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A successful and minimally invasive treatment for adolescent flexible flatfoot is subtalar arthroeresis. This study examines the short-term results of subtalar arthroereisis with a new PEEK device (Pit’Stop®); additional research will be required to determine the device’s true potential, but the preliminary findings are very encouraging, with a high success rate and a low complication rate (0.08).

BACKGROUND Standalone interspinous process devices (IPDs) to treat degenerative lumbar spinal stenosis with neurogenic intermittent claudication (NIC) have shown ambiguous results in the literature. OBJECTIVE To show that a minimally invasive percutaneous IPD is safe and noninferior to standalone decompressive surgery (SDS) for patients with degenerative lumbar spinal stenosis with NIC. METHODS A multicenter, international, randomized, controlled trial (RCT) was con- ducted. One hundred sixty-three patients, enrolled at 19 sites, were randomized 1:1 to treatment with IPD or SDS and were followed for 24 mo. RESULTS There was significant improvement in Zurich Claudication Questionnaire physical function, as mean percentage change from baseline, for both the IPD and the SDS groups at 12 mo (primary endpoint) and 24 mo (−32.3 ± 32.1, −37.5 ± 22.8; and −37.9 ± 21.7%, −35.2 ± 22.8, both P < .001). IPD treatment was not significantly noninferior (margin: 10%) to SDS treatment at 12 mo (P = .172) but was significantly noninferior at 24 mo (P = .005). Symptom severity, patient satisfaction, visual analog scale leg pain, and SF-36 improved in both groups over time. IPD showed lower mean surgical time and mean blood loss (24 ± 11 min and 6 ± 11 mL) compared to SDS (70 ± 39 min and 189 ± 148 mL, both P < .001). Reoperations at index level occurred in 18.2% of the patients in the IPD group and in 9.3% in the SDS group. CONCLUSION Confirming 3 recent RCTs, we could show that IPD as well as open decompression achieve similar results in relieving symptoms of NIC in highly selected patients. However, despite some advantages in secondary outcomes, a higher reoperation rate for IPD is confirmed.

Introduction Porous tantalum presents a bone-matched elastic modulus and an high coefficient of friction on cancellous and cortical bone. Furthermore, its open-cell tantalum structure of repeating dodecahedrons, similar to cancellous bone, should be favourable for bone ingrowth. These physical and mechanical properties should increase primary fixation and potential osteointegration of acetabular cups and should decrease periacetabular stress shielding. The purpose of this study was to radiographically evaluate the evolution of the metal-bone interface of porous tantalum acetabular components. Materials and Methods Serial radiographic evaluation of 41porous tantalum acetabular component has been performed in 40 patients. Twelve hips underwent total hip arthroplasty using a trabecular metal monoblock acetabular component and 29 hips using a trabecular metal modular acetabular system. All patients were clinically and radiographically evaluated at four, eight, 12, 24 weeks, 12 months and then annually. All cases were available for a minimum follow-up of two years (mean 35 months). On post-operative x-rays the metal-bone interface was investigated for areas in which the porous surface of the acetabular component was not in contact with bone. These gaps were measured and classified by location according to DeLee and Charnley zones. Evolution of postoperative gaps, presence of lysis or periacetabular radiolucencies and component migration were assessed during follow-up. Results On post-operative x-rays 36 components (88%) had a gap between the outer surface and the host bone but only in 12 cases (29%) gaps were larger then 1 mm. The gaps were mostly situated in the polar region (zone II) when compared with the peripheral zones and no one was bigger then 5 mm in width. At last follow-up 23 (64%) of the initial gaps were no longer radiographically evident, 10 (28%) had a favourable evolution and appeared reduced in dimension but still present and 3 (8%) didn’t fill at all and were unchanged when compared with post-operative controls. There was no progression progression of any post-operative gap and no evidence of new periacetabular radiolucent lines or lysis. No acetabular implant showed evidence of migration or needed revision for loosening. At last follow up the mean Harris Hip Score was 95. There were no dislocation or other complications. Discussion Short term results with porous tantalum acetabular component are encouraging: the bridging of the interface gaps and the absence of periacetabular radiolucencies indicate good mechanical and osteoconductive properties. Further follow-up will be required to confirm these results in the long term.

