Effectiveness of Therapeutical Interventions on the Scapulothoracic Complex in the Management of Patients with Subacromial Impingement and Frozen Shoulder: A Systematic Review

Shoulder pain is one the most common musculoskeletal complaints. The most common pathological causes of shoulder pain in the general population are subacromial impingement syndrome and adhesive capsulitis, commonly referred to as "frozen shoulder". The purpose of this study was to evaluate the role of the scapulo-thoracic complex, particularly in scapular kinematic functions, in rehabilitative interventions for shoulder pain in patients suffering from these two common conditions. This systematic review was performed using the scientific search engines PubMed, PEDro and Cochrane Library, considering only randomized controlled clinical trials. Selected articles were evaluated according to the level of evidence and methodological quality. Thirteen randomized clinical trials were selected. Interventions have been divided into three macro-categories: (1) manual therapy in patients with subacromial impingement, (2) therapeutic exercise programs including interventions on the scapulothoracic complex in patients with subacromial impingement syndrome, and (3) therapeutic exercise programs including interventions on the scapulothoracic complex in patients with frozen shoulder. Following this, a qualitative analysis was performed according to outcomes such as pain, shoulder function, and scapular kinematics. Physiotherapy exercise programs that included scapular motor control training and scapular mobilizations, in particular, those of the scapulo-thoracic complex in scapular kinematic function, represent valid alternatives in the management of patients with subacromial impingement syndrome.

3D-Printed Models versus CT Scan and X-Rays Imaging in the Diagnostic Evaluation of Proximal Humerus Fractures: A Triple-Blind Interobserver Reliability Comparison Study

Background

Proximal humerus fractures (PHFs) are one of the most frequent fractures in the elderly and are the third most fractures after those of the hip and wrist. PHFs are assessed clinically through conventionally standard imaging (X-ray and computed tomography (CT) scans). The present study aims to conduct the diagnostic evaluation and therapeutic efficacy of the 3D-printed models (3DPMs) for the PHFs, compared with the standard imaging.

Objectives

In terms of fracture classification and surgical indication, PHFs have poor interobserver agreement between orthopedic surgeons using traditional imaging such as X-rays and CT scan. Our objective is to compare interobserver reliability in diagnostic evaluation of PHFs using 3DPMs compared to traditional imaging.

Methods

The inclusion criteria were elders aged >65 years, fracture classification AO/OTA 11 B and 11 C, and no pathological fractures or polytrauma. In addition, 9 PHFs were assessed by 6 evaluators through a questionnaire and double-blinded administered for each imaging (X-ray and CT scan) and 3DPMs for each fracture. The questionnaire for each method regarded Neer classification, Hertel classification, treatment indication (IT), and surgical technique (ST). Interobserver reliability was calculated through the intraclass correlation coefficient (ICC).

Results

Nine patients with PHF were included in the study (66% female). The Neer and Hertel classifications between imaging types had similar ICC values between raters with no statistical differences. IT reliability using CT scan and 3DPMs (ICC = 1; (p=0.116)) assessed better agreement compared with X-rays IT. The ST reliability using 3DPMs (ICC = 0.755; p=0.002) was statistically superior to traditional imaging (ST-RX ICC = -0.004 (p=0.454); ST-CT ICC = 0.429 (p=0.116)).

Conclusion

Classification systems like Neer and Hertel offer poor reliability between operators. The 3DPMs for evaluating diagnostics are comparable to CT images but superior to the surgical technique agreement. The application of 3DPMs is effective for preoperative fracture planning and the modeling of patient-specific hardware.

Current trends in the treatment of supracondylar fractures of the humerus in children: Results of a survey of the members of European Paediatric Orthopaedic Society

PURPOSE

The purpose of this study was to evaluate the current trends in the treatment of supracondylar humerus fractures as well as the preferred post-operative follow-up protocol among members of the European Paediatric Orthopaedic Society.

METHODS

The survey was composed by four main domains and 26 items: (1) surgeon information (3 items); (2) treatment (8 items); (3) post-operative treatment (3 items); and (4) factors influencing the outcome (12 items). All active members of European Paediatric Orthopaedic Society were invited by email to answer an electronic questionnaire.

