinical test is considered diagnostic of thoracic outlet syndrome. However, the recent advances in imaging techniques together with a careful clinical evaluation give the surgeon the chance to recognize the constricting anatomy before surgery in many cases. No standard surgical procedure has been identified; however, in literature the largest series have been treated with transaxillary first rib resection. Here we report our experience in the surgical treatment of this syndrome with a minimum follow-up of three years. Our approach consists of performing a supraclavicular decompression without routine first rib resection. This allows for identifying and removing the constricting anatomy in most cases, with satisfactory results in 96.9% of patients and a low complication rate."

Transgenic mice over-expressing calcitonin gene-related peptide (CGRP) in osteoblasts have increased bone density due to increased bone formation, thus suggesting that CGRP plays a role in bone metabolism. In this study we determined the relationship between CGRP, the canonical Wnt signaling and apoptosis in human osteoblasts (hOBs) in consideration of the well-documented involvement of this pathway in bone cells. Primary cultures of hOBs were treated with CGRP 10−8 M. Levels of β-catenin, which is the cytoplasmic protein mediator of canonical Wnt signaling, and mRNA were determined. CGRP increases both the expression and the levels of cytoplasmic β-catenin by binding to its receptor, as this effect is blocked by the antagonist CGRP8–37. This facilitatory action on β-catenin appears to be mediated by the inhibition of the enzyme GSK-3β via protein kinase A (PKA) activation. GSK-3β is a glycogen synthase kinase that, by phosphorylating β-catenin, promotes its degradation by the proteosomal machinery. Moreover, the peptide is able to inhibit hOBs apoptosis stimulated by dexamethasone or by serum deprivation, possibly through the accumulation of β-catenin, since the inhibitor of PKA activity H89 partially prevents the antiapoptotic effect of the peptide. In conclusion CGRP, released by nerve fibers, exerts its anabolic action on bone cells by stimulating canonical Wnt signaling and by inhibiting hOBs apoptosis, thus favoring local bone regeneration. J. Cell. Physiol. 225: 701–708, 2010. © 2010 Wiley-Liss, Inc.

Research in tissue engineering has been focused on articular cartilage repair for more than a decade. Some pioneristic studies involved the use of hydrogels such as alginate and fibrin glue which still possess valuable potential for cartilage regeneration. One of the main issues in cartilage tissue engineering is represented by the ideal maturation of the construct, before in vivo implantation, in order to optimize matrix quality and integration. The present study was focused on the effect of in vitro culture on a fibrin glue hydrogel embedding swine chondrocytes. We performed an evaluation of the immunohistochemical and biochemical composition and of the biomechanical properties of the construct after 1 and 5 weeks of culture. We noticed that chondrocytes survived in the fibrin glue gel and enhanced their synthetic activity. In fact, DNA content remained stable, while all indices of cartilage matrix production increased (GAGs content, immunohistochemistry for collagen II and safranin-o staining). On the other hand, the biomechanical properties remained steady, indicating a gradual substitution of the hydrogel scaffold by cartilaginous matrix. This demonstrates that an optimal preculture could provide the surgeon with a better engineered cartilage for implantation. However, whether this more mature tissue will result in a more efficient regeneration of the articular surface still has to be evaluated in future investigations.

