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The term "bone marrow edema" was used for the first time in 1988 by Wilson. He noticed a high signal on fluid-sensitive sequences at MRI located in the subchondral bone. We can find bone marrow edema in many musculoskeletal diseases such as Inflammatory and Rheumatic diseases (Rheumatoid Arthritis, Spondylarthritis, etc.), Osteoarthritis (BMLs) and Bone Marrow Edema Syndromes (BMES). This classification is based on pathophysiological, histological and clinical differences despite the same imaging evidence. The distinction is useful also in terms of treatment. Bisphosphonates in association with NSAIDs or corticosteroids are the main therapy while TNF-a Inhibitors are used for the specific inflammatory origin. Bone marrow edema has become an important aspect to consider in the diagnostic path of the main musculoskeletal diseases. This paper starts from a systematic review of literature. We chose the most decisive contributions in order to develop a better description of the pathogenetic features about this "new" evidence.

Osteoarthritis (OA) is the most common painful arthritic disease in adults, causes severe disability and worsens the quality of life of the patients. The aim of this survey, carried out on 147 Italian orthopedic doctors who attended an ISIAT (International Symposium Intra Articular Treatment) educational course in Barcelona, was to investigate some aspects of daily clinical practice in the management of OA: the most used pharmacological treatments, compliance to the most important Guidelines, the advantages of COXIBs in this setting and pharmacoeconomic aspects. The main results of this survey are: a) inflammation has become the main target in OA; b) Guidelines are a useful and valid tool for daily clinical practice; c) acetaminophen is no longer a valid therapeutical option for OA patients; d) anti-inflammatory drugs (NSAIDs and COXIBs) have a primary role in the management of OA, due to their dual activity (anti-inflammatory and analgesic); e) selectivity of COXIBs for COX-2 is very important; f) within the COXIB class, the therapeutic value of etoricoxib has been widely recognized, especially in terms of safety and cost/benefit ratio.

Osteoarthritis is being increasingly characterised as an inflammatory incoming and recurrent disease, with the specific symptoms of inflammation at every stage of the disease. With regard to the pathogenesis over time, the degenerative and inflammatory components are combined and lead to osteocartilaginous degeneration. Such deterioration involves other joint tissues as well as the subchondral bone tissue, the suffering of which is the key event of the beginning and progression of OA; its involvement concerns the same pathogenetic mechanisms and the same chemical mediators of the chondropathy. The increase in joint inflammatory events leads to suspect the onset or the worsening of the osteometabolic disorder, which is documented by the MR as “bone edema” or as algodystrophic syndrome. The pain appears both while moving and resting and with signs of inflammation. The treatment of OA requires drugs, such as paracetamol, selective and nonselective NSAIDs and opiates, for pain control. Treatment should ensure the pharmacological control of the pain related to the osteometabolic juxta-articular alteration, through bisphosphonates, favouring those which can control bone loss, inflammation and pain.

Osteoarthritis (OA) is the most prevalent chronic joint disease and one of the major causes of disability in the adult population. Although OA is considered a progressive degenerative process which involves the whole joint, articular cartilage and subchondral bone play a determinant role in its pathogenesis. In particular, metabolic-triggered subchondral bone damage, together with biochemical markers, are referred as important indicators of the disease. Magnetic resonance (MR) is the best imaging technique to detect and characterize such bone abnormalities. It represents an effective method through which to not only diagnose, describe and follow the course of OA but also to deepen our understanding of the natural history of the disease, with the ultimate purpose of attaining improved outcome in terms of therapy and prognosis. Even though MR has enormous potential, some diagnostic pitfalls may occur in clinical practice, hence an accurate clinical assessment of the patient is mandatory in combination with optimal imaging evaluation.