Introduction The ‘‘bony PASTA’’ lesion is a partial articular-side bony avulsion of the supraspinatus tendon. It was described only once up to date in literature in 2007 by Bathia et al. These authors presented an arthroscopic technique for fixation of the avulsed fragment using a single medial suture anchor with simple mattress sutures. We present the use of the double pulley technique for arthroscopical fixation of bony PASTA lesions. Materials and methods We report the case of a 22 years old man presenting with a bony PASTA lesion to the right shoulder followinga motorbike accident. The lesion was documented with X-rays and MRI exams. The surgical technique involved the use of a 30° and 70° arthroscope. Intraarticular observation documented a 15 long and 5 mm wide avulsion with two principal fragments. Subacromial observation documented the integrity of the lateral insertion of the supraspinatus tendon to the greater tuberosity. Two double-loaded suture anchors were implanted through the lateral intact aspect of the supraspinatus tendon with a transtendinous technique. The anchors were placed at the anterior and posterior extremities of the bony lesion respecting the tendon insertion to the avulsed fragment. Each of the 4 medial sutures was retrieved in the subacromial space through the intact supraspinatus tendon medial to the fracture. Reduction and fixation of the avulsed fragment was initially obtained with a simple suture for each anchor oriented from medial to lateral. The remaining suture wires were coupled in double pulley configuration generating two sutures oriented from anterior to posterior. Results At the end of the procedure adequacy of reduction was confirmed by intra-articular arthroscopic observation throughout complete range of joint motion. At 2 months from surgery the patients fully recovered daylife activities and X-rays and arthro-MRI imaging documented healing of the fracture. Discussion The advantage of the double-pulley configuration is the compression of the osteo-tendinous complex obtained along the whole anterior-posterior length of the lesion, unreachable with mediolateral oriented simple sutures. Moreover double pulley configuration creates a waterproof reduction of the fragment, protecting the fracture site from the negative effect of sinovial fluid on bone healing. Conclusions In our opinion the double pulley technique allows optimal reduction of bony fragments and reconstruction of normal footprint anatomy even in comminuted fractures.

Introduction The ideal treatment for acute type III acromioclavicular (AC) dislocations is controversial. In fact, the literature reports little evidence on which treatment (surgical versus conservative) results in better clinical outcome. Recently, evidences for long term better outcome of surgical treatment have been published in literature, and development of scapular dyskinesis and SICK scapular syndrome following conservative treatment was described. Materials and methods We evaluated 34 patients surgically treated for acute type III AC dislocations with different techniques. Functional outcome, radiographic evaluation of clavicular reduction and scapular kinematics were all evaluated. Results Excellent Constant shoulder score (mean 95.7 points, SD ± 5.3) and Simple Shoulder Test (mean 11.2 points, SD ± 0.8) results were observed. In 4 patients recurrence of separation was observed. Scapular dyskinesis was observed in only 4 (11.7 %) patients, of which only 1 (2.9 % of the sample) was affected by SICK scapula syndrome. Scapular dyskinesis was classified as type I in 3 cases (75 %) and type III in 1 case (25 %). Discussion Excellent Constant shoulder score (mean 95.7 points, SD ± 5.3) and Simple Shoulder Test (mean 11.2 points, SD ± 0.8) results were observed. In 4 patients recurrence of separation was detected. The incidence of scapular dyskinesis and SICK scapula syndrome in the present study was significantly lower with respect to conservative treatment. On the other hand, the distribution of dyskinesis types was comparable, suggesting a possible common cause. However, pathogenesis of scapular dyskinesis following type III AC dislocation is still not clear: periscapular muscle dynamic stabilisation seems to be the means by which the scapula correctly accomplishes its functions, while the results hereby presented do not allow surely establishing a correlation between clavicle reduction and scapular dysfunctional syndromes. Conclusions Excellent clinical results for surgical treatment of type III acute AC joint dislocations at long term follow up are confirmed. Surgical treatment is also associated with a lower incidence of scapular dyskinesis and SICK scapula syndrome if compared to conservative treatment.