Study design Prospective, randomized, single blind. Objective To compare the effects of sevoflurane and propofol on lumbar-paraspinal-muscles regional blood flow, as well as bleeding when controlled hypotension is used. Summary of background data Controlled hypotension is the technique of choice to reduce blood loss during spine surgery, but changes in blood flow occurring to lumbar paraspinal muscles during controlled hypotension with propofol and sevoflurane, as well as the entity of bleeding, are unknown. Methods Blood flow was assessed by means of a laser Doppler flowmeter during the prehypotensive and hypotensive (defined as a 15% reduction of baseline mean arterial pressure) period in 28 patients (aged 28-73 years, American Society of Anesthesiologists (ASA) I-II) undergoing lumbar spine surgery. Patients were randomized to receive either sevoflurane or propofol as main anesthetic agent to achieve hypotension. At the end of the surgery, blood loss was calculated and intraoperative bleeding (Visual Analogue Scale ranging from 0 to 100) was evaluated by the surgeon. RESULTS.: Peripheral Blood flow was significantly greater in the propofol group both before and during the hypotensive period (median values of 32.7 FU vs. 7.7 and 38.5 FU vs. 10.5, respectively). Despite this fact, blood loss and intraoperative bleeding were significantly reduced when propofol had been used (P Conclusion Despite the greater blood flow when it is used, propofol causes less bleeding than sevoflurane during spine surgery and could be more indicated to produce hypotension during anesthesia. Moreover, it is possible to explain our findings hypothesizing a selective vasodilation of propofol (postcapillary, venous vasodilation), different from that of sevoflurane (precapillary, arteriolar vasodilation).

Mammary-type myofibroblastoma is a very rare, benign, spindle cell lesion, arising mainly in the inguinal region. This clinical entity strictly duplicates the features of its breast counterpart. To our knowledge, this is the first report of this particular lesion occurring in the popliteal fossa. We discuss the clinical, radiological and histopathological features of this case, emphasizing the role of incisional biopsy in such an unusual neoplasia.

Articular cartilage lesions have a poor intrinsic healing potential. The repair tissue is often fibrous, having insufficient biomechanical properties, which could frequently lead to the development of early osteoarthritis. In the last decade, tissue engineering approaches addressed this topic in order to restore joint function with a differentiated and functional tissue. Many biomaterials and techniques have been proposed and some of them applied in clinical practice, even though several concerns have been raised on the quality of the engineered tissue and on its integration in the host joint. In this study, we focused on engineering in vitro a biphasic composite made of cellular fibrin glue and a calcium-phosphate scaffold. Biphasic composites are the latest products of tissue engineering applied to articular cartilage and they seem to allow a more efficient integration of the engineered tissue with the host. However, a firm in vitro bonding between the two components of the composite is a necessary condition to validate this model. Our study demonstrated a gross and microscopic integration of the two components and a cartilage-like quality of the newly formed matrix. Moreover, we noticed an improvement of this integration and GAGs production during the in vitro culture.

The use of autologous chondrocytes seeded onto a biological scaffold represents a current valid tool for cartilage repair. However, the effect of the contact of blood to the engineered construct is unknown. The aim of this work was to investigate in vitro the effect of blood on the morphological, biochemical and biomechanical properties of engineered cartilage. Articular chondrocytes were enzymatically isolated from swine joints, expanded in monolayer culture and seeded onto collagen membranes for 2 weeks. Then, the seeded membranes were placed for 3 days in contact with peripheral blood, which was obtained from animals of the same species and diluted with a standard medium. As controls, some samples were left in the standard medium. After the 3 days' contact, some samples were retrieved for analysis; others were returned to standard culture conditions for 21 additional days, in order to investigate the "long-term effect" of the blood contact. Upon retrieval, all seeded samples showed increasing sizes and weights over time. However, the samples exposed to blood presented lower values with respect to the controls. Biochemical evaluation demonstrated a reduction in the mitochondrial activity due to blood contact at the early culture time (3 days post blood contact), followed by a partial recovery at the longer culture time (21 days post blood contact). Histological evaluation demonstrated evident cartilage-like matrix production for both groups. Biomechanical data showed a reduction of the values, followed by stabilization, regardless of the presence of blood. Based on the data obtained in this study, we can conclude that blood contact affects the chondrocyte activity and determines a delay in the dimensional growth of the engineered cartilage; however, at the experimental times utilized in this study, this delay did not affect the histological pattern and the biomechanical properties of the construct.

Conclusions: 3D tissue culture of expanded human mastoidderived periosteal progenitor cells in resorbable PGLA fleeces initiates bone and cartilage formation on the cellular and molecular level. The generation of different mesenchymal tissue makes 3D tissue cultured periosteal progenitor cells to promising candidates for the treatment of OA. Further investigations with periosteal progenitor cells from donors with OA were necessary for an autologous therapy strategy.