RESULTS

The survey was submitted to 397 European Paediatric Orthopaedic Society active members; 184 members answered (46.3%) the questionnaire. Among respondents, 64.1% declared >10 years of experience and 55.4% declared to treat >20 supracondylar humerus fractures per year. Closed reduction, percutaneous pinning, and supine position were the preferred treatment option for Gartland type II and III supracondylar humerus fractures by 79.9%, 95.5%, and 84.8% of respondents, respectively. Supracondylar humerus fractures are treated within 24 h from trauma by 33.2% of respondents. Pins are removed 4 weeks from index procedure by 58.2% of respondents. Fracture type (72.3%), surgeon experience, and (71.2%) are of "crucial importance" for expected outcome of supracondylar humerus fractures treatment.

CONCLUSION

Surgeon experience, type of fracture, treatment modality, and pins configuration were considered the main factors potentially influencing the outcome of supracondylar humerus fractures. European Paediatric Orthopaedic Society members agreed on the treatment modality of Gartland type II and III supracondylar humerus fractures, patient positioning, and timing of hardware removal. Other important issues such as timing of surgery, pins configuration, surgical approach, and post-operative protocol are still debated.

LEVEL OF EVIDENCE

level II.

Running Footwear and Impact Peak Differences in Recreational Runners

Simple Summary

Running is a physical activity practiced by many people to maintain good levels of movement. Recreational runners commonly strike the ground with the postero–lateral zone of the foot, which may be associated with a higher biomechanical load on the lower limb, called impact peak. Different running shoes with specific cushioning are available to overcome the biomechanical load, e.g., shoes with a thickness difference between the forefoot and heel parts of the sole, called heel-to-toe drop. Analyzing the running pattern of recreational runners may be challenging because biomechanics laboratories mainly analyze these characteristics in individuals with visible alterations. To overcome these limitations, we employed a 3D markerless system; furthermore, we investigated footwear use. These parameters were studied to understand the behavior of those runners with and without a higher impact peak. Thirty participants underwent a running analysis and a questionnaire about their footwear. The study’s main finding highlighted kinematic and spatiotemporal differences between the runners presenting a higher impact peak and those without it. Furthermore, we observed that runners without an impact peak prefer shoes with a lower heel-to-toe drop, while the other group prefers shoes with a higher heel-to-toe drop. Investigating biomechanics characteristics is essential to reduce possible injury.

Abstract

Running is a physical activity and the investigation of its biomechanical aspects is crucial both to avoid injuries and enhance performance. Recreational runners may be liable to increased stress over the body, particularly to lower limb joints. This study investigates the different running patterns of recreational runners by analyzing characteristics of the footwear impact peak, spatiotemporal, and kinematic parameters among those that present with a peak impact and those that do not, with a 3D markerless system. Thirty recreational runners were divided into two groups: impact peak group (IP) (n = 16) and no impact peak group (n = 14) (n-IP). Kinematic and spatiotemporal parameters showed a large Cohen’s d effect size between the groups. The mean hip flexion was IP 40.40° versus n-IP 32.30° (d = −0.82). Hip extension was IP 30.20° versus n-IP 27.70° (d = −0.58), and ankle dorsiflexion was IP 20.80°, versus n-IP 13.37° (d = −1.17). Stride length was IP 117.90 cm versus n-IP 105.50 cm (d = −0.84). Steps per minute was IP group 170 spm, versus n-IP 163 spm (d = −0.51). The heel-to-toe drop was mainly 10–12 mm for the IP group and 4–6 mm for the n-IP group. Recreational runners whose hip extension is around 40°, ankle dorsiflexion around 20°, and initial foot contact around 14°, may be predisposed to the presence of an impact peak.

Patellofemoral Pain Syndrome in Young Female Athletes: A Case-Control Study

Background

Patellofemoral pain syndrome (PFPS) is the most common cause of anterior knee pain in children and adolescents, and it is characterized by highly limiting, recurrent, frontal pain.

Objectives

The purpose of the study is to assess the incidence and onset of PFPS in the young female athletes and to compare it to healthy individuals.

Methods

Between 2017 and 2019, 51 subjects were reviewed and divided in three groups: rhythmic gymnastics athletes (RG; 21 individuals, mean age: 13.8 ± 3.6 years), basketball athletes (BG; 17 individuals, mean age: 14.2 ± 3.1 years), and control group (CG; 13 individuals, mean age: 14.5 ± 4.3 years). All patients underwent physical examination including patellar glide, tilt, grind and apprehension tests, tiptoe and jack tests, Coleman block, and navicular drop tests. The clinical and functional outcomes of the subjects were assessed using the Kujala patellofemoral score (KPS).

