The Intraoperative Use of Defensive Antibacterial Coating (DAC®) in the Form of a Gel to Prevent Peri-Implant Infections in Orthopaedic Surgery: A Clinical Narrative Review

Periprosthetic joint infections (PJIs) in arthroplasty and osteosynthesis-associated infections (OAIs) in reconstructive surgery still represent a challenging complication in orthopaedics and traumatology causing a burden worsening the patient's quality of life, for caregiver and treating physicians, and for healthcare systems. PJIs and OAIs are the result of bacterial adhesion over an implant surface with subsequent biofilm formation. Therefore, the clinical pathological outcome is a difficult-to-eradicate persistent infection. Strategies to treat PJIs and OAIs involve debridement, the replacement of internal fixators or articular prostheses, and intravenous antibiotics. However, long treatments and surgical revision cause discomfort for patients; hence, the prevention of PJIs and OAIs represents a higher priority than treatment. Local antibiotic treatments through coating-release systems are becoming a smart approach to prevent this complication. Hydrophilic coatings, loaded with antibiotics, simultaneously provide a barrier effect against bacterial adhesion and allow for the local delivery of an antibiotic. The intraoperative use of a hyaluronan (HY)-derivative coating in the form of a gel, loaded with antibiotics to prevent PJI, has recently raised interest in orthopaedics. Current evidence supports the use of this coating in the prophylaxis of PJI and IRIs in terms of clinical outcomes and infection reduction. Thus, the purpose of this narrative review is to assess the use of a commercially available HY derivative in the form of a gel, highlighting the characteristics of this biomaterial, which makes it attractive for the management of PJIs and IRIs in orthopaedics and traumatology.

The combined evaluation of fibrinogen and D-dimer levels are a helpful tool to exclude periprosthetic knee infection

This retrospective study was undertaken to (i) define the most appropriate thresholds for serum d-dimer and fibrinogen for differentiating aseptic failure from periprosthetic joint infection (PJI) and (ii) evaluate the predictive value of our d-dimer and fibrinogen threshold compared to previously proposed thresholds. This observational cohort study included consecutive patients who had undergone total knee arthroplasty (TKA) revision between January 2019 and December 2020. International Consensus Meeting diagnostic criteria were used to identify patients affected by the prosthetic infection. Receiver operating characteristic curve analyses assessed the predictive value of the parameters, and the areas under the curves were evaluated. We included 125 patients with a median age of 69 years (53-82) affected by painful TKA. Fifty-seven patients (47%) had PJI. Patients with PJI had higher median d-dimer, fibrinogen, ESR, and CRP when compared to patients believed to be free of PJI. The best threshold values for d-dimer and fibrinogen were 1063 ng/ml (sensitivity 0.72, specificity 0.74) and 420 mg/dl (sensitivity 0.67 and specificity 0.82), respectively. A d-dimer level >1063 ng/ml combined with a fibrinogen level >420 mg/dl had a sensitivity of 0.52, and a specificity of 0.90. We found that an increased d-dimer beyond 1063 ng/ml showed a better predictive value than the previously proposed threshold. The combined determination of d-dimer and fibrinogen displayed high specificity and should be considered an excellent tool to rule out an infection. The accuracy of the proposed cutoffs is more effective than previously reported.

Pragmatic observations from a post-COVID-19 cardiac evaluation register: prevalence of cardiological alterations from a basic diagnostic sequence and contribution of the clinical hystory

Introduction

The prevalence of cardiological sequelae in patients recovered from COVID-19 varies in different reports. This may be due to the population diversity studied or to the complementary methods on which the diagnosis was based.

Objective

1) To determine the prevalence of “de novo” cardiological alterations (DN) in the population recovered from COVID-19 using a basic cardiological evaluation sequence. 2) To evaluate the contribution of the clinical history (CH) in the detection of DN.

Methods

Patients (pts) with COVID-19, PCR (+) were included. The pts attended an ambulatory consultation office at least 30 days after discharge from COVID-19. The evaluation was performed in a stepwise manner: first Interview: CH, physical examination (PE), and EKG; second Interview: routine laboratory test, C-reactive protein, echocardiogram and cardiac biomarkers. Other complementary studies (Holter, RMI, CCG) were requested according to previous findings. The diagnosis of DN (by PE, EKG or echocardiogram, alone or with the addition of other methods) was defined as the appearance of cardiological alterations in patients with no pre-existing known heart disease or the progression of a known cardiac disease. The prevalence of DN is described. Sensitivity, specificity and predictive value of CH for DN are reported.

Results

A total of 246 pts were evaluated with the first interview (age: 52±13 years; women: 47.8%; caucasian: 60.6%; overweight: 79%; some pathological history: 71.5%; previous heart disease: 15.4%; hospitalization during the acute phase of COVID: 78.8%; mild Covid: 37%, moderate: 39%, severe: 24%; time between discharge and post-COVID evaluation: 68±42 days). DN were detected in 62 pts: rhythm disturbances: 41 (sinus tachycardia: 23 (18 isolated), sinus bradycardia: 3, supraventricular arrhythmia: 6, ventricular arrhythmia: 14); conduction disturbance: 10, ventricular dysfunction: 20 (12 de novo, 8 progression). Specific diagnoses: myocarditis: 6, coronary artery disease: 5, acute mitral insufficiency: 1. In 16 pts (6.5%) DN had clinical relevance. Six of them (2.4%) required hospitalization. In previously healthy pts with mild COVID, only rhythm disorders were detected in 3 pts. Se, Sp and PV of the CH is shown in Table 1. Eighteen Holter monitoring tests (5 +), 9 MRIs (5 +), 4 CCGs (2 +) were performed.

Conclusions

1) Using a basic cardiac diagnostic sequence, at least 30 days after discharge, a quarter of post-COVID patients had “de novo” cardiological findings. However, a small percentage became clinically relevant. The causal relationship of DN with COVID-19 cannot be unequivocally asserted. Previously healthy patients have low prevalence of cardiac findings detected with a basic diagnostic sequence.