Study Objective: To compare the onset time and duration of epidural anesthesia, and the quality of postoperative analgesia produced by levobupivacaine, racemic bupivacaine, and ropivacaine. Design: Prospective, randomized, double-blinded study. Setting: Inpatient anesthesia at a University Hospital. Patients: 45 ASA physical status I, II, and III patients, undergoing elective total hip replacement. Interventions: After standard intravenous midazolam premedication and infusion of 500 mL of Ringer's acetate solution, patients were randomly allocated to receive epidural block with 0.5% levobupivacaine (n = 15), 0.5% bupivacaine (n = 15), or 0.5% ropivacaine (n = 15). Postoperatively, after pinprick sensation recovered at T t , a patient-controlled epidural infusion was provided with 0.125% levobupivacaine, 0.125% bupivacaine, or 0.2% ropivacaine, respectively (baseline infusion rate 5 mL/hr; incremental bolus 2 mL, lockout time: 20 min). Intravenous ketoprofen was also available for rescue analgesia if required. Measurements and Main Results: The onset time of sensory block was 31 ± 16 minutes with levobupivacaine, 25 ± 19 minutes with bupivacaine, and 30 ± 24 minutes with ropivacaine (p = 0.98), after a median (range) volume of 15 (10-18) mL in Group Levobupivacaine, 14 (10-18) mL in Group Bupivacaine, and 15 (10-18) mL in Group Ropivacaine ( p = 0.85). Six patients in the ropivacaine group (40%) showed an intraoperative Bromage score p = 0.02). Recovery of pinprick sensation at T t occurred after 214 ± 61 minutes with levobupivacaine, 213 ± 53 minutes with bupivacaine, and 233 ± 34 minutes with ropivacaine ( p = 0.26). A similar degree of pain relief was observed in the three groups without differences in local anesthetic consumption and need for rescue analgesia. Motor blockade progressively resolved without differences among the three groups. Conclusions: Levobupivacaine 0.5% produces an epidural block of similar onset, quality, and duration as the one produced by the same volume of 0.5% bupivacaine, with a motor block deeper than that produced by 0.5% ropivacaine. When prolonging the block for the first 12 hours after surgery with a patient-controlled epidural infusion, 0.125% levobupivacaine provides adequate pain relief after major orthopedic surgery, with similar recovery of motor function as compared with 0.125% bupivacaine and 0.2% ropivacaine.

Pseuodaneurysms are an extremely rare complication of osteochondromas. We describe a case of traumatic pseudoaneurysm of the brachial artery presenting as a soft tissue mass in a patient who was treated for an osteochondroma 3 years earlier. This case demonstrates that radiographic follow-up of large osteochondromas is mandatory and that, in patients with soft tissue masses and a history of osteochondroma, pseudoaneurysms should be included in the differential diagnosis.

BackgroundThe humerus is the second most common site of metastatic bone disease involving long bones. Tumors which have a predilection for dissemination to bone are those of breast, prostate, thyroid, lung and kidney. The rationale for surgical treatment of these lesions is to prevent or treat pathological fractures in order to relieve pain and improve function.Materials and methodsForty patients who had resection of the proximal humerus for metastatic bone disease and reconstruction with a modular prosthesis were retrospectively reviewed.ResultsMean functional outcome was 73.1% (Enneking score) and better results were achieved when a reverse prosthesis was implanted. Overall survival was 70% at 1 year, 42.5% at 2 years and 20% at 5 years. Local recurrence occurred in 4 patients, each of whom had initially been treated for a pathological fracture.ConclusionsIt is important to follow rational guidelines, like those of Capanna and Mirels, in order to prevent pathological fractures and to give the patient a definitive treatment, as the advances in the management of cancer prolong the survival of these patients. In this series, satisfactory results were obtained, giving the patients an acceptable quality of life.