Results

In RG patients were recorded 66.7% of normal footprint (NF), 9.5% of cavus feet (FCF), and 23.8% of flatfeet (FFF); 14.8% patellar positive tests, KS = 98.6 ± 13.7. BG patients had 70.6% of NF, 11.8% FCF, and 17.6% of FFF; 23.5% patellar positive tests, KS = 98.3 ± 12.4. CG patients had 61.5% of NF, 7.7% of FCF and 30.8% of FFF; 15.4% patellar positive tests, KPS = 98,9 ± 15.3. No statistically significance was found between the three cohorts of patients.

Conclusions

PFPS is a common pathology; muscular imbalance and overuse could exacerbate pain and discomfort in young female athletes. Our findings show high type and level of sport activity are not related to increase frequency of clinical symptoms related to PFPS.

Clinical Effects of L-Carnitine Supplementation on Physical Performance in Healthy Subjects, the Key to Success in Rehabilitation: A Systematic Review and Meta-Analysis from the Rehabilitation Point of View

L-carnitine supplementation improves body strength, sports endurance and exercise capacity, as well as delaying the onset of fatigue. The aim of this study was to identify the correct dosage of supplementation to obtain improvements in physical performance and evaluate the changes related to L-carnitine supplementation in specific metabolic parameters, such as serum lactate, VO₂, serum total and free carnitine at rest and after physical activities, in healthy subjects. The search was conducted on PubMed, EMBASE, Cochrane Library, Scopus and Web of Science and identified 6404 articles with the keywords: "carnitine" AND "exercises" OR "rehabilitation" OR "physical functional performance" OR "physical activity" OR "sports" OR "health" OR "healthy". A total of 30 publications met the inclusion criteria and were included in the systematic review. The meta-analysis did not show any significant differences in serum lactate values at rest and after exercise in healthy subjects who took L-carnitine supplementation (p > 0.05). On the contrary, L-carnitine administration significantly changed maximal oxygen consumption (VO₂) at rest (p < 0.005), serum free and total carnitine at rest and after exercise (p < 0.001). The dosage of supplementation that obtained a significant change in serum total carnitine was 2 g/dL for 4 weeks at rest, 1 g/dL for 3 weeks after exercise, and in serum free carnitine was 2 g/dL for 3 weeks and 2 g/dL for 4 weeks at rest. Based on our study, serum total and free carnitine at rest and after exercise, and VO₂ at rest could be used to clinically follow individuals during physical activity and rehabilitation programs. Moreover, the supplementation should have a correct dosage to have maximum effect. Other robust trials are needed to find the best dosage to obtain positive results in metabolic parameters and in physical performance.

Surgical treatment with cannulated screws for pediatric femoral neck fractures: A case series

INTRODUCTION

Femoral neck fractures are uncommon injuries in children, but the high incidence of long-term complications makes it important clinical entity. Early surgical treatment to achieve optimal results and to avoid a high rate of complications is widely advised. The purpose of this study was to retrospectively analyze the outcome of 8 children who sustained a femoral neck fracture.

PATIENTS AND METHODS

The patients (6 boys and 2 girls with an average age of 9.2 years) were treated within 24 h following admission to hospital by closed reduction and internal fixation. The type of fracture was distinguished according to Delbet's classification system. The outcome was analyzed using Ratliff's criteria, and a detailed record of complications was maintained.

RESULTS

According Delbet's classification system, there were 3 type I, 2 type II, 2 type III, and 1 type IV fractures. The average follow-up was 39.2 months (range 8-95). A satisfactory outcome was obtained in 6 (75%) children. Avascular necrosis was the most notable complication, which was reported in the 2 fair outcomes (25%).

CONCLUSIONS

Early and aggressive surgical treatment aimed at anatomical reduction result in a satisfactory outcome in pediatric femur neck fractures. Development of avascular necrosis is the main complication.

Comparison between Surgical and Conservative Treatment for Distal Radius Fractures in Patients over 65 Years

BACKGROUND

Fractures of the distal radius (DRF) are the most common orthopedic injuries, representing one of the typical fractures indicating underlying osteoporosis. The aim of the study was to compare conservative and surgical treatment, analyzing quality of life and clinical outcome in an over 65 years old population.

