Health and welfare assessment of beef cattle during the adaptation period in a specialized commercial fattening unit

Beef cattle welfare and health status are influenced by housing and management systems. The present study aimed to assess the welfare and health status in the first 15 days after arrival of Limousine bulls imported from France and fattened in a commercial fattening unit in Italy. A total of 264 bulls were included in the study. Welfare, biosecurity, and major hazard and warning system were assessed on days 2 (T1) and 15 (T2) after arrival to the unit. At T1 and T2 an inspective clinical examination was performed on all bulls. At T1 and T2 blood samples were collected from 88 bulls for haematological analysis. Both at T1 and T2, the welfare, biosecurity, and major hazards and warning systems were classified with a general score of medium but with a decrease on animal-based measurements in T2. At T1 and T2 the clinical examination revealed a significant increase (p-value≤0.05) of skin lesions and lameness in T2. A high incidence of respiratory disease was noticed in both assessed times. Leucocytes and all differentials count, and platelets were significantly increased (p-value≤0.05) at T2, while the fibrinogen was significantly decreased. The haematological changes suggest that the bulls were under higher stress in T2 when compared with T1 linked with a difficult adaptation response to the fattening unit. A multi-factorial approach that integrates the indicators of the checklist and the clinical and haematological findings of animals can be a useful method to deepen the assessment of welfare in beef cattle.

Tracheal lesion during shoulder surgery: a case report and systemic review of the literature

Pneumomediastinum (PNM) and pneumothorax (PNX) are documented complications of arthroscopic shoulder surgery (ATS). Plexus anesthetic block and tracheal lesions during endotracheal intubation are hypothesized to be the underlying risk factors; however, the actual evidence supporting this hypothesis is scarce.A case of bilateral laterocervical emphysema, subcutaneous edema, and signs of PNM after ATS performed under general anesthesia and supra-scapular nerve block is presented. An up-to-date systematic review of PNM/PNX during orthopedic surgery was performed, involving six databases: PubMed (1996-present), Embase (1974-present), Scopus (2004-present), SpringerLink (1950-present), Ovid Emcare (1995-present), and Google Scholar (2004-present).Twenty-five case studies met the eligibility criteria. In 24 cases, the patient underwent general anesthesia and orotracheal intubation; in 9 of these, a plexus anesthetic block was also performed. One case involved ATS under plexus anesthetic block only. In 10 cases, the diagnostic finding was PNM. In 5 cases, the diagnostic finding was associated with PNX. PNX was detected in 17 cases. In 2 cases, SE was found in the absence of any evidence of either PNM or PNX. A tracheal lesion was identified in 3 cases.Endotracheal intubation and loco-regional anesthesia are not the only predisposing risk factors at play in the pathogenesis of PNM/PNX. Rather, multi-factorial pathogenesis seems more probable, necessitating that specific attention is paid during ATS to the change in patient position on the operating bed, to any slipping of the endotracheal tube, to patient monitoring whilst under the drapes, and to the cuff pressure. PROSPERO registration number: CRD42021260370.

Treatment options for massive rotator cuff tears: a narrative review

The treatment of massive rotator cuff tears poses a challenge to orthopedic surgeons. The prevalence of massive rotator cuff tears is 40% of all rotator cuff tears. Compared with smaller tears, massive rotator cuff tears are often complicated by structural failure and poor outcomes and present a higher rate of recurrent tearing after surgical repair. Several management options are available but the selection of the most appropriate treatment for each patient can be challenging. To achieve the best outcomes, the orthopedic surgeon should have a good understanding of the indications, the pathomechanics and the clinical outcomes of the various treatment modalities. Treatment options include non-operative management, arthroscopic debridement with a biceps tenotomy or tenodesis, complete or partial repair, patch augmentation, superior capsular reconstruction, muscle/tendon transfer and reverse total shoulder arthroplasty. The purpose of this article is to review treatment options and clinical outcomes for the management of massive rotator cuff tears. (www.actabiomedica.it)

Cementless reverse total shoulder arthroplasty in a patient affected by Osteogenesis Imperfecta: a case report and review of the literature

Background and aim of the work

Osteogenesis Imperfecta is a rare genetic condition. The use of total shoulder arthroplasty in these patients is very uncommon, with only two cases reported in the literature. This study describes a cementless reverse total shoulder arthroplasty (rTSA) for a multi-fragmented fracture in a patient affected by Osteogenesis Imperfecta (OI) type 1 and aims to review literature results of shoulder replacement in patients affected by this uncommon condition.

Methods:

The case of a woman affected by OI type 1 treated with a cementless rTSA for a multi-fragmented proximal humerus facture is reported. Focusing on the fixation technique, a literature review regarding the orthopaedic options in patients affected by Osteogenesis Imperfecta was performed and compared to the techniques used in the unaffected population.

Result:

Our patient shows good results in terms of clinical and radiological outcomes at the short term follow up. Few studies treat the orthopaedic manifestation of this rare genetic condition and only two are focused on shoulder arthroplasty. Cement is the preferred method for fixation in both papers.

Conclusion:

Cementless reverse shoulder arthroplasty may be an option in patients affected by OI type 1, although literature seems to support cement as the fixation method of choice. (www.actabiomedica.it)

Clinical and radiological outcomes with PEEK suture anchors used in rotator cuff repair: our experience confirm that a perianchor fluid signal on RM does not affect clinical outcome at one year of follow up

Introduction / objectives:

Osteolytic-type reactions of the perianchor bone which in magnetic resonance are manifested as hyperintensity of the signal in T2 images are reported in many studies. The doubt that this reaction of the bone could result in a loss of pull-out in the short and medium term and that it could therefore negatively affect tendon healing is the subject of an increasing number of studies. An osteolytic type signal around absorbable anchors can be explained by the metabilic processes in progress foreseen by the very nature of the material used, however this type of signal is also recognized around sutured implants or made of notoriously inert material. The objective of the present study is to evaluate and compare to the literature data the clinical and radiological results of a group of patients who underwent arthroscopic suture of a rotator cuff tear using polyetherketone (PEEK) suture anchors.

Materials and methods:

Twenty patients, aged between 44 and 73 years, who underwent arthroscopic repair of the rotator cuff for lesions smaller than 4 cm considered reparaible between August 2017 and January 2019, were enrolled in the present study. Patients were evaluated clinically with clinical examination, Constant scale and ASES scale pre and post surgery. MRI either pre and post operation at one year were evaluated to obtain data about tendon healing and evaluate bone reaction to PEEK anchors.

Results:

The mean lesion size was 16.8 mm +/- 7.8 mm and the mean tendon retraction was 15.6 mm +/- 14.9 mm. The mean increase in Constant and ASES scores at the one year-follow up was respectively 36.8 (p<0.01) and 47.2 (p<0.01). MRI analysis showed a tendon signal according to Sugaya classification of type 1 in the 25% of patients, type 2 in the 60% of cases and type 3 in the remaining 15% . Osteolysis was grade 0 in 65%, grade 1 in 30 % and grade 2 in 5% of cases. No anchors pull out or mobilization were reported.