The control problem for LVADs is to set pump speed such that cardiac output and pressure perfusion are within acceptable physiological ranges. However, current technology of LVADs cannot provide for a closed-loop control scheme that can make adjustments based on the patient's level of activity. In this context, the SensorART Speed Selection Module (SSM) integrates various hardware and software components in order to improve the quality of the patients' treatment and the workflow of the specialists. It enables specialists to better understand the patient-device interactions, and improve their knowledge. The SensorART SSM includes two tools of the Specialist Decision Support System (SDSS); namely the Suction Detection Tool and the Speed Selection Tool. A VAD Heart Simulation Platform (VHSP) is also part of the system. The VHSP enables specialists to simulate the behavior of a patient's circulatory system, using different LVAD types and functional parameters. The SDSS is a web-based application that offers specialists with a plethora of tools for monitoring, designing the best therapy plan, analyzing data, extracting new knowledge and making informative decisions. In this paper, two of these tools, the Suction Detection Tool and Speed Selection Tool are presented. The former allows the analysis of the simulations sessions from the VHSP and the identification of issues related to suction phenomenon with high accuracy 93%. The latter provides the specialists with a powerful support in their attempt to effectively plan the treatment strategy. It allows them to draw conclusions about the most appropriate pump speed settings. Preliminary assessments connecting the Suction Detection Tool to the VHSP are presented in this paper. © 2014 Elsevier Ltd.

This paper presents an analytical model of the cobalt-based alloy-ultra-high molecular weight polyethylene (UHMWPE) wear coupling. Based on a previous model in which the cup wear volume over a gait cycle (WG) was calculated under the simplifying assumption of an ideal rigid coupling, the current version proposes a more realistic wear simulation. All three components of the hip loading force were considered for the contact pressure calculation and all three components of the hip motion were taken into account for the sliding distance calculation. The contact pressure distribution was calculated on the basis of the Hertzian theory for the elastic contact of two bodies with non-conforming geometrical shapes. The wear factor was taken from hip simulator wear tests. The calculated WG is 67 × 10−6mm3 for a standard reference patient. The parametric model simulations show that WG increases linearly with the patient weight, femoral head diameter and surface roughness. It increases non-linearly to a maximum and decreases to an asymptotic value with increasing cup/head clearance and with cup isotropic elastic modulus. The cup orientation in the pelvis affects only slightly the total amount of WG whereas it is the dominant factor affecting the shape of the wear distribution. The iso-wear maps show paracentral patterns at low cup inclination angles and marginal patterns at higher inclination angles. The maximum wear depth is supero-posterior when the cup is in neutral alignment and supero-anterior at increasing anteversion angles. Complex patterns with a combination of paracentral and marginal wear were obtained at specific clearance values and cup orientations. The results of the simulations are discussed in relation to the wear distribution measured on the articular surface of 12 UHMWPE components retrieved from failed hip joint prostheses, after a period of in situ functioning.

The biomechanics of an elliptical-head femoral prosthesis, considered in relation to the physiology of the coxo-femoral joint, can be taken as the rationale for its use in the treatment of medial fractures of the neck of the femur. Short-term results based on clinical variables (Harris's evaluation method) and X-ray findings show a functional joint and good preservation of radiographic relations between the prosthetic epiphysis and the acetabulum, and between the stem and femoral metadiaphysis. These findings confirm the validity of the biomechanical concepts underlying the design of the elliptical-head femoral prosthesis. It is an “etiological” solution for patients with medial fractures of the neck of the femur since it fits in with the coxo-femoral physiology without interfering with the normal anatomical/biomechanical relations between the two joint components.

The recommendations for the management of osteoarthritis (OA) of the knee firstly proposed by the EULAR in 2000, have been updated in 2003. One of the most important objectives of the expert charged to provide these recommendations was their dissemination. Thus, the information generated may be used by each individual country to produce their own set of management guidelines and algorithms for treatment in primary care. The Italian Society of Rheumatology (SIR) and the Italian League against Rheumatism (LIMAR) have organised a Consensus on the EULAR recommendations 2003 with the aim to analyse their acceptability and the applicability according to our own experience and local situations in the Italy. The results of this Consensus have demonstrated that a large majority of the EULAR recommendations are endorsed by the Italian experts. Furthermore, the final document of the Italian Consensus clearly indicated the need that the specialists involved in the management of knee OA strongly encourage the dissemination of the EULAR 2003 recommendations also in Italy.