METHODS

Ninety one patients were divided into two groups: the ORIF group (39 patients) underwent surgery, and the conservative group (52 patients) was treated conservatively. The clinical and functional outcomes of all patients were evaluated using Short Form 36 (SF36), Modified Mayo Wrist Score (MMWS), Disability of the Arm Shoulder Hand (DASH), and Visual Analogue Scale (VAS). Range of motion at the joint was measured and compared with the contralateral healthy wrist.

RESULTS

No significant difference was found between the overall SF36 score, DASH score, MMWS, and VAS results. Role limitation was significantly better in the surgical group (p < 0.05), and complication incidence was significantly higher (p < 0.05) in the conservative group.

CONCLUSION

The results of this study conform to recent literature, suggesting that a surgical reconstruction of the radius articular surface in an elderly population provides no clear clinical advantage. Treatment decisions must arise from careful diagnoses of the fracture and communication with the patient.

Growing pains: What do we know about etiology? A systematic review

BACKGROUND

Growing pains is the most common cause of musculoskeletal pain in early childhood and was first described in 1823 by French physician Marcel Duchamp. Although it has been researched extensively, the etiology is still unknown. Several theories have been proposed throughout the years.

AIM

Analyze the available scientific literature to provide an update on the latest evidence on the etiology.

METHODS

According to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, the scientific literature on the etiology of growing pains was systematically reviewed using the following inclusion criteria: studies of any level of evidence reporting clinical or preclinical results and dealing with the etiology of growing pains. The medical electronic databases PubMed and Web of Science were searched by two independent authors on October 20, 2018. The search string used was “(growing pains OR benign nocturnal limb pains OR musculoskeletal pains) AND (etiology OR pathogenesis) AND (pediatrics)”.

RESULTS

A total of 32 articles were included. The etiology of growing pains still remains poorly understood. Many theories have been proposed, but none of them are decisive. A lower pain threshold has been found among patients suffering from growing pains in comparison to healthy controls. Furthermore, evidence suggests an association between growing pains and reduced bone strength in young patients, although this finding still remains controversial. Changes in the vascular perfusion pattern have also been studied. However, the etiology of growing pains does not seem related to a vascular component. The anatomical/mechanical theory has not been supported, but the role of vitamin D deficiency has been investigated many times. Strong recent evidence indicates a genetic susceptibility in the pathogenesis of growing pains. Furthermore, psychological factors also seem to play a strong role in the onset.

CONCLUSION

The scientific literature about the etiology of growing pains presents heterogeneity and lack of consensus; more studies are needed to understand the genesis of benign musculoskeletal pain syndrome of childhood.

Aetiology of Legg-Calvé-Perthes disease: A systematic review

BACKGROUND

Legg-Calvé-Perthes disease (LCPD) is a clinical condition affecting the femoral head of children during their growth. Its prevalence is set to be between 0.4/100000 to 29.0/100000 children less than 15 years of age with a peak of incidence in children aged from 4 years to 8 years. LCPD aetiology has been widely studied, but it is still poorly understood.

AIM

To analyse the available literature to document the up-to-date evidence on LCPD aetiology.

METHODS

A systematic review of the literature was performed regarding LCPD aetiology, using the following inclusion criteria: studies of any level of evidence, reporting clinical or preclinical results and dealing with the aetiology or pathogenesis of LCPD. Two reviewers searched the PubMed and Science Direct databases from their date of inception to the 20th of May 2018 in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. To achieve the maximum sensitivity of the search strategy, we combined the terms: ‘‘Perthes disease OR LCPD OR children avascular femoral head necrosis” with “pathology OR aetiology OR biomechanics OR genetics” as either key words or MeSH terms.

RESULTS

We include 64 articles in this review. The available evidence on LCPD aetiology is still debated. Several hypotheses have been researched, but none of them was found decisive. While emerging evidence showed the role of environmental risk factors and evidence from twin studies did not support a major role for genetic factors, a congenital or acquired predisposition cannot be excluded in disease pathogenesis. One of the most supported theories involved mechanical induced ischemia that evolved into avascular necrosis of the femoral head in sensible patients.

CONCLUSION

The literature available on the aetiology of LCPD presents major limitations in terms of great heterogeneity and a lack of high-profile studies. Although a lot of studies focused on the genetic, biomechanical and radiological background of the disease, there is a lack of consensus on one or multiple major actors of the etiopathogenesis. More studies are needed to understand the complex and multifactorial genesis of the avascular necrosis characterizing the disease.