Conclusions:

The presence of a T2 hyperintense signal osteolysis like on MRI control using PEEK anchors for the sutur of rotator cuff lesions does not find correlation whit the final clinical result of the procedure. Indeed, both patients with a major degree of osteolysis and those with degree 0 had an improvement both in terms of clinical and scores evaluation and in termsof tendon healing according to Sugaya’s score found in our cohort. (www.actabiomedica.it)

Anterior cruciate ligament reconstruction: the role of lateral posterior tibial slope as a potential risk factor for failure

Background and aim of the work:

Anterior cruciate ligament (ACL) reconstructions is an extremely frequent surgery. The analysis of anatomical factors is becoming increasingly important and the study of clinical, arthroscopic and radiological methods to evaluate and understand them aims to positively affect the patient’s outcome. This work aims to analytically analyze the anatomical factors that can influence the failure of an ACL reconstruction, to evaluate the data collected on a sample of patients undergoing ACL revision and compare them with those is present in the literature.

Materials and Methods:

At the Clinic of Orthopedic of Udine, between November 2018 and August 2020 were performed 47 revisions of the ACL. We analyzed MRI scans about Lateral Posterior Tibial Slope (LPTS). Patient surveys were analyzed by a single senior orthopedic surgeon who was blinded to patient history, age and gender.

Results:

Comparing with a value considered in the norm (LPTS estimated 6.5°) we see how the difference between the average LPTS values in the sample is significantly higher than the normal values (P <.0001). Dividing the simple according to sex, we notice that the LPTS in female patients is 11.8 while in male patients it is 8.7° (P <.005).

Conclusion:

The data collected show how an increased posterior lateral tibial slope can be correlated with a higher risk of ACL failure. The results are in line with what is present in the literature. Our analysis is absolutely preliminary, but it is intended to be the starting point of a path that allows us to think of the reconstruction of the ACL as an intervention to be planned more carefully based on the individual characteristics of the patient. (www.actabiomedica.it)

Reliability of open architecture anchors in biocomposite material: medium term clinical and MRI evaluation. Our experience

OBJECTIVES

Comparing radiologic bone ingrowth and the clinical outcomes of an open-construct (PEEK) (polyether ether ketone) suture anchor with those of a bio-composite suture anchor (glycolic polylactic acid anchors, beta-tricalcium phosphate and calcium sulphate) in patients with arthroscopic rotator cuff repair.

METHODS

From August 2017 to January 2019, 33 patients of both sexes, aged between 44 and 78 years underwent arthroscopic rotator cuff repair for tears considered repairable with an extension not exceeding4 cm. The bioabsorbable anchors used comprised glycolic polylactic acid/beta-tricalcium phosphate/ calcium sulphate, and the non-absorbable anchors in polyetheretherketone (PEEK). All patients underwent MRI evaluation at 12 months postoperatively to determine complications and identify any re-tear.

RESULTS

Clinical scores showed an improvement from both clinical and functional point of view. There were no statistically significant changes compared to the physical examination. On radiographs, mobilizations, anchor pull-outs or other complications did not occur in each group.

CONCLUSIONS

Shoulder function improved after complete repair of the rotator cuff and similar clinical results were achieved regardless of the material and shape of the suture anchor. The bioabsorbable anchors in innovative open architecture material seem to have results comparable to peek anchors. Unfortunately, further studies are needed to define the advantages in using one material compared to the other. (www.actabiomedica.it).

Histological analysis of ACL reconstruction failures due to synthetic-ACL (LARS) ruptures

INTRODUCTION

Anterior Cruciate Ligament (ACL) reconstruction is an established surgical procedure. Synthetic ligaments represent an option for ACL reconstruction. Their popularity declined for the raising concerns due to re-ruptures, knee synovitis and early arthritis related to I and II generation artificial ligaments. The introduction of a III generation synthetic ligament (Ligament Advanced Reinforcement System-LARS) permitted renewed interest in the adoption of this kind of graft. Main purpose of our study was to describe the histological findings on samples obtained from a consecutive series of ACL revision surgeries due to LARS ACL reconstruction failures. Secondary aim was to determine the reason for LARS rupture.

METHODS

In a period between 2016 and 2018 eleven patients underwent ACL revision surgery due to LARS ACL reconstruction failure. At the time of the arthroscopic procedure, samples of synovial membrane and remnants of the torn LARS were sent to the Pathological-Anatomy Institute of our Hospital for a histological analysis.

RESULTS

Histological analysis of the synovial tissues confirmed the arthroscopic evidence of synovitis mainly characterized by chronic inflammation with predominance of multinucleated giant cells. The adoption of polarized light microscopy revealed the presence of brightly bi-refractive material (LARS wear particles) in the synovial tissue; at higher magnification wear debris were detected inside the cytoplasma of multi nucleated cells. The histological analysis of the removed LARS revealed a surrounding typical foreign body reaction with poor signs of fibrovascular ingrowth of the synthetic ligament.

CONCLUSIONS

Our findings could not clearly advocate a unique mechanism of LARS-ACL reconstruction failure: biologic issues (poor tissue ingrowth) and mechanical issues (fibers properties and tunnel position) probably concur in a multi factorial manner. ACL reconstruction using artificial ligaments can not be considered a simple surgery. Artificial augments require some expertise and could therefore achieve better results if used by skilled sport surgeons other than trainees or low volume surgeons. The Authors believe that ACL reconstruction with synthetic devices still have restricted indications for selected patients (e.g. elderly patients who require a fast recovery, professional athlete, autologous tendons not available and/or refusing donor tendons). Our study arises additional suspicion on the unresponsiveness of synthetic fibers and claim some concern in the implantation of synthetic devices.

Onlay versus Inlay humeral steam in Reverse Shoulder Arthroplasty (RSA): clinical and biomechanical study

Background and aim of the work: Reverse shoulder arthroplasty (RSA) is becoming treatment of choice in glenohumeral arthropathies with massive lesion of the rotator cuff, due to a gradual extension of indications and new designs that provide better outcome. In this study we compared two different reverse shoulder prosthesis designs, defined as Inlay (or typical Grammont type) and a relatively new model defined as Onlay (that preserves tuberosity bone stock). We analyzed clinical, biomechanical and radiological outcomes, as well as complications of RSA in these two groups. Methods: We performed a prospective study on a population of 42 patients undergoing Reverse Shoulder Replacement by a single expert surgeon. We consider 21 patients (group A) who underwent to reverse shoulder replacement with a curved onlay steam with 145° inclination (Ascend Flex group, Wright medical, Memphis, TN, USA) and 21 patients who underwent to reverse shoulder replacement with a traditional Inlay Grammont steam (Modular Shoulder System SMR, Systema Multiplana Randelli; Lima-LTO, San Daniele del Friuli, Italy) between August 2010 and October 2018. We studied the following items: active range of motion (AROM), radiological parameters (lateralization shoulder angle LSA, Distalization Shoulder Angle DSA), functional scale (Constant-Murley Score), post-operative complications (infection, aseptical implant mobilitazion, residual pain, scapular notching, fractures, tuberosity reabsorbtion, dislocation, bleedings, nerve palsy, pulmonary embolus). Results: A significant improvement in ROM and functional score (Constant Shoulder Score) were observed in both groups. Group A (Onlay design 145°, medial tray) provides improvement in adduction, extension and external rotation compared to group B. No significant differences were found in abduction, external rotation and forward flexion. At 6 months follow-up, pain relief was detected in all patients. Although complications occur in a high percentage of patients in literature, no postoperative complications were observed in our cases series. Conclusions: Our results showed how RSA is a real solution to improve quality of life and to restore pain-free shoulder ROM in patients where cuff tear arthropathy occurs. Onlay design 145° may provides better active external rotation, extension, adduction: it is necessary to continue follow up and include more cases to prove these data. (www.actabiomedica.it)