Background Anatomic and pathological characteristics of the valgus knee deformity represent a challenging issue for the implant of a total knee arthroplasty. The surgical approach in such cases should allow a direct ad easy exposure of the joint, easy lateral soft tissue balancing and adequate patellar tracking. Materials and Methods Twenty-four total knee arthroplasties were implanted in valgus knees between January 2002 and September 2005. A mean preoperative valgus deformity of 18° was assessed on standing x-rays. Four posterior stabilized, eighteen posterior stabilized rotating platform prosthesis and two superstabilized prosthesis were implanted in 21 patients. The surgical approach has been in all cases a lateral parapatellectomy. Follow-up assessments were obtained for all patients at a mean 23 months. They consisted of a Knee Society Score and a Patellar Score evaluation, standing AP and lateral radiograms and skyline x-rays obtained at a flection of 45°. Results A mean preoperative Knee Society Clinical Score of 32,7 points (range, -4 to 64 points) significantly improved at follow-up to an average 88,8 points (range, 57 to 99 points; p

The arthroscopic technique for the treatment of the glenoid and the proximal humerus fractures is a technically demanding surgical approach. Few very skilful surgeons with a lot of experience in the classic shoulder arthroscopic procedures (instability and rotator cuff repair) have been able to perform reduction and internal fixation in selected cases. Greater and lesser tuberosity fractures, Bony-Bankart and articular glenoid fractures have been successfully managed by mean arthroscopic technique. K-wires, cannulated screws and suture-anchors have been used to fix the bony-fragments. A new field of arthroscopic surgery is the treatment of acute and chronic acromion-clavicular dislocation and new different techniques have been described. Those arthroscopic treatments follow the trend to develop minimally invasive surgical techniques in the orthopaedic surgeons community

The authors describe an arthroscopic reconstruction technique for type III, IV and V acromioclavicular symptomatic chronic joint dislocation. It consists of a closed reduction and transfer of the acromial attachment of the coracoacromial ligament to the resected surface of the distal clavicle, associated to the positioning of a cannulated screw between the clavicle and the coracoid under arthroscopic control to achieve greater primary stability. Coracoacromial ligament is secured to the superior surface of clavicle by an Endobutton (Smith and Nephew, Andover, Massachusetts). The resection of the distal clavicle is minimal. The screw is finally removed under local anesthesia 12 weeks after surgery. The described procedure has been performed in three patients. Preliminary results show an excellent functional outcome without any residual pain. Among the advantages of the technique are a minimally invasive approach, the possibility of searching the glenohumeral joint for associated lesions and eventually treating them, and the benefits of not exposing the patient or surgical team to ionizing radiation.

Introduction Acetabular aseptic loosening is the main cause of failure in prosthetic hip surgery and the first cause of revision. Uncemented hemispherical cups are widely used and different biomaterials have been developed to obtain primary and secondary stability through osteointegration. Porous tantalum’s structure is similar to cancellous bone and presents with mechanical and biological characteristics aimed to enable rapid and complete osteointegration and improve the survival of the prosthesis. Materials and methods From May 2004 to June 2007 one hundred TMT modular acetabular components were implanted in 97 patients for primary THA. For this study we assessed 89 prostheses in 86 patients with 56 months (42–77 months) follow-up, both clinically and radiographically. Results At the last follow-up no implant appeared mobilized. Harris Hip Score changed from 52.75 points preoperatively to 95.72 postoperatively (p\0.0001). Oxford Hip Score improved from 37.16 to 14.78 points (p\0.0001). Gaps at the bone-prosthesis interface were documented at the immediate postoperative X-rays in 51 implants (57%), mostly in zone II. At the last radiographic assessment they appeared completely filled in 87% of the cases (mean time to fill 1 year), partially filled in 10%, leaving less than 1 mm gap, while in 2 cases they remain unchanged. Osteointegration signs according to Moore and McAuley were also considered: at least three signs were present in all cases indicating complete osteointegration of the implants. There was no evidence of radiolucent lines at last follow-up. One dislocation occurred in one case at 21 months and it was reduced in narcosis with no recurrence. Discussion Medium-term results of this cup are comparable with those reported in literature for porous tantalum monoblock components. The presence of the titanium layer in the metal-back of the modular component, that theoretically could affect the biomechanical characteristics of the cup, does not seem to affect host bone biological response when compared to the monoblock socket. Thanks to its mechanical characteristics and excellent osteoconduction, this biomaterial provides a good primary stability and excellent osteointegration of the component. Conclusions The results reported suggest that this cup represents at a medium-term follow-up a good implant for acetabular arthroplasty.