The elliptical femoral prosthesis was designed for solving the problem of the relationship between the prosthetic head and the anatomical acetabulum and to minimize the incidence of cotyloiditis, i.e. acetabular wear-protrusion and pain. Long -term clinical tests have been performed using the Cathcart prosthesis, which is the most advanced technological design. Its basic feature lies in the ellipticity of the head and its development was based on the anatomy and biomechanics of the hip: the femoral head is, in fact, naturally elliptical. The acetabulum is a “deformable” structure, the fades lunata being a stress contact and bearing area, whereas the trabecular system of a “gothic arch”, the “sourcil” and the ileum cortical laminae serve as a load distribution and carrying structure. Clinical results have shown a very low percentage of “cotyloiditis” (1-3%), thanks to the optimal relationship between the prosthetic head and the antomical acetabulum, which guarantees improved distribution of the lubrication stresses and nourishment of the articular cartilage.

Osteoarthritis (OA), a degenerative arthro-pathy, produces damage and cartilage loss in one or more joints. Genetic factors contribute substantially to the risk of OA. The nature of the genetic influence in OA is speculative and may involve both a structural defect (i.e. collagen), alterations in cartilage or bone metabolism. Analyses of the frequencies of HLA antigens in various OA populations showed differentThe aim of this study was to verify the prevalence of HLA-DRB1 haplotypes in 92 outpatients of the Rheumatological Center of Genoa University.Ninety-two outpatients (69 females, 23 males) affected by OA were enrolled and divided into a group with OA of the hands and a group with different joints localizations. Both groups have been compared with a control group, represented by 150 Italian marrow donors, to detect a typology of second class HLA alleles that, if present, may represent a risk factor of disease. The statistical significance between the groups were assessed by means of the contingency table to compare frequencies (P0.05 was considered as significant).The results obtained showed that the frequency of DRB1*12 and *10 alleles families, not present in the second study group, has been compared only between the first study group and the control group. Haplotypes *07 e *04 are more frequent in the second group than in the first group and in the control group and haplotype *13 is the most represented in the first and second group. Haplotypes *11 and *13 are more significantly represented in the control group.The results obtained with the study of HLA-DRB1 locus in patients affected by OA and living in Liguria may suggest a research on a larger number of OA patients to confirm the data obtained in this study and to define DRB1 haplotypes as more frequent markers both in OA of the hand and in OA of other joints.

The recommendations for the management of osteoarthritis (OA) of the hip were proposed by EULAR in 2005. Among the most important objectives of the expert charged to provide these recommendations were their wide dissemination and implementation. Thus, the information generated can be used by each individual country to produce their own set of management guidelines and algorithms for treatment in primary care. According with that previously executed for the EU-LAR recommendation 2003 for the knee, the Italian Society of Rheumatology (SIR) has organised a Consensus on the EULAR recommendations 2005 for the management of hip OA. To obtain an acceptability as large as possible, the group of experts was composed by many physicians interested in the management of hip OA, including Orthopaedics, Rheumatologists, Physiatrists, and General Practitioners. Main aim of the Consensus was to analyse the acceptability and applicability of the recommendations according to own experience and local situations in the Italy. The results of this Consensus have demonstrated that a large majority of the EULAR recommendations are endorsed by the Italian experts. Furthermore, the final document of the Italian Consensus clearly indicated the need that the specialists involved in the management of hip OA strongly encourage the dissemination of the EULAR 2005 recommendations also in Italy.

Patients with symptomatic osteoarthritis of the cervical spine were treated with very low-power modulated laser (LPL). Two applications were performed at an interval of 20 days. Changes in pain and ultrasound thickness of the soft connective tissue layer above the right and the left superior trapezium were studied. No worsening of pain was observed. Pain improved after the first application of LPL in 9 out of 14 patients, but the difference was not significant. Pain improvement remained stable between the first assessment and the second assessment, which was performed after 20 days. In comparison with the first application, at the second application the number of patients with improved pain after LPL increased to 12 out of 14 (p0.01). An appreciable difference in the thickness of the subcutaneous soft tissue layer overlying the two superior trapezia was demonstrated in all patients at the first examination. Comparison of the measurements before and after the application of LPL showed significant differences.