Groin pain caused by iliopsoas synovial cyst treated with endoscopic approach. A case report

The diagnosis of iliopsoas synovial cyst is a rare finding. The normal approach to treat this condition has been conservative therapies or open surgery, with its associated complications and morbidity. The arthroscopic – endoscopic surgery is less invasive and with an increase in complications and days of hospitalization. We report the case of a 70-year old woman with clinical and imaging signs of a fluid-filled cyst near iliopsoas distal tendon. After fluid aspiration, the patient reported symptom-free interval of several weeks, but then groin pain and swelling feeling return, increased with hip movements. The cyst was removed through arthroscopy approach and the iliopsoas tendon was released. The removal of iliopsoas synovial cyst is necessary to avoid complications such as pain and functional limits. Arthroscopy has the advantage of less soft-tissue damage and quicker recovery. The treatment of associated tendon pathology can be done. Hip arthroscopy can be a safe and effective technique for the removal of iliopsoas synovial cyst. (www.actabiomedica.it)

Arthroscopic treatment of iliopsoas impingement syndrome after hip arthroplasty

BACKGROUND AND AIM OF THE WORK

Groin pain after hip arthroplasty (HA) ranges from 0.4% to 18.3%. Defining the cause of groin pain after HA can be difficult. Iliopsoas impingement (IPI) has been reported to be the underlying cause of groin pain in up to 4.4% of cases. The purpose of this study is to present arthroscopic surgical outcomes in the treatment of IPI after HA.

METHODS

Between September 2013 and March 2018, 13 patients, 11 total hip arthroplasty (THA), 1 hip endoprosthesis and 1 total hip resurfacing affected by groin pain due to unceasing iliopsoas tendinopathy for impingement after HA were treated arthroscopically. The patients underwent to physical examination, blood analysis, hip X-rays, bone scintigraphy and CT assessment. We performed the arthroscopic OUT-IN access to hip joint in all patients. VAS scale, Harris Hip Score (HHS) and Medical Research Council (MRC) scale were performed before surgery and during follow up at 1-3-6-12 months.

RESULTS

After 10 months of mean follow-up, average HHS and MRC scale improved significantly from preoperatively to postoperatively. No complications arose in our case series.

CONCLUSIONS

Hip arthroscopy after hip arthroplasty is supported in the literature for a variety of indications. Hip arthroscopy is a viable and reproducible technique in treatment of IPI, being less invasive than the classic open technique. This simple arthroscopic release provides satisfactory results and preserves HA function. Moreover an arthroscopic OUT-IN access proves good clinical outcomes, few complications and iatrogenic lesions.

Can UKA after KineSpring system failure be a viable option? A case report

Background and aim of the Work: The KineSpring System is an alternative treatment offered in selected symptomatic patients suffering from mild to moderate medial knee osteoarthritis (OA). This device reduces medial compartment loads in the OA knee without compromising the integrity of the lateral or patellofemoral knee compartments, maintaining the normal knee anatomy. Currently, papers about KineSpring System installation show promising results. The current authors describe a case of unicompartmental knee arthroplasty (UKA) employed to treat medial knee OA after Kinespring system failure. Methods: A 64-year old male patient presented to our hospital after failure of a Kinespring system implantation into his left knee at an external hospital, where the outcomes obtained were not satisfactory. The surgical options discussed with the patient were the TKA or medial UKA. A medial UKA was preferred by the patient. Results: One year from UKA, the patient complained of frequent joint effusions and weight bearing pain despite a good ROM without radiographic signs of implant loosening. Therefore, after two years we replaced UKA with total knee arthroplasty (TKA). Conclusions: Further experience is needed to provide reliable clinical data about the results of the UKA after KineSpring System discharge. (www.actabiomedica.it)

Heterotopic Ossification in Primary Total Hip Arthroplasty: which is the role of drainage?

Background and aim of the work: The Heterotopic Ossification (HO) is a common complication following Total Hip Arthroplasty (THA). Although there is no concordance in Literature regarding the etiopathogenic mechanism, various HO risk factors have been recognized, both related to the patient and associated with the surgical procedureLiterature does not consider the use of intra-articular drainage as a possible risk factor. Our hypothesis is that this item can contribute to the development of HO. Materials and Methods: 425 implants of hip arthroplasty performed between 2014 and 2017 at the Ortopedic Clinic of Udine were included in the study. No patient performed pre-operative or post-operative anti-HO prophylaxis during follow-up. Radiographs of preoperative and postoperative at 1 year were analyzed according to the Brooker Classification.Results: The incidence of HO in patients with intra-articular drainage is 24.6%, while the incidence of HO in patients without intra-articular drainage is 15.3%, with a statistically significant difference. Conclusions: The data obtained suggest to consider the use of intra-articular drainage as a possible intra-operative risk factor for HO. This is a retrospective cohort study, so we need more studies and more robust experimental designs to confirm these results. (www.actabiomedica.it)

Rotator cuff tears reparability index based on pre-operative MRI: our experience

Background and aim of the work: It is recognised that a significant percetage of large and massive rotator cuff tears (RCT) cannot be anatomically repaired and this correlates with a worste outcome in terms of pain, active range of motion, increased incidence of retair. The aim of our work is to find reliable index on pre-operative MRI shoulder image to assist orthopaedist in surgical planning of rotatator cuff tears repair. Methods: We performed a retrospective study on a population on 131 patients undergoing arthroscopic cuff repair by a single expert surgeon. Pre-operative MRI images were evaluated by a single orthopaedist, trained on MRI shoulder images ad blinded to surgical outcome. For each magnetic resonance we evaluated the following 9 parameters: fatty Infiltration (FI), Patte Stage (PS), tear size measured in medial-lateral (ML) and anterior-posterior (AP) dimension, Tangent Sign (TS), Occupation Grade (OG), Acromion-Humeral Distance (AHD), Inferior Gleno-Humeral Distance (IGHD), Glenoid Version Angle (GVA). We divided population into two groups: patients who obtained a complete repair of RCT (n=110) and patients who obtained only a partial repair of RCT (n=21). For each MRI index we conducted statistical analysis (Student’s t test, Mann-Whitney U test, Shapiro-Wilk test, Chi-square test, Fisher exact test, ROC curves and maximum Youden index) to find a Cut Off value useful to predict partial repair. Results: We have found statistical significance in predicting partial repair on MRI mesurements of Fatty Infiltration (FI grade ≥3; test di Fisher p<0.001), Patte Stage (grade= 3; test di Fisher p<0.001), Tear size measured in ML (>36 mm; Mann-Whitney p<0.001), Positive Tangent Sign (Chi-quadro p<0.001; sensitivity 95,3%, specificity 83,6%), Occupation Grade (OG <0,46; t-test p<0.001). Acromion-Humeral Distance (AHD <7 mm), Inferior Gleno-Humeral Distance (IGHD >5 mm). Tear size measured in AP (>21 mm; Mann-Whitney p<0.001) seems to be dependent on the contextual size of the lesion in ML. We haven’t found statistical significance in predicting partial repair of Glenoid Version Angle. Conclusions: A systematic observation of seven independent MRI parameters (FI, PS, tear size ML, TS, OG, AHD, IGHD) can help the surgeon to predict the impossibility to obtain complete repair of RCT and to consider different surgical approach. (www.actabiomedica.it)

Rivaroxaban and early periprostethic joint infection: our experience

BACKGROUND AND AIM OF THE WORK

Periprostethic joint infection (PJI) is a severe post-operative complication after Primary Total Hip Arthroplasty (THA). According to the classification of PJI early acute PJI occurs within 4 weeks from surgery. Some authors think that Rivaroxaban is a risk factor in the incidence of early acute PJI. We analyze our experience about this item.