2) The data obtained from the clinical history have a low positive predictive value.

Funding Acknowledgement

Type of funding sources: None.

Is debridement really the best we can do for periprosthetic joint infections following total ankle replacements? A systematic review and meta-analysis

BACKGROUND

Ankle periprosthetic joint infections are rising in number, but an evidence-based gold standard treatment has not been defined yet.

METHODS

We made a systematic review about the operative treatment of infections following total ankle arthroplasty. Proportional meta-analysis was used to summarize effects of the surgical techniques included. Primary outcome of this study was infection eradication, followed by complications, re-interventions, amputation rates and functions.

RESULTS

We included six studies(113 patients) reporting 6 types of surgical interventions, mostly irrigation and debridement (35.4%) and two-stage revisions (24.8%). No differences among all analyzed techniques were found in the infection eradication outcome as well as in the secondary outcomes. Patients receiving a permanent spacer are most likely to end up with amputation.

CONCLUSIONS

Literature dealing with infections after total ankle replacement is currently composed by few low-quality articles. The overlapping of confidence intervals related to all analyzed interventions showed no superiority of either technique.

LEVEL OF EVIDENCE

III.

Osteomyelitis, Oxidative Stress and Related Biomarkers

Bone is a very dynamic tissue, subject to continuous renewal to maintain homeostasis through bone remodeling, a process promoted by two cell types: osteoblasts, of mesenchymal derivation, are responsible for the deposition of new material, and osteoclasts, which are hematopoietic cells, responsible for bone resorption. Osteomyelitis (OM) is an invasive infectious process, with several etiological agents, the most common being Staphylococcus aureus, affecting bone or bone marrow, and severely impairing bone homeostasis, resulting in osteolysis. One of the characteristic features of OM is a strong state of oxidative stress (OS) with severe consequences on the delicate balance between osteoblastogenesis and osteoclastogenesis. Here we describe this, analyzing the effects of OS in bone remodeling and discussing the need for new, easy-to-measure and widely available OS biomarkers that will provide valid support in the management of the disease.

Can the Leukocyte Esterase Strip Test Predict Persistence of Periprosthetic Joint Infection at Second-Stage Reimplantation?

BACKGROUND

We evaluated the reliability of intraoperative assessment of leukocyte esterase (LE) in synovial fluid samples from patients undergoing reimplantation following implant removal and spacer insertion for periprosthetic joint infection (PJI). Our hypothesis was that a positive intraoperative LE test would be a better predictor of persistent infection than either serum C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) or the combination of serum CRP and ESR.

METHODS

The records of 76 patients who received a 2-stage exchange for PJI were retrospectively reviewed. Synovial fluid was collected for LE measurement during surgery before arthrotomy in 79 procedures. Receiver operating characteristic curves were generated. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the curve (AUC) of LE, CRP, ESR, and CRP + ESR were calculated.

RESULTS

Sensitivity, specificity, positive predictive value, and negative predictive value of the LE assay were 82%, 99%, 90%, and 97%, respectively. Receiver operating characteristic analysis revealed an LE threshold of 1.5 between the first (negative) and the second (positive) level of the ordinal variable, so that a grade starting from 1+ was accurate for a diagnosis of persistent infection (AUC 0.9044). The best thresholds for the CRP and the ESR assay were 8.25 mg/L (82% sensitivity, 84% specificity, AUC 0.8416) and 45 mm/h (55% sensitivity, 87% specificity, AUC 0.7493), respectively.

CONCLUSION

The LE strip test proved a reliable tool to diagnose persistence of infection and outperformed the serum CRP and ESR assays. The strip test provides a valuable intraoperative diagnostic during second-stage revision for PJI.

Classification and management options for prosthetic joint infection

Periprosthetic joint infection (PJI) is one of the major complications following arthroplasty implantation. Management of PJIs is a challenge for surgeons and various classification systems have been introduced, which consider variables such as onset of symptoms, pathogenesis and clinical manifestation. In an attempt to overcome the shortcomings which may limit their usefulness in borderline cases, a new classification system focusing on the topography of the infectious process has been proposed. This theory relies on the identification of the exact location of the bacterial colonization thus allowing to decide between a conservative or a more radical intervention irrespectively of the timing. The use of nuclear medicine device like radiolabelled white blood cells (WBC) scan could lead the path in identifying pathogenetic processes and their exact location thus guiding orthopaedic surgeons to the most appropriate diagnosis and treatment options. Currently management relies on debridement, antibiotics and implant retention (DAIR), which is traditionally performed at early stages, 1- or 2-stage revision arthroplasty which is commonly limited to chronic cases. Reports have demonstrated similar rates of infection recurrence following one and two-stage revisions, and the use of one-stage revision surgery is gaining popularity. More recently, satisfying results following partial implant retention during revision total arthroplasty for septic failures have been reported. In addition, in severe cases, definitive articulating antibiotic spacer, excision arthroplasty, arthrodesis or amputation can be performed.

A spacer infection by Candida albicans secondary to a Staphylococcus capitis prosthetic joint infection: a case report

BACKGROUND

Prosthetic joint infection (PJI) is one of the most feared complications following total arthroplasty surgeries. Gram-positive bacteria are the most common microorganisms implicated in PJIs, while infections mediated by fungi only account for 1% of cases. When dealing with PJIs, a two-stage revision arthroplasty is widely used. Briefly, a spacer is introduced until re-implantation of the definitive prosthesis to provide skeleton stabilization while delivering antibiotics in the site of the infection. Sometimes, antimicrobial therapy may fail, but the isolation of a second microorganism from the spacer is uncommon and even less frequent that of a yeast.