The evaluation of osteoarthritis pain is principally based on a subjective rating scale. Accuracy in recording pain score is obviously important. In the present study we evaluated the effect of better standardization of information given to patients in determining the visual analog scale (VAS) score. Fifty-three consecutive male and female outpatients aged 18-65 years (40 women and 13 men) fulfilling the criteria for osteoarthritis of the hands were included in the study. Eligible patients attended the Rheumatology Center on three occasions: day 1, day 3 and day 6 of the study. Two information cards were prepared. On the first card, given to the patient at the end of the first visit, osteoarthritis of the hands was described as a less dangerous disease than rheumatoid arthritis. On the second card, given to patients at the end of the second visit, greater emphasis was placed on anatomo-pathological description of the destructive lesions. VAS score was recorded on days 1, 3 and 6 of observation. ANOVA for repeated measures demonstrated a significant reduction of VAS score between the first and the second assessment and a significant increase between the second and the third assessment. A further significant difference was found in the comparison between the first and third assessment. These results show that different standards of information given to patients may modify VAS score.

The aim of the study was to evaluate the effect on articular pain of 100 mg of disodium-clodronate administered daily by intramuscular injection in patients affected by rheumatoid arthritis.We studied 24 patients with established rheumatoid arthritis, in the II and III stage according to Steinbrocker. Visual analogue pain scale, physician global assessment activity and patient global assessment activity were recorded at baseline, after 30 days and after 60 days of treatment.VAS significant improvement after 30 days was found. The physician and patient global assessment activity were improved after 60 days of treatment.Disodium-clodronate given by intramuscular injection at the dose of 100 mg/die in rheumatoid patients vas effective in relieving joint pain during a two-month observation.

Morning stiffness in osteoarthritis (OA) of the hands is a troublesome symptom that deserves attention in many OA patients. The aim of this research was to verify the action of oral dexketoprofen-trometamol (50 mg) administered early in the morning on morning stiffness in hand OA. Thirty-five patients were compared with 19 controls. The degree of morning stiffness, evaluated by means of the WOMAC scale for OA stiffness, was significantly diminished 40 min after drug administration in treated patients but not in controls. This drug acted rapidly and was effective in reducing morning stiffness in OA of the hands.

Disodium-clodronate is one of the most experimented drugs for the management of bone pain caused by vertebral fractures induced by skeletal metastases and myeloma as well as by osteoporosis. In a previous study, treatment with intravenous disodium-clodronate 300 mg/day in saline produced satisfactory relief of moderate or severe back pain in 15 patients with painful vertebral crush. The present study examines the general behavior of pain in patients suffering from vertebral crush when treated with intravenous disodium-clodronate and after discontinuation of medication. At the end of treatment, pain relief was significantly greater in patients treated with disodium-clodronate. After discontinuation of treatment the patients who had been taking disodium-clodronate for pain due to vertebral crush were generally better than those previously on acetaminophen. At the end of follow-up, no significant differences were found between the two groups. In our study, the use of disodium-clodronate was associated with a reduction in the number of days the patients experienced severe pain, which suggests that disodium-clodronate is a first-line drug in the treatment of recent vertebral crush.

This article identifies and describes a small group of patients with trochanteric tendinitis and bursitis in whom all modes of traditional therapy failed. We hypothesized that obstinate pain could be due to an increase in bone turnover associated with the formation of marginal bony outgrowths or enthesophytes. Injectable disodium clodronate is known to be highly efficacious in inhibiting bone reabsorption and is able to reduce several types of bone pain. The aim of the study was to evaluate the effectiveness of disodium clodronate in periarticular pathology of the hip in a group of patients resistant to traditional treatments and who were hypothesized to have a component of bone pain in their pain syndrome. Periarticular ultrasound examination is a useful method for detecting soft tissue alterations and is of interest in the study of these patients. In this study ultrasound examination showed periarticular alterations even when results of radiography were negative. Reduction in the hyperechoic ultrasound image, which confirms periarticular calcification, was observed in 75% of the patients treated with disodium clodronate vs. 33% of those treated with paracetamol. At the end of the study, all patients treated with disodium clodronate had a reduction in spontaneous and provoked painor = 1/3 vs. the basal visual analogue scale, unlike those treated with paracetamol.