MATERIALS AND METHODS

We analyze our experience from 1st January 2015 to 31th December 2016. We consider all consecutive hip arthroplasty implants in this period.

RESULTS

In the 205 patients analysed we not find early acute PJI in Rivaroxaban group nor in the others assuming another kind of thromboprophylaxis.

CONCLUSIONS

In our series there is no evidence of association between Rivaroxaban and early acute PJI. This is a retrospective cohort study, so we need more studies and more robust experimental designs to confirm these results.

The SMR reverse shoulder arthroplasty in rotator cuff arthropathy management

BACKGROUND AND AIM OF THE WORK

Cuff tear arthropathy (CTA) is a well-defined  degenerative pathology  of the shoulder. When conservative treatments are unable to permit a good quality of life, the reverse shoulder arthroplasty (RSA) can guarantee a good restitution of range of motion, function and strength of the shoulder without pain. In this paper we show our clinical, functional and radiological outcomes, as well as complications of RSA in patients with CTA.

METHODS

We analyzed 31 patients who underwent to reverse shoulder replacement with Modular Shoulder System (SMR, Systema Multiplana Randelli; Lima-LTO, San Daniele del Friuli, Italy) reverse shoulder system, between August 2010-July 2014.

RESULTS

A significant improvement in ROM and functional scores (Constant Shoulder Score and UCLA score) were observed in our cases series. At the time of follow-up  pain relief was detected in 28 patients and 3 patients declared mild pain. Overall, 90.3% of patients rated their satisfaction as good or excellent. Although  complications occur in a high percentage of patients in literature, no postoperative complications was observed in our cases series.

CONCLUSIONS

Our results showed how reverse shoulder arthroplasty is a real solution to improve quality of life, to restore pain-free ROM, function and strength of the shoulder in patients where cuff tear arthropathy occurs.

Partial repair in irreparable rotator cuff tear: our experience in long-term follow-up

AIM OF THE WORK

Massive rotator cuff tears are a common source of shoulder pain and dysfunction, especially in middle age patient; these lesions represent about 20% of all rotator cuff tears and 80% of recurrent tears. Some lesions are not repairable or should not be repaired: in this case, a rotator cuff partial repair should be recommended. The aim of the study is to evaluate the outcome of rotator cuff partial repair in irreparable rotator cuff massive tear at medium and long-term follow-up.

MATERIALS AND METHOD

We have evaluated 74 consecutive patients treated with functional repair of rotator cuff by the same surgeon between 2006 and 2014. We divided patients into 2 groups, obtaining 2 average follow-up: at about 6,5 (group A) and 3 years (group B). In December 2015, we evaluated in every patient ROM and Constant Score. We analyzed difference between pre-operatory data and the 2 groups.  Results: We found statistical significant difference in ROM and in Constant Score between pre-operatory data and group A and group B. Between group A and group B there is relevant difference in Constant Score but not in ROM.

CONCLUSIONS

Partial repair can give good results in a medium follow-up, in terms of pain relief and improvement of ROM, as well as in quality of life. Difference in ROM and Constant Score between group A and group B may indicate the begin of partial repair failure; according to our data, 6-7 years may be the time limit for this surgery technique.

Acute periprosthetic knee infection: is there still a role for DAIR?

BACKGROUND AND AIM OF THE WORK

Periprosthetic knee infection is a rare complication associated with prosthetic failure; incidence change from 0,4-2% of primary total knee replacement and 5.6% in revisions. Indications for debridment, antibiotics and implant retention (DAIR) are early acute infections or acute delayed infection. Aim of the work is to check if this technique is still a successful in early infections.

METHODS

We have analyzed recent literature data on DAIR and all DAIR procedures in our clinic in the last 10 years, the mean time between onset of symptoms and surgery, the mean antibiotic therapy duration and results we have obtained. We evaluate the diagnostic process and different treatments in early knee periprosthetic infections, especially the DAIR approach.

RESULTS

If correct indications are followed, DAIR has a success rate in 31-100% of the cases; if it is applied in late chronic infection the success rate is 28-62%. In our experience DAIR has an 80% success rate: in 20 patients treated with DAIR we had 4 failures.

CONCLUSIONS

DAIR can be considered a successful treatment, but it depends from individual patient factors, from the microorganisms involved, from the duration of antibiotic therapy and from correct choice in timing and in execution of DAIR by the orthopedic surgeon.

Computer assisted total knee arthroplasty: a real navigation to better results?

BACKGROUND AND AIM OF THE WORK

Computer assisted surgery in knee replacement is still in discussion, but majority of papers affirm an increase of the accuracy in alignment. Aim of our study is to evaluate the accuracy of mechanical axis, the posterior tibial slope and the femoral component rotation with navigation, x-ray and CT data.

METHODS

We have analysed 145 patients who underwent total knee arthroplasty between January 2012 and December 2014. We have checked each patient at 6, 12 and 24 months of follow-up. During each visit, we did a clinical evaluation checking the ROM and a clinical score (KOOS). At 2 years, we did a CT evaluation and a plain x-ray evaluation.

RESULTS

125 patients have completed the follow-up. Mean follow-up time was 2,6 years. Both ROM and KOOS values increased during follow-up. About the mechanical axis, both x-ray and CT data showed a mean deviation <2° from the target. About posterior tibial slope and femoral component rotation, CT data showed a mean deviation of <3° from the target. Mean difference between navigation and CT data was <1°.

CONCLUSIONS

According to literature data, our data confirm that computer assisted surgery in knee replacement have a good accuracy of coronal alignment, rotational alignment and posterior tibial slope.

Two-stage revision after total knee arthroplasty

BACKGROUND AND AIM OF THE WORK

Periprosthetic knee infection is a complication associated with prosthetic failure; incidence change from 0,4-2% of primary total knee replacement and 5,6% in revisions; incidence is increasing over the years. Two-stage revision is the technique used in chronic infection. Aim of the work is to check success rate in our data. Methods. We analyzed retrospectively data of patients who undergone two stage revision surgery between 01/01/2010 to 31/12/2015. We made a clinical and radiological control after 1, 3, 6, 12, 24 months and we evaluate the outcome in December 2016. Results. Between 2010 and 2015 we treated 45 patients with two-stage revision. Mean follow-up was 3,4 years. Success rate is 89,9%. We had failure in 5 patients: everyone had knee surgery before first knee arthroplasty and Charlson Comorbidity Score was greater then 4 in 4 cases. Conclusions. Two stage revision can be considered a successful treatment in chronic periprosthetic knee infection. It has an optimal success rate, but it has some disadvantages as joint stiffness and pain in the interval between stages. This is a technique with two major surgery procedure with associated morbidity, discomfort, cost and prolonged stay in hospital.