CASE PRESENTATION

Here is described a case of a 75-year-old woman who underwent two-stage revision surgery of the left hip prosthesis secondary to a Staphylococcus capitis infection, whose spacer was found to be infected by Candida albicans at a later time. Briefly, the patient underwent revision surgery of the hip prosthesis for a suspected PJI. After the debridement of the infected tissue, an antibiotic-loaded spacer was implanted. The microbiological analysis of the periprosthetic tissues and the implant depicted a S. capitis infection that was treated according to the antimicrobial susceptibility profile of the clinical isolate. Three months later, the patient was admitted to the emergency room due to local inflammatory signs. Synovial fluid was sent to the laboratory for culture. No evidence of S. capitis was detected, however, a yeast was identified as Candida albicans. Fifteen days later, the patient was hospitalized for the removal of the infected spacer. Microbiological cultures confirmed the results of the synovial fluid analysis. According to the susceptibility profile, the patient was treated with fluconazole (400 mg/day) for 6 months. Seven months later, the patient underwent second-stage surgery. The microbiological tests on the spacer were all negative. After 12 months of follow-up, the patient has fully recovered and no radiological signs of infection have been detected.

CONCLUSIONS

Given the exceptionality of this complication, it is important to report these events to better understand the clinical outcomes after the selected therapeutic options to prevent and forestall the development of either bacterial or fungal spacer infections.

High rate of infection eradication following cementless one-stage revision hip arthroplasty with an antibacterial hydrogel coating

PURPOSE

We conducted a retrospective study to evaluate the outcomes of one-stage revision total hip arthroplasty (THA) following periprosthetic joint infection (PJI) in terms of eradication of the infection, improvement of pain and joint function. We hypothesized that this treatment strategy could lead to satisfying results in selected patients after preoperative microorganism isolation.

METHODS

Ten patients underwent cementless one-stage revision hip arthroplasty with antibacterial hydrogel coating for the treatment of an infected THA. Inclusion criteria were: the presence of a known organism with known sensitivity, patients non-immunocompromised with healthy soft tissues with minimal or moderate bone loss. Mean age at surgery was 69.4 years. Assessment included objective examination, Harris hip score, visual analog scale pain score, standard X-rays.

RESULTS

At a mean follow-up of 3.1 years (range, 2-5 years), none of the patients had clinical or radiographic signs suggesting recurrent infection. Follow-up examination showed significant improvement of all variables compared to pre-operative values (p < 0.05). Radiographs did not show progressive radiolucent lines or change in the position of the implant.

CONCLUSIONS

One-stage revision THA with antibacterial hydrogel coated implants represents a safe and effective procedure providing infection eradication and satisfying subjective functional outcomes in selected patients.

Self-reported prevalence of sleep disorders among medical and nursing students

BACKGROUND

Sleep disorders are highly prevalent among university students. In particular, the symptoms of sleep disorders are more prevalent among healthcare students.

AIMS

To assess the prevalence of risk factors of insomnia and sleep disorders and to examine the correlations between them among nursing and medical students. We also compared the effects of shift work during internship.

METHODS

The sample was 417 healthcare students; 202 of them were nursing students, and the remaining 215 were medical students. We used a self-administered questionnaire to assess the risk factors for insomnia (i.e. age, BMI, tobacco consumption, physical activity and perceived stress, using the General Health Questionnaire-12). We also used the Sleep and Daytime Habits Questionnaire and Epworth Sleepiness Scale to assess the prevalence of sleep disorders and daytime sleepiness.

RESULTS

A higher percentage of nursing students than medical students were aged 25 years or older, engaged in inadequate levels of physical activity and consumed tobacco. With the exception of tobacco consumption among nursing students, high scores on the GHQ-12 were the only risk factor associated with daytime and nighttime symptoms and poor sleep quality. There was no significant association between the symptoms of sleep disorders and shift work including night shifts.

CONCLUSIONS

Since sleep disorders are highly prevalent among healthcare students, early detection and management is recommended. This will decrease the risk of harm to students and patients, due to medical mistakes.

One-stage revision surgery provides infection eradication and satisfying outcomes for infected knee arthroplasty in selected patients

OBJECTIVES

We conducted a retrospective study to evaluate the outcomes of one-stage revision total knee arthroplasty (TKA) in terms of eradication of the infection, improvement of pain, and knee function.

METHODS

Between 2009 and 2016, 20 patients underwent one-stage revision TKA for the treatment of a prosthetic joint infection (PJI). Inclusion criteria were: patients nonimmunocompromised with minimal or moderate bone loss, known organisms with known sensitivity. Assessment included clinical signs of infection eradication, range of motion, Knee Society clinical rating score, visual analog scale pain score, and radiographic assessment.

RESULTS

After a mean follow-up of 6.2 years (range, 2-10 years), none of the patients had signs suggesting recurrent infection. Follow-up examination showed significant improvement of all variables compared to preoperative values (p < 0.001).

CONCLUSIONS

One-stage revision surgery provides infection eradication and satisfying subjective functional outcomes for infected knee arthroplasty in selected patients.

EXPERT OPINION

One-stage revision knee arthroplasty is a valuable resource to approach PJIs in selected patients whose infecting micro-organism and sensitivity are determined before surgery. In order to succeed strict inclusion criteria should be applied, as only non-immunocompromised patients with healthy soft tissues with minimal or moderate bone loss are eligible for this procedure.

Secondary breast angiosarcoma: A multicentre retrospective survey by the national Italian association of Breast Surgeons (ANISC)

BACKGROUND

Breast angiosarcoma is a malignant mesenchymal neoplasm, which accounts for approximately 2% of all soft tissue sarcomas. Secondary breast angiosarcoma (SBA) may be related to chronic lymphedema after a mastectomy with lymph node dissection (Stewart Treves syndrome) and previous radiotherapy for complications from breast radiation treatment. It is a very rare condition; therefore, diagnosis and management are still a challenge.

METHODS

The ANISC collected SBA data by means of a survey sent to all Italian breast centres in the ANISC. The clinicopathological characteristics and the management of this disease were analysed.