We considered the association between diabetes and risk of endometrial cancer using data from a large case-control study conducted in Italy. Cases were 752 women with incident, histologically confirmed endometrial cancer

In the case of extensively damaged meta-diaphyseal femoral bone with cortices thinning and widened femoral canal, tapered stems allow a good primary fixation and early weight-bearing. A retrospective review was conducted to evaluate long-term results of modular revision taper stems implanted from March 1999 to December 2002. Sixty-five consecutive hip revision surgeries were performed, mostly for aseptic loosening (75% of the cases). Femoral bone stock defects were classified according to AAOS's criteria and consisted mainly in type II (cavitary defects, 44.6%) and type III (combined defects, 33.9%). A trochanteric osteotomy was performed in 25 cases (38%) to remove primary implants that were cemented in 35 cases (54%). The mean postoperative follow-up was 109 months (range, 76 to 131 months). Clinical assessment at follow-up showed a significantly improved mean Harris Hip Score from 42 points preoperatively to 81 points postoperatively, while the x-ray examination did show a satisfactory distal integration of the stem in all cases and satisfactory reconstitution of the femoral bone stock in 47% of cases. The average subsidence of the stem at follow-up was less than one millimeter. According to data analysis, a leg-length discrepancy exceeding 15 millimeters caused significantly worse functional outcome and pain.

Aim of our study was to investigate the expression of nerve growth factor (NGF) and its tyrosine kinase receptor (TrkA) on tendinosic tissue harvested from Achilles and rotator cuff tendons. The presence of NGF and TrkA receptor was proven through immunofluorescence. We randomly recruited 6 patients that underwent rotator cuff arthroscopic repair and 10 patients that were treated for an acute Achilles tendon lesion. During surgery we harvested samples of the rotator cuff and of Achilles tendon. Furthermore we took a sample of macroscopically healthy tissue from each Achilles tendon. Fromeach specimen 4 slideswere obtained.Two slideswere employed for the search of NGF, one was treated with specific antibodies and marked with FITC (Fluorescein Isothiocyanate Conjugated), the second slide was for control purposes and was exposed to FITC, butwithout prior exposition to the specific antibody.The same procedurewas repeated to obtain on two more slides in order to repeat the search for Trka, with specific antibodies. All the slides were studied on a fluoromicroscope. The analysis of these specimens revealed the presence of the NGF and of the TrkA in all the rotator cuff specimens: the immunoistochemical reaction between the specimens and the specific antibodies marked with FITC was seen under fluoromicroscopy, but in none of the control cases treated with only FITC. The samples of Achilles tendon revealed the presence of NGF in 9 of 10 cases. In one case the sample was negative for NGF and TrkA receptor and no inflammatory reaction was spotted. The specimens harvested from the macroscopically healthy Achilles tendon revealed no inflammatory reaction and immunofluorescence revealed no NGF or TrkA receptor expression. There is considerable evidence that shows that the system constituted by the NGF and his high-affinity receptor TrkA plays a fundamental role in the molecular processes underlying the main forms of persistent pain.This indicates a possible therapeutic area for the antibodies that could block the NGF/TrkA system, in order to modulate the frequency and the duration of the action potential of nociceptive neurons during chronic inflammation. NGF and TrkA were absent on normal tissue and increased on degenerative tendon specimens. These findings could suggest a role of NGF in the pathophysiology of degenerative tendon rupture.