Rivaroxaban and early periprostethic joint infection: our experience

BACKGROUND AND AIM OF THE WORK

Periprostethic joint infection (PJI) is a severe post-operative complication after Primary Total Hip Arthroplasty (THA). According to the classification of PJI early acute PJI occurs within 4 weeks from surgery. Some authors think that Rivaroxaban is a risk factor in the incidence of early acute PJI. We analyze our experience about this item.

MATERIALS AND METHODS

We analyze our experience from 1st January 2015 to 31th December 2016. We consider all consecutive hip arthroplasty implants in this period.

RESULTS

In the 205 patients analysed we not find early acute PJI in Rivaroxaban group nor in the others assuming another kind of thromboprophylaxis.

CONCLUSIONS

In our series there is no evidence of association between Rivaroxaban and early acute PJI. This is a retrospective cohort study, so we need more studies and more robust experimental designs to confirm these results.

Computer assisted total knee arthroplasty: a real navigation to better results?

BACKGROUND AND AIM OF THE WORK

Computer assisted surgery in knee replacement is still in discussion, but majority of papers affirm an increase of the accuracy in alignment. Aim of our study is to evaluate the accuracy of mechanical axis, the posterior tibial slope and the femoral component rotation with navigation, x-ray and CT data.

METHODS

We have analysed 145 patients who underwent total knee arthroplasty between January 2012 and December 2014. We have checked each patient at 6, 12 and 24 months of follow-up. During each visit, we did a clinical evaluation checking the ROM and a clinical score (KOOS). At 2 years, we did a CT evaluation and a plain x-ray evaluation.

RESULTS

125 patients have completed the follow-up. Mean follow-up time was 2,6 years. Both ROM and KOOS values increased during follow-up. About the mechanical axis, both x-ray and CT data showed a mean deviation <2° from the target. About posterior tibial slope and femoral component rotation, CT data showed a mean deviation of <3° from the target. Mean difference between navigation and CT data was <1°.

CONCLUSIONS

According to literature data, our data confirm that computer assisted surgery in knee replacement have a good accuracy of coronal alignment, rotational alignment and posterior tibial slope.

The SMR reverse shoulder arthroplasty in rotator cuff arthropathy management

BACKGROUND AND AIM OF THE WORK

Cuff tear arthropathy (CTA) is a well-defined  degenerative pathology  of the shoulder. When conservative treatments are unable to permit a good quality of life, the reverse shoulder arthroplasty (RSA) can guarantee a good restitution of range of motion, function and strength of the shoulder without pain. In this paper we show our clinical, functional and radiological outcomes, as well as complications of RSA in patients with CTA.

METHODS

We analyzed 31 patients who underwent to reverse shoulder replacement with Modular Shoulder System (SMR, Systema Multiplana Randelli; Lima-LTO, San Daniele del Friuli, Italy) reverse shoulder system, between August 2010-July 2014.

RESULTS

A significant improvement in ROM and functional scores (Constant Shoulder Score and UCLA score) were observed in our cases series. At the time of follow-up  pain relief was detected in 28 patients and 3 patients declared mild pain. Overall, 90.3% of patients rated their satisfaction as good or excellent. Although  complications occur in a high percentage of patients in literature, no postoperative complications was observed in our cases series.

CONCLUSIONS

Our results showed how reverse shoulder arthroplasty is a real solution to improve quality of life, to restore pain-free ROM, function and strength of the shoulder in patients where cuff tear arthropathy occurs.

Two-stage revision after total knee arthroplasty

Background and aim of the work: Periprosthetic knee infection is a complication associated with prosthetic failure; incidence change from 0,4-2% of primary total knee replacement and 5,6% in revisions; incidence is increasing over the years. Two-stage revision is the technique used in chronic infection. Aim of the work is to check success rate in our data. Methods: We analyzed retrospectively data of patients who undergone two stage revision surgery between 01/01/2010 to 31/12/2015. We made a clinical and radiological control after 1, 3, 6, 12, 24 months and we evaluate the outcome in December 2016. Results: Between 2010 and 2015 we treated 45 patients with two-stage revision. Mean follow-up was 3,4 years. Success rate is 89,9%. We had failure in 5 patients: everyone had knee surgery before first knee arthroplasty and Charlson Comorbidity Score was greater then 4 in 4 cases. Conclusions: Two stage revision can be considered a successful treatment in chronic periprosthetic knee infection. It has an optimal success rate, but it has some disadvantages as joint stiffness and pain in the interval between stages. This is a technique with two major surgery procedure with associated morbidity, discomfort, cost and prolonged stay in hospital. (www.actabiomedica.it)

Partial repair in irreparable rotator cuff tear: our experience in long-term follow-up

AIM OF THE WORK

Massive rotator cuff tears are a common source of shoulder pain and dysfunction, especially in middle age patient; these lesions represent about 20% of all rotator cuff tears and 80% of recurrent tears. Some lesions are not repairable or should not be repaired: in this case, a rotator cuff partial repair should be recommended. The aim of the study is to evaluate the outcome of rotator cuff partial repair in irreparable rotator cuff massive tear at medium and long-term follow-up.

MATERIALS AND METHOD

We have evaluated 74 consecutive patients treated with functional repair of rotator cuff by the same surgeon between 2006 and 2014. We divided patients into 2 groups, obtaining 2 average follow-up: at about 6,5 (group A) and 3 years (group B). In December 2015, we evaluated in every patient ROM and Constant Score. We analyzed difference between pre-operatory data and the 2 groups.  Results: We found statistical significant difference in ROM and in Constant Score between pre-operatory data and group A and group B. Between group A and group B there is relevant difference in Constant Score but not in ROM.

CONCLUSIONS

Partial repair can give good results in a medium follow-up, in terms of pain relief and improvement of ROM, as well as in quality of life. Difference in ROM and Constant Score between group A and group B may indicate the begin of partial repair failure; according to our data, 6-7 years may be the time limit for this surgery technique.

Acute periprosthetic knee infection: is there still a role for DAIR?

BACKGROUND AND AIM OF THE WORK

Periprosthetic knee infection is a rare complication associated with prosthetic failure; incidence change from 0,4-2% of primary total knee replacement and 5.6% in revisions. Indications for debridment, antibiotics and implant retention (DAIR) are early acute infections or acute delayed infection. Aim of the work is to check if this technique is still a successful in early infections.

METHODS

We have analyzed recent literature data on DAIR and all DAIR procedures in our clinic in the last 10 years, the mean time between onset of symptoms and surgery, the mean antibiotic therapy duration and results we have obtained. We evaluate the diagnostic process and different treatments in early knee periprosthetic infections, especially the DAIR approach.

RESULTS

If correct indications are followed, DAIR has a success rate in 31-100% of the cases; if it is applied in late chronic infection the success rate is 28-62%. In our experience DAIR has an 80% success rate: in 20 patients treated with DAIR we had 4 failures.

CONCLUSIONS

DAIR can be considered a successful treatment, but it depends from individual patient factors, from the microorganisms involved, from the duration of antibiotic therapy and from correct choice in timing and in execution of DAIR by the orthopedic surgeon.