RESULTS

Twenty-four centres participated in this survey in which 112 cases of SBA were analysed. The median age of the women with SBA was 68.9 years and it appeared approximately 90 months after the first irradiation for breast cancer. In 92% of cases, a mastectomy was performed without axillary dissection for those patients having a high grade of SBA (74.2%). The prognosis was worse in the high-grade cases (overall survival-OS: 36 months) as compared with the low-grade cases (OS: 48 months). After a follow-up of 5 years, 50.5% of the patients were still alive. Disease-free survival (DFS) was 35 months, and there were no differences between the groups of patients with either high- or low-grade histology.

CONCLUSIONS

Secondary breast angiosarcoma is a very aggressive disease associated with a short survival outcome. The surgical approach still remains an important step in the course of treatment; furthermore, an accurate histological examination is helpful in establishing the prognosis of the patient. A mastectomy is mandatory. A longer OS was observed in patients with low-grade angiosarcoma as compared to high-grade angiosarcoma (C.I. 40-57 vs. 31-41 months).

A new perspective on current prosthetic joint infection classifications: introducing topography as a key factor affecting treatment strategy

Periprosthetic joint infection (PJI) is a relatively frequent and devastating complication following prosthetic joint implantation. Several classification systems have been presented by various authors and are routinely used in clinical practice to help in early diagnosis and treatment. The most widely accepted classifications of periprosthetic infections rely on the timing of clinical presentation. Unfortunately, these schemes possess important shortcomings which limit their usefulness in clinical practice, as data reported in literature are contrasting, with success rate ranging from 60 to 80%, irrespectively of prosthetic infection timing. An attempt is made by us to update the current knowledge on PJIs by looking them from a different perspective, introducing a topographic principle in their classification. Our approach is based on the theory that identifying the exact location of the bacterial colonization may allow to decide whether to conservatively treat the patient or to perform a more radical intervention. The aim is to improve the understanding of the aetiology of this serious complication, lead to the appropriate treatment strategy according to the stage of the disease thus enhancing the outcomes of surgical management. Such a strategy, if widely accepted, could guide research studies on the management of PJIs. The availability of investigations like scintigraphy could aid in identifying pathogenetic processes and their exact location, which may be missed on conventional radiographs, and could enable orthopaedic surgeons to have a better understanding of PJI patterns.

Management of periprosthetic shoulder infections with the use of a permanent articulating antibiotic spacer

INTRODUCTION

Management of periprosthetic shoulder infections (PSIs) still remains challenging. We conducted a retrospective case study to assess the outcomes of definitive articulating antibiotic spacer implantation in a cohort of elderly, low-demanding patients. We hypothesized that in patients with low functional demands seeking pain relief with chronic PSIs, treatment with a definitive articulating antibiotic spacer would lead to satisfying results concerning eradication of the infection, improvement of pain, and improving shoulder function.

MATERIALS AND METHODS

19 patients underwent definitive articulating antibiotic spacer implantation for the treatment of an infected shoulder arthroplasty. Mean age at surgery was 70.2 years. Patients were assessed pre-operatively with functional assessment including Constant-Murley score, and objective examination comprehending ROM, visual analog scale pain score, and patient subjective satisfaction (excellent, good, satisfied, or unsatisfied) score. Radiographs were taken to examine signs of loosening, and change in implant positioning.

RESULTS

At the most recent follow-up, none of the patients had clinical or radiographic signs suggesting recurrent infection. Most patients reported satisfying subjective and objective outcomes. Follow-up examination showed significant improvement of all variables compared to pre-operative values (p < 0.001). Radiographs did not show progressive radiolucent lines or change in the position of the functional spacer. In one case, glenoid osteolysis was reported, which did not affect the clinical outcome.

CONCLUSIONS

In selected elderly patients with low functional demands seeking pain relief with infected shoulder arthroplasty, definitive management with a cement spacer is a viable treatment option that helps in eradicating shoulder infection and brings satisfying subjective and objective outcomes.

LEVEL OF EVIDENCE

Case series, Level IV.

Deltoid muscle activity in patients with reverse shoulder prosthesis at 2-year follow-up

PURPOSE

The reverse shoulder prosthesis (RSP) was developed to relieve pain and improve functional outcomes in patients with glenohumeral arthritis and deficiency of the rotator cuff. Even if clinical and functional outcomes regarding the use of the RSP were reported by literature, data concerning progressive deltoid adaptation to this non-anatomic implant are still missing. The purpose of our study was to correlate clinical and functional outcomes with deltoid fibers activity and muscle fatigability in patients with reverse shoulder prosthesis at 2 years follow-up.

METHODS

Twenty patients with reverse shoulder prosthesis due to symptomatic deficient or nonfunctional rotator cuff associated with osteoarthritis were referred by Cervesi Hospital Shoulder and Elbow Surgery Unit. Exclusion criteria were: axillary nerve palsy, a nonfunctioning deltoid muscle, diabetes, previous trauma, malignancy. Furthermore patients who received the RSP for revision arthroplasty, proximal humerus fractures were excluded. All the patients underwent clinical and functional evaluation with the support of electromyography measurement focused on deltoid activity.

RESULTS

RSP surgical treatment in shoulder osteoarthritis confirms his good outcome in terms of pain relief. At 2 years anterior and lateral deltoid electromyographic activity was significantly lower compared with contralateral side (p < 0.001). Posterior deltoid activity was no detectable. Range of motion at 2 years of follow-up decreased in terms of forward flexion (p = 0.045), abduction (p = 0.03) and external rotation (p < 0.001).

CONCLUSIONS

Our study demonstrates that even if the patients remain pain-free, progressive deterioration of the deltoid activity is unavoidable and may lead to poor functional outcomes overtime.