Bone loss is the principal problem in hip prosthesis revision surgery; repair of this loss may identify the method itself of reimplantation. In light of thirteen years of hip reimplantation surgery the authors propose a classification of bone loss that correlates pathologic anatomy with surgical strategy. Thus, three types of acetabular bone loss and four types of femoral bone loss are distinguished, to which correspond just as many surgical strategies, aimed at an attempt to obtain stability of the revision implant and its longer duration in time.

The authors describe an unusual case of extrusive synovitis of the hip that they believe is an anatomo-clinical variant of transient synovitis of the infantile hip. Transient synovitis of the hip (TSH) is a benign pathology of the hip with complete healing within a few days after onset of the disease. The case reported distinguishes itself for the expulsive tendency of the femoral head from the acetabular cavity with potential ischemic disturbances due to an increased pressure inside the articular joint causing stretching of the circumflex vessels supplying the femoral head.

Preservation of the femoral neck in hip arthroplasty creates a particular biomechanical situation which is clearly different from what is found even after partial neck removal. The femoral neck consists in fact of a "cylinder of cortical bone" that can be used as the "base" for anchoring the stem to the femur, in contrast to the press-fit procedure or other solutions. The mechanical and biological advantages are as follows: 1) Primary triplanar stem stability, in particular rotational stability. Rotational movements of the stem are blocked by the tough lateral cortical cylinder of the neck. Resistance to varus-valgus stress and collapse is also increased vertically and frontally. 2) Proximal cortical fixation. Primary fixation of the stem is provided by the neck cortex, whereas its mid-distal part is merely held by the metaphyseal cancellous bone and the tip is undersized with respect to the medullary canal. 3) Stress loads distributed along physiological lines of stress. Retention of the neck permits preservation of the trabecular systems, along which the stress is distributed towards the diaphysis and the greater trochanter. 4) Elasticity of the bone-prosthesis system. Most of the stem is contained within the metaphyseal cancellous bone that lies between the prosthesis and the cortical bone, creating a bone-prosthesis module with variable and integrated elasticity. 5) Preservation of the bone-stock. The amount of residual bone following implant of the prosthesis increases, not only because of the presence of the femoral neck, but also as a result of the preservation of most of the metaphyseal cancellous bone. There is therefore greater bone-ingrowth, which is also favoured by the fewer changes in the endosteal blood supply. 6) Prosthesis revision is simpler, since the stem can easily be removed and a second neck resection performed. Our clinical and experimental studies, together with those of Freeman et al., confirm that the femoral neck is present for a long time after implant. Finally, we report a study of 200 prostheses with a follow-up of 1 to 6 years, demonstrating neck reabsorption in only 1% of the cases.

Over the past several years ultrasound has become the main means of early diagnosis of hip dysplasia. The success of this diagnostic test lies in the fact that it is non-invasive, can be performed at a very early age, and can be repeated. Moreover, it has made a more modern nosographic approach to this disorder possible, especially regarding correct orthopedic treatment. The results of the first 1500 patients (3000 hips) examined with ultrasound confirm the validity of our classification, which is based on both anatomical and clinical criteria. When performed correctly, ultrasound examination permits early diagnosis, precise anatomical differentiation, and monitoring of the progress of conservative treatment especially in cases of congenital dislocation treated with the Hoffmann-Pipino harness.