Growth Plate Lesions of Fattening Bulls

Lameness related to growth plate lesions is an important problem in the beef industry. This article describes the macroscopic and microscopic lesions in the distal metatarsal physis of bulls from an association of farmers in northeastern Italy. The metatarsal bones of 62 bulls (12 with severe lameness and 50 without lameness), average age 16.44 ± 1.72 months, were examined at the abattoir. The animals came from the same geographic area and shared intensive husbandry practices and a diet based on maize starch. A total of 124 metatarsal bones were sectioned, and the distal metaphyseal growth plate was grossly examined. Twenty-three cases, including 12 lame and 9 nonlame animals with visible lesions on macroscopic examination, and 2 controls (a total of 46 physes) were examined microscopically. Eight of 12 bulls with severe lameness had a chronic purulent physitis in at least 1 limb. Segmental thickening of the hypertrophic zone, consistent with osteochondrosis (OC), was present contralaterally ( n = 3 cases) and bilaterally ( n = 3 cases) in 6 of these animals. In the group of nonlame bulls, 19 of 50 (38%) had similar segmental thickening of the physis consistent with OC. In the remaining bulls, minor findings included partial closure of the physis and a variable degree of metaphyseal hyperemia. A high incidence of OC was found in both lame and nonlame fattening bulls. It is likely that lame animals were clinically more severe due to secondary hematogenous implantation of bacteria, resulting in a purulent physitis and severe lameness that required emergency slaughter in some cases.

Causes of Failure of Anterior Cruciate Ligament Reconstruction and Revision Surgical Strategies

Purpose

Long-term outcomes of anterior cruciate ligament (ACL) reconstruction are good or excellent; however, 0.7%–20% of patients suffer from recurrent instability due to graft failure. The purpose of this paper was to analyse failure aetiology and the possibilities of revision surgical strategies, with a description of our experience. We obtained optimal and good results in most of our patients.

Materials and Methods

We retrospectively reviewed 42 patients who underwent revision surgery (43 revisions) due to relapsing instability after ACL reconstruction between 2006 and 2015. We used allografts in 39 cases and autografts in 4 cases.

Results

The 85.7% of the patients obtained optimal results (normal knee; group A) and the 7.2% obtained good results (nearly normal knee; group B) according to the International Knee Documentation Committee score. The most frequent failure causes were traumatic events, non-anatomic tunnel placement, and lack of graft incorporation.

Conclusions

A correct revision surgery requires accurate patient evaluation and knee imaging. Preoperative planning starts with the identification of the cause of failure of the primary reconstruction. Then, the most suitable procedure should be determined for each case. It is also important to accurately inform the patient of all the complexity of an ACL revision surgery even if it is a procedure with high rates of excellent and good outcomes.

Extracapsular vs standard approach in hip arthroscopy

BACKGROUND

Over the last decades, the arthroscopic treatment of hip pathology has highly grown thanks to the evolution of surgical and diagnostic techniques and instrumentation development. Furthermore the higher life expectancy and functional request make younger patients to be evaluated more frequently for non-arthrosic hip pathologies like labral lesion, FAI, cartilage tears. Treatment substantially has to be chosen between arthroscopy and arthrotomy. This study pretends to compare the clinical outcome between two different arthroscopic access techniques: the traditional one and the extrarticolar one (OUT-IN) we are using regularly in our clinic.

METHODS

From 2012 to 2014, 37 patients with FAI were treated with traditional technique (Group A) and 28 with extra-articular access (Group B). Indication to surgery treatment was given on the basis of radiological imaging (Pelvis Rx, Hip Rx in AP, Frog Leg view, Dunn view, Pelvic MRI) (8, 9), dynamic range of motion, clinical examination and functional scores (MHHS, MHOT). Pain was scored with NRS.  Minimum follow up for each patient was 12 month with clinical controls and functional score recording at 3-6-12 month after surgery. Complications or iatrogenic lesions were assessed.

RESULTS

At 12 month after surgery there was no statistically significant differences in hip R.O.M., MHHS and MHOT (33) score. We observed an higher number of iatrogenic lesions and complications in the group A (standard technique) than group B.

CONCLUSIONS

Hip arthroscopy is a viable and reproducible alternative technique when treating articular lesion such as femur-acetabular impingement and it is demonstrated by the increase of functional score. We can furthermore appreciate that an extra-articular access technique leads to a vary good outcome both in hip R.O.M. and functional scores and has a very low number of complications and iatrogenic lesions.

Histopathological aspects and staging systems in non-traumatic femoral head osteonecrosis: an overview of the literature

BACKGROUND

The pathogenesis of non traumatic osteonecrosis of the femoral head (ONFH) has not yet been established. The literature shows a variable nomenclatura for this condition that often leads to confusion. Several risk factors have been identified but histopathological and radiological outcomes are common.

PURPOSE

To provide the overview on the current knowledges about the nomenclatura, etiology, disease progression, relationship between histopathological changes and imaging techniques in order to stage the disease accurately. Etiology and pathogenesis: Genetic predisposition, metabolic factors, local factors affecting blood supply such as vascular damage, increased intraosseous pressure and mechanical stress are involved in this desease. The final results are bone ischemia and infarction getting bone deathand FH collapse. Histopathological aspects and staging systems: Several staging systems have been developed to stage ONFH based on imaging techniques.The  subchondral collapse, the size or quantification of the lesion, and the lesion location within the femoral head are identified as the most important prognostic factors in ONFH disease. Histological analysis plays a critical role to evaluate the quality of necrotic area and the differences between microscopic, macroscopic and imaging outcomes were detected.

CONCLUSIONS

an ideal staging system is necessary to stage ONFH desease to detect several aspects, but itìs more difficult to create. At the present time we summarize some aspects that are advisable to focus during ONFH for the correct treatment.

The role of intraoperative frozen section in arthroplasty revision surgery: our experience

BACKGROUND AND AIM OF THE WORK

Due to the increasing the number of hip and knee replacement in the future will be increasing the number of cases of prosthetic revision. Our aim is to test the validity of extemporaneous exam for differentiation between septic and aseptic loosening of prosthetic.

METHODS

159 patients underwent surgery for the prosthesis revision from 2008 to 2014 An intraoperative histological examination was performed during all the surgeries and multiple samples were taken for the conclusive histological examination and culture.

RESULTS

Sensitivity of the intraoperative histological examination resulted 38,3% (IC 0,26; 0,51); specificity 82,5% (IC 0,73; 0,90), where positive predictive value was 57,5% (IC 0,41; 0,73) and negative predictive value 68,4% (IC 0,59; 0,76).

CONCLUSIONS

In the absence of a universally accepted method to diagnose infection in patients with mobilization of the prosthesis, intraoperative histological examination is, in spite of everything, a method easy to perform and reproduce, it shows high specificity and sensitivity in the presence of highly virulent pathogens.

Arthroscopic rotator cuff repair with or without PrP: our experience

BACKGROUND AND AIM OF THE WORK

Arthroscopical rotator cuff repair has good results, but the rate of tendon healing is 80% in small tears with a decrease to 30% in large and massive tears. Platelets are an endogenous source of growth factors present during rotator cuff healing. Aim of the work is checking if Cascade Autologous Platelet System may improve rotator cuff healing in small sovraspinatus tears.

METHODS

Each patient enrolled in cases  has surgical arthroscopical repair of sovraspinatus  small tear and then treated with intraoperatory Cascade. Patients of control group undergoing the same surgery with traditional arthroscopic repair. Follow-up time was at 3, 6, 12 month from surgery with evaluation of ROM, strength, Constant score, NRS. RMN was repeated at 12 month from surgery with evaluation of sovraspinatus tendon thickness, signal intensity, fat degeneration and muscle atrophy.