Tuberculosis of the Knee: A Case Report and Literature Review

Tuberculosis (TB) is currently in resurgence due to immigration from endemic areas. Skeletal TB frequently mimics more common etiologies and can be difficult to diagnose. A case of TB knee arthritis in a young woman with painful and swelling knee is reported here. Arthrotomy was performed and inflamed synovial tissue was found, with multiple rice bodies in the eroded lateral femoral condyle. The patient was treated with an antituberculosis polytherapy and at 1-year follow-up, she reported relief from pain and swelling. We believe that all surgeons assessing patients from TB endemic regions have to adopt an updated approach to TB treatment. Thus, a literature review is also reported here on the current strategies used in different knee TB cases.

Imaging of postoperative shoulder instability

Postoperative imaging in shoulder instability is still a challenge for radiologists due to various postsurgical anatomical findings that could be considered pathologic in treated shoulder. For this reason is very important a deep knowledge about surgical procedures, anatomical changes after surgery and the appropriate diagnostic imaging modalities to work up the symptomatic postoperative shoulder. Postoperative imaging options include use conventional radiography, magnetic resonance imaging (MRI), MRI arthrography, computed tomography (CT) and CT arthrography. The purpose of our review is to explain the different surgical procedures and to describe postoperative changes detected with radiological imaging.

Can posterior capsular stretching rehabilitation protocol change scapula kinematics in asymptomatic baseball pitchers?

PURPOSE

Scapular dyskinesis is a recognized cause of shoulder pain in the throwing shoulder of baseball pitchers and athletes who participate in overhead sports. Past studies have assessed scapular kinematics using electromagnetic tracking devices and have shown a correlation between posterior shoulder tightness and forward scapular posture. The purpose of our study is to evaluate the scapular kinematics, before and after a 4-week posterior stretching protocol in asymptomatic pitchers.

METHOD

Eleven asymptomatic collegiate baseball pitchers were involved in the study and divided into group A (6 pitchers) underwent 4 weeks of a regimented therapy protocol and group B (5 pitchers) did not receive any treatment. Each pitcher was tested on two separate days: at the first day of the study (S1) and after 4 weeks (S2).

RESULTS

The results demonstrate that there are statistically significant differences in the kinematics of several athletes from the "treated group" (group A) between S1 and S2. It is also important to notice that variations in group A occurred in both flexextension and ab/adduction movements, strengthening the conclusion that the variation was real.

CONCLUSION

The results of the study can indicate that, in order to prevent the pathologic cascade linked to these sports activities, this physical training protocol might become integral part of the normal daily exercises of baseball pitchers and overhead athletes. Level of evidence II.

Neurological soft signs in primary headache patients

Neurological soft signs (NSS) are semeiotic anomalies not assessed by the standard neurological examination, primarily developed in psychiatric settings and recently proposed as potential markers of minor brain circuit alterations, especially the cerebellar-thalamic-prefrontal network. Primary headache patients present with normal neurological examination and frequent psychiatric comorbidity. Aim of this exploratory study consisted in assessing NSS in 20 episodic frequent migraine (MH) and in 10 tension-type headache (ETTH) outpatients compared to 30 matched healthy controls. NSS were assessed by the Heidelberg scale; clinical characteristics and brain MRI were additionally obtained in all patients. NSS were increased by ∼70 and ∼90% in ETTH and MH, respectively, with respect to controls (p<0.001) and the difference remained significant even after controlling for age and education. Headache type and characteristics did not influence NSS presentation, while headache patients with white matter hyperintensities (WMH) at brain MRI had higher NSS scores compared both to normal controls and patients without WMH. NSS identify a subset of primary headache patients sharing the same comorbidities or minimal brain anomalies, suggesting that tailored prophylactic options might apply.

Optimal positioning of the humeral component in the reverse shoulder prosthesis

INTRODUCTION

Total reverse shoulder arthroplasty is becoming more and more the standard therapeutic practice for glenohumeral arthropathy with massive lesions of the rotator cuff. The biomechanical principle of this prosthesis is represented by the reversion of the normal anatomy of the shoulder joint. This non-anatomical prosthesis leads to a medialization of the rotation centre of the glenohumeral joint and also to a distalization of the humeral head. All that causes a deltoid tension increasing so allowing a larger abduction of the arm. Main complications of the reverse shoulder prosthesis are due to the joint instability, the scapular notching and the wear of the polyethylene insert.

PURPOSE

The main goal of the present work is to study the effect of the positioning of the humeral component on the intrinsic stability of the reverse shoulder prosthesis. In particular, through finite element method simulations, the variation of the stability ratio of the shoulder joint has been calculated for both vertical and horizontal dislocating loads depending on the humeral stem version angle. Moreover, in order to estimate the wear of the polyethylene cup, some analyses have been developed to calculate the pressures on the polyethylene insert.

RESULTS

The obtained results demonstrate the dislocation of a shoulder prosthesis and the wear of the polyethylene insert can be prevented or limited by conveniently varying the version angle of the humeral component.

Gap formation in a transosseous rotator cuff repair as a function of bone quality

BACKGROUND

The transosseous approach has been well known for a long time as a valid repair approach. Over time, various criticisms have been raised over this technique principally classifiable in two main categories: technical difficulty and related reproducibility in an arthroscopic environment, and repair stability (in the suture-bone contact area). About cyclic performance, several authors have conceived test setups with the aim of simulating a real environment in dynamic load conditions. The aim of this study was to monitor gap formation in a cyclic test setup.

METHODS

The performance (measured as gap formation) has been monitored as a function of bone density to verify the effect of the latter. The test blocks have been shaped using sawbones® test bricks (Malmo, Sweden) of different densities, and the following values have been tested: 10, 15, 20, 30 and 40pcf.

FINDINGS

The comparison has been made between the two groups: traditional transosseous and new approach with an interposed device. Regarding the traditional transosseous approach in a 10-pcf environment, not even the first loading cycle was completed, the whole bone bridge was destroyed in the first loading ramp and no further loading capability was present in the repair. By increasing the block density, the surface damage in the suture-block contact decreased.