A clinical and radiographic study of prosthetic replacement of the hip with a very long follow-up permitted us to evaluate the various factors influencing the long-term stability of this arthroprosthesis. Seventeen patients who underwent this operation during the 15 year period from 1969 to 1973 were reviewed clinically (using a points system adopted in our Clinic), and radiographically after periods ranging from 12 to 16 years. There was a reassuringly high proportion (72%) of excellent or good results. The metaphyseal cementation of the stem and the support of the collar were two particularly interesting features observed in this study. This accords with modern concepts of the biomechanics of hip arthroprosthesis.

The causes of the loosening of a hip prosthesis may be inflammatory, mechanical, immunitary or due to detritus. A bacteriological and histological study, in cases where further surgery was needed, may clearly contribute to the aetiopathogenesis of failure. Loose hip prostheses removed at operation were studied from a bacteriological and, in particular, histological point of view. There results were then correlated to clinical, radiographic and laboratory data obtained during follow-up. Inflammation proved to be a constant histological finding. The hyalinosis observed in 22 cases revealed significant analogies with histological pictures of silicotic granuloma, for which an immunitary pathogenesis is the current hypothesis. Thus, it is our belief that this correlation is suggestive of an immunitary based approach in cases where hip prostheses fail due to loosening.

In 1971 Cathcart proposed the use of an elliptical head for the femoral endoprosthesis, based on his anatomical studies which had proved that the normal femoral head is elliptical and not spherical. Important biomechanical studies have also shown that the periacetabular trajectory system also assumes an elliptical gothic arch shape during stress loading (Fischer and Olivier, 1979). The authors therefore decided to use an elliptical head because it improves lubrication and therefore nourishment of the acetabular cartilage, and because it better distributes the load. Between 1977 and 1987 121 endoprostheses were implanted, of which 92 were followed up after an average of 5 years. The follow-up showed that good results may be obtained with this type of prosthetic head, and in particular that there was almost no acetabular erosion and only a moderate decrease in the joint space. These results show that the elliptical head is better adapted to the acetabulum during load as compared to the spherical head, and is therefore better at safeguarding the osteoarticular structures with which it articulates. The authors therefore regard it as superior not only to the spherical head, but also to the so-called bipolar double-hinge prostheses.

Nineteen patients with acute joint pain and 12 patients with chronic rheumatic disorders were treated with 450 mg/day of proglumetacin for a period ranging between 15 and 30 days. The overall results revealed a satisfactory response to treatment, and tolerance was rated as "good" or "very good" in all patients.

To compare the respective performance and effectiveness of autologous chondrocyte implantation (ACI) and mosaicplasty at resurfacing local full-thickness chondral defects of the knee.Randomized clinical trial.Multicenter trial at orthopedic clinics and university hospitals conducted from 1997 to 2000.A population of patients selected according to eligibility criteria of age, traumatic origin of the defect, its localization, size, and gravity, and above all, no previous surgical treatment of the lesion. Forty-seven patients were randomly assigned to ACI or mosaicplasty and subjected to arthroscopic debridement of the lesion at the time of enrollment. They were called for surgery 6 months after the initial debridement.Improved knee functionality as assessed by repeated clinical evaluation based on the International Knee Documentation Committee Scale and the Lysholm Knee Scoring Scale.Fourteen patients (31.8%) experienced substantial improvement following the initial debridement and, being clinically cured, received no further treatment. Seven patients (15.9%) were lost to follow-up. Among the 23 patients (52.3%) who could effectively be evaluated, a complete recovery (ie, Lysholm Knee Scoring Scale score, 90-100) was observed upon clinical examination in 88% of the mosaicplasty-treated patients and in 68% of the ACI-treated ones (P = 0.093).Although the low power of our study prevents definitive conclusions, ACI and mosaicplasty are cartilage repair techniques that are clinically equivalent and similar in performance. The high percentage of spontaneous improvement ((1/3) of the patients) observed after simple debridement calls into question the need for prompt surgical treatment of patients with lesions similar to those included in this clinical trial. Moreover, this finding warrants further investigation, ideally through randomized clinical trials in which patients subjected to debridement alone are compared with patients undergoing reconstructive surgery.