RESULTS

Between 2010 and 2013, 18 patients have undergone sovraspinatus repair in arthroscopic surgery  with intraoperatory Cascade and 18 patients with traditional arthroscopic repair. Only sovraspinatus tendon thickness and  signal intensity were  statistically difference in the cases group. In ROM, strength, Constant score, NRS, fat degeneration and muscle atrophy were not a statistically difference compared with controls.

CONCLUSIONS

In small sovrapinsatus tears Cascade Autologous Platelet System did not result in improved ROM, strength, Constant score, NRS, tendon fat degeneration and muscle atrophy. Only sovraspinatus  tendon thickness and  signal intensity were improved.

Design evolution in total knee replacement: which is the future?

Total knee replacement (TKR) procedures have evolved in the last 40 years to guarantee improvements implants life and an excellent joint function. The goals for the future evolutions are make easier prosthesis implantation and promote precision. The demand for TKR will rise for the life length increase and for the risk factors impact increase. Design evolution in total knee replacement has to satisfy these new necessities: anatomic congruence, range of motion, less material wear and better resistance to the weight bearing and to the stresses. This paper analyzes design evolution, materials development and future purposes in total knee arthroplasty. At the beginning, TKR history is treated; then we compare several prosthetic designs developed during years. At last the paper speak about recent innovations, like CAD (computer aided design) for example, born to reach the most important goal in the future: better TKR design, is the one that better imitate natural knee characteristics, and that is able to integrate it-self with capsule-ligaments and muscle-tendons patient structures.

Arthroscopic treatment of isolated subscapolaris lesions: our experience

BACKGROUND AND AIM OF THE WORK

Subscapularis tendon lesions, in particular the isolated ones, are often not recognized and undervalued, so in the literature they are described with a variable incidence. Aim of the work is presenting our experience with the short to medium term follow up results of the arthroscopic repair of isolated subscapularis lesions.

METHODS

We retrospectively analyzed 311 shoulder arthroscopies performed by a single senior surgeon, from which we have found 10 isolated subscapularis lesions. After the arthroscopic repair of subscapularis tendon the patients have been evaluated with a median follow up of 17.7 months with specific tests for the subscapularis (Napoleon's and lift off tests) and clinical scores (Constant and UCLA scores).

RESULTS

We have obtained the tests negativization with an internal rotation level up to D8. The Constant score reached 86.7 with a median improvement of 49.4 points. The UCLA score at the last follow up was 30.8 with a median improvement of 20.1 points.

CONCLUSIONS

Isolated subscapularis lesions are uncommon and often they are not correctly diagnosed. Arthroscopy has a decisive role in both the diagnostic and therapeutic side, with good short to medium term results.

Persistence ofCandida albicansCandidemia in Non-Neutropenic Surgical Patients: Management of a Representative Patient in the Absence of Second-Line Treatment Guidelines

Primary treatment failure and mortality in non-neutropenic patients with candidemia is high according to clinical trial experience. Current guidelines are mainly useful only for first line treatment strategies.We describe treatment failure and persistent protracted Candida albicans candidemia without clinically evident ocular involvement nor catheter recolonization in a malnourished non-neutropenic surgical patient with peritonitis. Primary antifungal treatment failure with fluconazole and secondary treatment failure with caspofungin occurred in the absence of evident Candida seeding the eye, valvular endocardium, or the intravascular catheter. Switch to liposomal amphotericin B was followed by clinical and microbiological cure. In patients with multiple risk factors for the acquisition of candidemia and life-threatening clinical conditions, the possibility of primary/secondary failure of new potent antifungal regimens may be initially neglected. Additional multicenter controlled clinical data are needed to guide the timing and choice of secondary antifungal treatment regimens in non-neutropenic candidemia patients.

A prospective survey of febrile events in hematological malignancies

The Hema e-Chart prospectively collected data on febrile events (FEs) in hematological malignancy patients (HMs). The aim of the study was to assess the number, causes and outcome of HM-related FEs. Data were collected in a computerized registry that systematically approached the study and the evolution of FEs developing in a cohort of adult HMs who were admitted to 19 hematology departments in Italy from March 2007 to December 2008. A total of 869 FEs in 3,197 patients with newly diagnosed HMs were recorded. Fever of unidentified origin (FUO) was observed in 386 cases (44.4%). The other causes of FE were identified as noninfectious in 48 cases (5.5%) and infectious in 435 cases (50.1%). Bacteria were the most common cause of infectious FEs (301 cases), followed by fungi (95 cases), and viruses (7 cases). Mixed agents were isolated in 32 episodes. The attributable mortality rate was 6.7% (58 FEs). No deaths were observed in viral infection or in the noninfectious groups, while 25 deaths were due to FUO, 16 to bacterial infections, 14 to fungal infections, and three to mixed infections. The Hema e-Chart provided a complete system for the epidemiological study of infectious complications in HMs.

Human cases of West Nile Virus Infection in north-eastern Italy, 15 June to 15 November 2010

In 2010, for the third consecutive year, human cases of West Nile virus (WNV) infection, including three confirmed cases of neuroinvasive disease and three confirmed cases of West Nile fever, were identified in north-eastern Italy. While in 2008 and 2009 all human cases of WNV disease were recorded in the south of the Veneto region, cases of WNV disease in 2010 additionally occurred in two relatively small northern areas of Veneto, located outside those with WNV circulation in the previous years. WNV IgG antibody prevalence in blood donors resident in Veneto was estimated as ranging from 3.2 per 1,000 in areas not affected by cases of WNV disease to 33.3 per 1,000 in a highly affected area of the Rovigo province. No further autochthonous human cases of WNV disease were notified in Italy in 2010. The recurrence of human cases of WNV infection for the third consecutive year strongly suggests WNV has become endemic in north-eastern Italy.

Human cases of West Nile Virus infection in north-eastern Italy, 15 June to 15 November 2010

In 2010, for the third consecutive year, human cases of West Nile virus (WNV) infection, including three confirmed cases of neuroinvasive disease and three confirmed cases of West Nile fever, were identified in north-eastern Italy. While in 2008 and 2009 all human cases of WNV disease were recorded in the south of the Veneto region, cases of WNV disease in 2010 additionally occurred in two relatively small northern areas of Veneto, located outside those with WNV circulation in the previous years. WNV IgG antibody prevalence in blood donors resident in Veneto was estimated as ranging from 3.2 per 1,000 in areas not affected by cases of WNV disease to 33.3 per 1,000 in a highly affected area of the Rovigo province. No further autochthonous human cases of WNV disease were notified in Italy in 2010. The recurrence of human cases of WNV infection for the third consecutive year strongly suggests WNV has become endemic in north-eastern Italy.