INTERPRETATION

With this work, it has been demonstrated how the traditional transosseous approach is strongly influenced by the bone quality up to the point where, in certain conditions, a safe and reliable repair is not guaranteed.

Prediction bands and intervals for the scapulo-humeral coordination based on the Bootstrap and two Gaussian methods

Quantitative motion analysis protocols have been developed to assess the coordination between scapula and humerus. However, the application of these protocols to test whether a subject's scapula resting position or pattern of coordination is "normal", is precluded by the unavailability of reference prediction intervals and bands, respectively. The aim of this study was to present such references for the "ISEO" protocol, by using the non-parametric Bootstrap approach and two parametric Gaussian methods (based on Student's T and Normal distributions). One hundred and eleven asymptomatic subjects were divided into three groups based on their age (18-30, 31-50, and 51-70). For each group, "monolateral" prediction bands and intervals were computed for the scapulo-humeral patterns and the scapula resting orientation, respectively. A fourth group included the 36 subjects (42 ± 13 year-old) for whom the scapulo-humeral coordination was measured bilaterally, and "differential" prediction bands and intervals were computed, which describe right-to-left side differences. Bootstrap and Gaussian methods were compared using cross-validation analyses, by evaluating the coverage probability in comparison to a 90% target. Results showed a mean coverage for Bootstrap from 86% to 90%, compared to 67-70% for parametric bands and 87-88% for parametric intervals. Bootstrap prediction bands showed a distinctive change in amplitude and mean pattern related to age, with an increase toward scapula retraction, lateral rotation and posterior tilt. In conclusion, Bootstrap ensures an optimal coverage and should be preferred over parametric methods. Moreover, the stratification of "monolateral" prediction bands and intervals by age appears relevant for the correct classification of patients.

Can the osteosynthesis with locking plates be a better treatment for unstable fractures of the proximal humerus?

PURPOSE

The purpose of this study is to review our experience with proximal humeral locking plates, including complications, functional outcomes, strength recovery and predictors of successful treatment.

METHODS

Seventy unstable proximal humeral fractures were treated with open reduction internal fixation (ORIF) with the use of locking proximal humerus plate. At an average follow-up of 31 months, the clinical and subjective outcomes were evaluated, and complication was analysed.

RESULTS

The average Constant score was 72. The mean disabilities of the arm, shoulder and hand score was 23. The average range of motion was as follows: mean range of anterior elevation and abduction 120°-150°; external rotation in abduction 64° and in adduction 44°; and internal rotation T12.

CONCLUSION

On the basis of the overall functional and clinical outcome obtained, it is possible to suggest that the ORIF of the proximal humerus fractures using locking plate represents a helpful option that can lead to a good clinical and functional outcome even in the most complex fractures.

Motion analysis assessment of alterations in the scapulo-humeral rhythm after throwing in baseball pitchers

PURPOSE

Throwing a baseball requires a coordinated sequence of scapula and humerus movements also called scapulo-humeral rhythm (SHR). Fatigue associated with repetitive throwing can lead to scapular dyskinesia, a recognized cause of shoulder disability in pitchers and overhead athletes. We introduce a novel device, the Xbus Kit, which can objectively assess scapular biomechanics and the effect of pitching on SHR.

METHODS

SHR was studied using the Xbus Kit (Xsens Technologies B.V., NL). Thirteen collegiate baseball pitchers (aged 20 ± 2.6) were studied, evaluating SHR in forward elevation and abduction in three sessions: before throwing (S1), after 60 pitches (S2) and 24 h after a pitching session (S3).

RESULTS

SHR changes were found in 85 % of pitchers (11 cases), and no changes were observed in 2 cases (15 %). We were able to subdivide pitchers into four groups, based on their response to pitching.

CONCLUSION

Repetitive movement of pitching leads to SHR changes and sometimes, incomplete restoration of normal shoulder biomechanics.

Modified Phemister procedure for the surgical treatment of Rockwood types III, IV, V acute acromioclavicular joint dislocation

Acromioclavicular (AC) joint dislocations are common in young, active patients. In case of surgical indications, Rockwood type IV, type V and selected type III dislocation, we use modified Phemister procedure. At mid-term follow-up, by an average of 35.1 months, we reassessed the records of 14 patients surgically treated for acute AC dislocation from February 2007 to November 2010. In patients with a diagnosis of grade III lesion, indication for surgery was given on the basis of the patient's functional demand. Full recovery was obtained on average 3 months after surgery. Constant Score accounted for 92.7 points, mean Disabilities of the Arm, Shoulder and Hand Score for 3.2 points, and mean Simple Shoulder Test Score for 11.4 points. X-ray findings were partial loss of reduction (9 cases), subclinic re-dislocation (2 cases), calcification (5 cases) and post-traumatic arthritis (2 cases). Modified Phemister is a reliable technique, technically easy, a low learning curve procedure and cheap with low hardware's costs.

Financial aspects of sentinel lymph node biopsy in early breast cancer

AIM

At present, early breast cancer is treated with conservative surgery of the primary lesion (BCS) along with axillary staging by sentinel lymph node biopsy (SLNB). Although the scintigraphic method is standardized, its surgical application is different for patient compliance, work organization, costs, and diagnosis related group (DRG) reimbursements.

METHODS

We compared four surgical protocols presently used in our region: (A) traditional BCS with axillary lymph node dissection (ALND); (B) BCS with SLNB and concomitant ALND for positive sentinel nodes (SN); (C) BCS and SLNB under local anaesthesia with subsequent ALND under general anaesthesia according to the SN result; (D) SLNB under local anaesthesia with subsequent BCS under local anaesthesia for negative SN, or ALND under general anaesthesia for positive SN. For each protocol, patient compliance, use of consumables, resources and time spent by various dedicated professionals, were analyzed. Furthermore, a detailed breakdown of 1-/2-day hospitalization costs was calculated using specific DRGs.