Introduction Anatomic acetabular cup, studied in 1999 by Prof. M. D’Imporzano, is born to solve the problem of acetabular revision in grade I and II mobilization (GIR), respectively, characterized by widening and deformation of cavity with eventual superior or posterior wall loss. The problem in these lesions is not such bone stock reconstruction, as correct positioning of new cup. Indeed superior wall loss can set wrong collocation of the cup tending to verticalization and superior migration of rotation centre, while posterior loss can lead to retroversion. Material and methods The hemispheric cup owns a cranial fin for iliac support with 4 holes for stabilization with spongiosa screws. In its equatorial area features 3 holes for posterior and medial screws, according to Pauwels, and circular retention cavities in order to increase the initial stability. The external shell is covered with a porous titanium layer so as to facilitate secondary osteointegration The tapered liner is in ceramic or polyethylene eventually protruded. The originality of this cup consists in having the insertion seat of the articular liner oriented by 18° in antiversion. This choice was made in order to automatically guarantee the necessary antiversion, even if the supero-posterior iliac wall is eroded, the latter being the reason why normal symmetrical revision cups lead to undesired positioning in insufficient antiversion. Considering these features, the cup can be used, as well as in revision surgery, in treatment of Coxa Profunda, Displasic Coxo-femural Osteoarthritis and acetabular fractures out-comes. In this study we present the results of 60 revisions between 2000 and 2007, with a 1–7 years follow-up. Results and conclusions The clinical outcome was good with an improvement from 55 to 88 considering the Harris Hip Score. As complications we observed only 1 case of sepsis, neither dislocation nor mobilization. Radiographical study of rotation centre pointed out a reduction of the superior migration from 1.2 to 0.8 cm after surgery. The shortness of follow-up period does not allow to conclude definitively about the effectiveness of this cup as the optimal solution in this surgery; however, we can state that it can be a valid solution for treatment of grade I and II contrasting the two principal problems of these revisions: superior migration of rotation centre and retroversion tendency.

Background Late periprosthetic fractures of the femur are the third most frequently reported cause of surgery after total hip artroplasty. Revision total hip artroplasty can be difficult, especially when poor bone stock is encountered. The aim of this study was to examine the results of late periprosthetic fractures complicated with primary implant loosening performed with distal fixation modular revision stem. Methods From November 1999 to May 2006, 16 late periprosthetic fractures were treated with distal-fixation, modular, straight stem. There were 13 females (82%) and 3 males (18%) whose mean age at surgery was 76.7 years (range, 48 to 95 years). Femoral revision surgery was performed with the Revitan (2 cases) and ZMR (14 cases) to get a stable distal primary fixation. X-rays were assessed accordingly to the Vancouver classification: there were 3 type B2 and 13 type B3 fractures. Mean post-operative follow-up was 52 months (range, 10 to 88 months). At the time of the last follow-up visit 4 patients already passed away, all of them for causes unrelated to the procedure. The clinical outcome was monitored with the Harris Hip Score, subjective VAS, pain and satisfaction evaluation. Standard AP and lateral x-rays of the hip were obtained at each follow-up visit. Leg-length discrepancy was also investigated as a factor possibly affecting outcome. Complications included one septic loosening that was treated with a two-stage revision. Results All the patients but one were finally able to walk and had minimal to no pain at all. A satisfactory functional outcome was achieved with an average 76 (range, 25 to 100) Harris Hip Scores points. The subjective pain and satisfaction scores were respectively 2.4 and 7.8 points. As far as radiograms are concerned, all the sixteen femur did show a good healing of the fracture, with no secondary stem subsidence. Discussion Generally, considering the severity of an event such as a periprosthetic late fracture in an elderly patient, results were satisfactory. The average Harris Hip Score and subjective satisfaction would have been even higher if one patient wouldn’t have been so much disappointed because of her severe leg-length discrepancy, dependent on the acetabular side. From a surgical point of view, the employed devices proved to be handy in bridging the fracture with distal fixation while adequately stabilizing it. Conclusions According to the reported results, straight modular-revison stems provide an adequate treatment option of Vancouver type B3 and in selected cases of B2 type periprosthetic femoral fracture.

The case of a 19 years old caucasian male, involved in a car accident and reporting an atypical posterior fracture-dislocation of the right proximal humerus is described. Classification of the fracture according to Neer's 4 fragments criteria, was not applicable even if a CT scan of the shoulder was obtained in the emergency room. The patient was taken to the operative room, the dislocation was easily reduced under general anaesthesia by means of gentle manual manoeuvres and an arthroscopy of the right shoulder was performed in the beach chair position. The arthroscopic gleno-humeral joint inspection revealed the morphology of the fracture, consisting of a proximal humerus fragment including the bicipital groove, part of the lesser tuberosity and a portion of the greater tuberosity. The reduction of the fragment was performed percutaneously by means of two 1.5 mm K-wires employed as levers to make it slide back in the original distal position, under direct arthroscopic control Then, a 7 mm partially threaded cannulated screw was inserted in the greater tuberosity. The anterior portion of the fragment was secured by means of a suture anchor and a stitch passed through the subscapularis tendon and locked with a DTK knot.