Conserved T cell and natural killer cell function in treatment-experienced adults receiving tenofovir plus didanosine as nucleoside reverse transcription inhibitor backbone

Anti-retroviral treatment (ART) usually results in efficient control of virus replication and in immune reconstitution. Among potential adverse effects, impairment of immune responses in terms of CD4(+) T cell counts has been attributed to some ART regimens, as with didanosine-tenofovir. We studied the functional integrity of adaptive and innate immunity during didanosine-tenofovir-containing ART. Two groups of extensively pretreated patients completing at least 48 weeks of ART containing either lamivudine-didanosine (n = 21) or tenofovir-didanosine (n = 25) were identified. In addition to standard clinical immune and virological parameters, we performed a flow cytometric analysis of natural killer (NK) cells, of memory and naive CD4(+) T cells and of T cell receptor alphabeta(+) T cells co-expressing inhibitory NK receptors. Functional analysis consisted in specific and total interferon-gamma production by NK cells and of recall antigen proliferation of peripheral blood mononuclear cells. Comparable clinical immunological reconstitution and virological control were confirmed in the two groups of patients in the absence of clinically relevant adverse effects. The proportion of CD4(+)CD45RA(+) T cells and of functionally inhibited killer immunoglobulin-like receptor T cell receptor alphabeta(+) cells, the proliferation to recall antigens as well as NK cell phenotype and function as determined by interferon-gamma production in patients treated with tenofovir-didanosine were comparable to those treated with a different regimen. Thus, no differences in functional innate or adaptive immune reconstitution are detected in drug-experienced human immunodeficiency virus-infected patients on tenofovir-didanosine nucleoside reverse transcription inhibitor regimens.

A fatal case of invasive fungal sinusitis by Scopulariopsis acremonium in a bone marrow transplant recipient

A fatal case of Scopulariopsis acremonium sinus infection in an allogeneic hematopoietic stem cell transplant patient is reported. Rapid vascular diffusion of the fungus to the major head vessels was observed, which led to subsequent repeated cerebral ischemia and death. The presence of hyphae in the right carotid wall might be considered an indirect sign of fungal blood diffusion in the absence of positive blood cultures. The infection developed during the course of prolonged voriconazole prophylaxis, which was found to be effective in the in vitro antifungal drug assay. This finding induced us to consider the capacity of this drug to reach infected paranasal sinuses, and the need in cases such as this of a combined systemic and local pharmacological therapy or a combined medical and surgical approach.

Clinical experience with eperisone in the treatment of acute low back pain

AIM

A muscle contracture is the main responsible for low back pain and it consists of a persistent and involuntary muscle shortening, but it may be also the consequence of back pain thus fostering the painful condition. The goals of a pharmacological treatment for acute low back are, therefore, not only the relief of pain, but also the reduction of muscle spasm and inflammation, since nociception often results from local secondary inflammation and muscle spasm. Although systematic reviews have shown that muscle relaxants are effective in the management of non-specific low back pain, the use of these compounds is often limited by adverse effects on central nervous systems (CNS), such as drowsiness. Thus, the effects of eperisone, a new muscle relaxant agent with no CNS adverse effects, have been investigated.

METHODS

A total of 100 patients (38 males and 62 females) with acute low back pain and moderate contracture of the spinal muscles arisen since less than 48 h were enrolled in the study. After physical examination, these patients were treated with eperisone 50 mg every 8 h for 10 consecutive days and were visited again after 3 days and at the end of treatment.

RESULTS

Only 4 patients (4%) were obliged to stop treatment because of minor gastrointestinal adverse reactions. The administration of eperisone resulted in a prompt reduction of both spontaneous and provoked pain, as well as in a progressive decontracture of spinal muscles, as suggested by a reduction in resistance to passive movement, antalgic rigidity and ''hand-to-floor'' distance.

CONCLUSION

Eperisone is thus a muscle relaxant agent, with a mechanism of action slightly different from that of other muscle relaxants. In addition to an inhibition of mono- and multisynaptic reflexes in the spinal cord and supra-spinal structures, eperisone regulates the blood supply to skeletal muscles; this action is noteworthy since a muscle contracture may compress the small blood vessels and induce an ischemia leading to release of nociceptive compounds. Most importantly, eperisone is devoid of detrimental effects on CNS.

Therapeutical aspects and outcome of HIV/HCV coinfected patients treated with pegylated interferon plus ribavirin in an Italian cohort

BACKGROUND

One-third of HIV-infected individuals suffer from chronic hepatitis C virus infection (HCV) in Europe. Recommendations from HCV-HIV International Panel advise current treatment with pegylated interferon plus ribavirin. We assessed the impact of interferon and ribavirin combination in 43 patients between 2002 and 2006.

PATIENTS AND METHODS

All coinfected patients treated for HCV during the 5-year period were included in retrospective data collection. CD4+ T-lymphocyte count, HAART discontinuation, reasons for treatment interruption and factors correlated to sustained virological response (SVR) were monitored.

RESULTS

The mean age was 41 +/- 6.7 years; the risk factor for coinfection was intravenous drug abuse in 32/43 (74%). The baseline CD4+ T-lymphocytes cell count was > 500 in 51% (22/43). Genotype 3a represented 51% (22/43); 37% were on HAART at baseline (16/43) and half of patients showed high HCV RNA levels (> 800,000 IU/ml). High rates of treatment discontinuation were observed (27/43, 63%), caused by voluntary interruptions in 52% (14/27) and virological failure in 26% (7/27). The overall population had an SVR of 30%; genotypes 3a and 1 had SVR of 38% and 24%, respectively. The SVR was significantly lower in three groups: high HCV RNA viral load (chi2 = 6, p < 0.0025), CD4+ T-lymphocyte historical nadir <350 cells/mm3 (chi2 = 3.26, p < 0.01) and genotype 1 with high viral load (chi2 = 4.8, p < 0.005).

CONCLUSIONS

Although factors such as HCV viral load rates and genotype 1 have been confirmed to threaten the response to therapy, we observed a significant response rate when patients had a history of CD4+ T-lymphocyte nadir >350 per mm3. The high dropout rates due to voluntary discontinuations complicated the patients' case management.

[An unusual case of severe arterial hypertension and acute renal failure in an obese young adult]

We report a case of type-B aortic dissection occurring in a 38-year-old obese man, whose past medical history was positive for arterial hypertension and apparently negative for chronic kidney disease. The patient had severe refractory hypertension and acute renal insufficiency due to renal vascular impairment. The correct diagnosis was delayed because the clinical presentation was atypical, initially mimicking an acute abdominal inflammatory process (such as acute pyelonephritis) with secondary sepsis, and there was no major hemodynamic impairment. Percutaneous management (endografting of the thoracic aorta to seal the thoracic intima tear and renal revascularization by PTA+stenting) led to remission, albeit partial, of the acute renal insufficiency and to target blood pressure achievement with use of multiple antihypertensive agents. Follow-up at 12 months showed stable renal function, normal endograft placement and normal aortic diameter at CT examination. The percutaneous endovascular management of aortic dissection is a valid alternative to traditional surgery, with less morbidity and mortality; when the renal circulation is impaired by the aortic dissection, aortic endografting and renal revascularization by PTA+stenting, where appropriate, may allow at least partial reversal of renal insufficiency and target blood pressure achievement.

Neurological manifestation of tick-borne encephalitis in North-Eastern Italy

Tick-borne encephalitis (TBE) is an infectious zoonotic disease, moving from Central Europe to other countries and still rare in Italy. The disease, produced by the European subtype virus, typically takes a biphasic course with neurological disorders of different severity during its second phase. We report the first three TBE cases in Friuli Venezia Giulia (FVG), characterised by extremely variable clinical features. Knowledge of these different presentations will assist physicians in increasing their level of attention to TBE also in this region, where no cases of TBE had been reported in the past, despite the fact that it borders countries with high prevalence of the infection.