RESULTS

We reported a mean costs variation that ranged from 1,634 to 2,221 Euros (protocols C and D). The number of procedures performed and the pathologists' results are the most significant variables affecting the rate of DRG reimbursements, that were the highest for protocol D and the lowest for protocol B.

CONCLUSIONS

In our experience protocol C is the most suitable in terms of patient compliance, impact of surgical procedures, and work organization, and is granted by an appropriate DRG. We observed that a multidisciplinary approach enhances overall patient care and that a revaluation of DRG reimbursements is opportune.

Treatment of clavicle fractures

Clavicle fractures are very common injuries in adults (2-5%) and children (10-15%) (1) and represent the 44-66% of all shoulder fractures (2). Despite the high frequency the choice of proper treatment is still a challenge for the orthopedic surgeon. With this review we wants to focus the attention on the basic epidemiology, anatomy, classification, evaluation and management of surgical treatments in relationship with the gravity of injuries. Both conservative and surgical management are possible, and surgeons must choose the most appropriate management modality according to the biologic age, functional demands, and type of lesion. We performed a review of the English literature thought PubMed to produce an evidence-based review of current concept and management of clavicle fracture. We finished taking a comparison with our survey in order to underline our direct experience.

Laparoscopic versus laparotomic approach to endometrial cancer

OBJECTIVE

The aim of our study was to compare the feasibility, morbidity, long-term safety, disease-free survival, and overall survival of the laparoscopic (LPS) approach to early-stage endometrial cancer (EC) compared to the traditional laparotomic approach.

METHODS

We reviewed retrospective data of patients who underwent primary surgery from 1997 to 2009. We recorded clinical parameters, surgical stage, histological type, operative and peri-operative complications, time to resumption of normal functions, conversion to laparotomy, overall survival, and disease-free survival.

RESULTS

LPS, did not increase operative risk and peri-operative complications even in obese and older women. The number of pelvic lymph and aortic nodes removed was similar for the two groups. One hundred and eight patients had a follow-up of 60 months. The two groups were similar for disease-free survival and overall survival.

CONCLUSIONS

Laparoscopic approach to EC provides a reduction in postoperative complications and hospital stay compared to the laparotomic approach.

Fine structure of the female reproductive system in a viviparous insect, Glossina morsitans morsitans (Diptera, Glossinidae)

The female reproductive system of the tsetse fly Glossina morsitans morsitans is analysed by scanning electron microscopy (SEM). The study focuses in particular on the choriothete, a peculiar uterine structure involved in the viviparous mode of reproduction of Glossina morsitans morsitans. Under light microscopy, the choriothete appears formed by numerous tongue-like folds projecting towards the uterine lumen and lined by a thin cuticle. SEM analysis highlights for the first time a distinctive new feature that is not visible by traditional histological methods. That is a cuticular covering of the choriothete, which shows numerous thorns in the form of crest-like structures arranged in nearly parallel lines. The role of the choriothete in pregnancy and in larval nourishment is discussed.

Age-specific patterns of unsatisfactory results for conventional Pap smears and liquid-based cytology: data from two randomised clinical trials

OBJECTIVE

To investigate the rate of unsatisfactory cervical cell samples in liquid-based cytology (LBC) versus conventional cytology (CC) by age.

DESIGN

Randomised clinical trials.

SETTING

Population-based cervical cancer screening in the Netherlands and Italy.

POPULATION

Asymptomatic women invited for screening enrolled in two randomised trials: Netherlands ThinPrep versus conventional cytology (NETHCON; 39 010 CC, 46 064 LBC) and New Technologies in Cervical Cancer Screening (NTCC; 22 771 CC, 22 403 LBC).

METHODS

Comparison of categorical variables using Pearson's chi-square test, logistic regression and trend tests.

MAIN OUTCOME MEASURES

Proportion of unsatisfactory samples, ratio of LBC versus CC, and variation by 5-year group.

RESULTS

In NETHCON, a lower percentage of LBC samples were judged to be unsatisfactory compared with CC samples (0.33 versus 1.11%). There was no significant trend in unsatisfactory results by age group for conventional cytology (P(trend) = 0.54), but there was a trend towards an increasing percentage of unsatisfactory results with increasing age for LBC (P(trend) < 0.001). In NTCC, a lower percentage of LBC samples were judged to be unsatisfactory compared with conventional cytology (2.59 versus 4.10%). There was a decrease in the unsatisfactory results by age group with conventional cytology (P(trend) < 0.001) and with LBC (P(trend) = 0.01), although the latter trend arose from the 55-60-years age group (P(trend) = 0.62 when excluding this group).

CONCLUSIONS

The clinical trial in which the results were collected and the cytologic method used were the most important determinants of unsatisfactory cytology. In all situations, the proportion of unsatisfactory samples was lower in LBC compared with CC. The effects of age depended on the criteria used to define unsatisfactory results.

[Ectopic breast fibroadenoma. Case report]

Among the rare anomalies of the breast development, polythelia is the most common, between 1% and 5% of women and men present supernumerary nipples. Polymastia, usually presenting as ectopic breast tissue without areola-nipple complex, is seen mostly along the milk line, extending from the axilla to the pubic region. Ectopic breast tissue is functionally analogous to mammary gland and it is subjected to the same alterations and diseases, whether benign or malignant, that affect normal breast tissue. We report the case of a 21 years-old female evaluated by the medical staff after founding a solid nodular mass by suspect axillary lymphadenopathy. Differential diagnosis with lymphoma is the major problem in these cases. The mass was removed and the intraoperative histological examination showed fibroadenoma in axillary supernumerary breast. Presence of ectopic breast tissue is a rare condition; development of benign mass or malignant degeneration is possible, but it is very unusual. In case of polymastia diagnosis is simple; in case of isolated nodule, without local inflammation or infection, there are greater difficulties. Ultrasonography is diagnostic in case of breast fibroadenoma, but it might be inadequate in ectopic localizations owing to the shortage of mammary tissue around the mass. Preoperative diagnosis is important to plan an adequate surgical treatment; lumpectomy is indicated in case of benign tissue; in case of malignancy, therapy is based on the standard treatment used for breast cancer (surgery, chemotherapy and radiation therapy).

Clinical improvement in systemic sclerosis resulting from urokinase therapy explained by light and electron microscopy skin examination

OBJECTIVE

In our previous work, patients affected by SSc were treated with intravenous urokinase and showed clinical improvement. In this study we used microscopy to document ultrastructural alterations occurring in sclerodermic skin from SSc patients treated with urokinase.

METHODS

Ten patients with SSc were selected for this study. Skin biopsies were taken from the medial side of the right forearm on the third proximal on the volar surface. The patients were then treated with urokinase for 7 consecutive days. At the end of the treatment, the patients were examined and a new skin biopsy was taken close to the above-mentioned zone of the forearm for optic and electron microscopy examination.

RESULTS

The patients showed a gradual improvement of the skin after urokinase treatment. Raynaud's appeared to be less intense, and they had an increased articular range, with the restoration of movements that had previously been limited. Histological findings showed that, after treatment, skin alterations appeared attenuated, in particular the connective tissue showed a decreased density and inflammatory infiltrate was slight. Electron microscopy findings showed that collagen fibres appeared to have a more regular diameter, and the capillary vessels' lining was thicker, with fewer pinocytotic vesicles.

CONCLUSION

These observations show that urokinase treatment seems to be an interesting therapeutic strategy to consider for the treatment of SSc.

Genetic diversity of Armillaria spp. infecting highbush blueberry in northern Italy (Trentino region)

Armillaria spp. are the causal agents of root rots of several woody plants, including highbush blueberry. Since 2003, highbush blueberry plants infected by Armillaria spp. have been found in Valsugana Valley, Trentino region, northern Italy. Our aim was to identify the Armillaria spp. involved in these infections, as well as possible sources of inoculum in blueberry fields. Samples of Armillaria spp. were collected from diseased blueberry plants in 13 infected blueberry fields, from bark spread along the blueberry rows, from infected trees in the vicinity of the fields, and from four forest locations. The identification of Armillaria spp. was accomplished using a species-specific multiplex polymerase chain reaction method and by sequencing the rDNA at a specific locus. The differentiation between genotypes was performed by using simple-sequence repeat analysis. Armillaria mellea and A. gallica were the most frequently observed species infecting blueberry in the Valsugana Valley. Three to eight Armillaria genotypes were identified in each blueberry field. No individual genotypes were found in more than one blueberry field. Two-thirds of the genotypes found colonizing trees in the immediate vicinity of infected fields and two-thirds of the genotypes found colonizing the bark spread in blueberry rows were also isolated from blueberry plants in the field, indicating that bark used as mulch and infected trees surrounding the fields may be important sources of inoculum.

Use of cardiac troponin T rapid assay in the diagnosis of a myocardial injury secondary to electrical cardioversion

BACKGROUND AND HYPOTHESIS

This study was carried out to determine whether cardiac troponin T test in rapid assay gives positive results in patients previously submitted to cardioversion or electrical defibrillation.

METHODS

Forty patients with supraventricular tachyarrhythmias lasting no more than 2 days were treated with electrical cardioversion. The total creatine phosphokinase (CPK)-MB isoenzyme and troponin T in rapid assay were measured at baseline and at 6, 12, and 24 h thereafter.

RESULTS

Total CPK baseline levels were normal in all cases; within 4 h, the serum CPK levels increased by 98%, at 6 h by 111.5%, at 12 h by 168%, and at 24 h by 225% (p > 0.01). The CPK-MB isoenzyme showed no percentage increase of total CPK higher than 5%, measured at 6, 12, and 24 h after the shock, independent of the number of attempts of cardioversion. The troponin T test was also negative in all cases at baseline and at 6, 12, and 24 h after cardioversion.

CONCLUSION

We conclude that the absence of elevations in CPK-MB levels and cardiac troponin T levels matched clinical and electrocardiographic results showing absence of myocardial damage after electrical cardioversion.

Behavioural sensitisation during dopamine replacement therapy in Parkinson's disease is reminiscent of the addicted brain

The intermittent oral intake of the dopamine (DA) precursor L-3,4-dihydroxyphenylalanine (L-DOPA) is the classic therapy of Parkinson's disease (PD). In this way, the drug precursor can be metabolised into the active neurotransmitter DA. Although this occurs throughout the brain, the therapeutic relief is believed to be due to restoring extracellular DA levels within the dorsal striatum (more in the putamen than the caudate nucleus) which lacks endogenous DA as a consequence of the disease process. However, differing from physiological DA transmission, this therapeutic pattern leads to abnormal peaks of non-synaptic DA, which are supposed to trigger behavioural sensitisation expressed as abnormal involuntary movements. A similar pattern of abnormal DA stimulation occurs during methamphetamine (METH) intake. In the present review we will provide evidence showing the similarities between METH- and L-DOPA-induced DA stimulation with an intact and denervated striatum respectively. This comparison will encompass various features; the timing, the areas and the amount of extracellular DA levels which reveal surprising homologies. Such an overlapping between L-DOPA in PD and METH will be further analysed to critically assess the commonalities concerning the following points: abnormal receptor stimulation, recruitment of altered transduction pathways, abnormal gene expression, alterations in the phenotype of striatal neurons, and the establishment of behavioural sensitisation which appear as distinct phenomena (i.e. abnormal involuntary movements in PD and drug addiction in METH abuse); nonetheless, this may also lead to common behavioural alterations (METH-like addictive behaviours in PD patients during the course of DA replacement therapy in subsets of PD patients).