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PURPOSE: The purpose of this study was to translate the Achilles tendon Total Rupture Score (ATRS) into Italian and establish its cultural adaptiveness and validity. METHODS: The original version of the ATRS was translated into Italian in accordance with the stages recommended by Guillemin. A web-based survey was developed to test the construct validity of the Italian ATRS. Eighty patients with an average age of 45.5 years (SD 11) were included in the study. The ATRS was completed twice at 5 days intervals for test-retest reliability. The intraclass correlation coefficient was used to calculate the test-retest reliability, and Cronbach's α coefficient was used for internal consistency. Validity was evaluated by external correlation (Spearman's rank correlation coefficient, r) of the ATRS with the Italian versions of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A), the 17-Italian Foot Function Index (17-FFI), the Lower Extremity Functional Scale (LEFS), and the Short-Form 36 (SF-36). RESULTS: The internal consistency (α = 0.97) and the test-retest reliability (ICC = 0.96) were excellent. The correlation coefficient showed strong correlation of the Italian ATRS with the VISA-A and the LEFS (r = 0.72 and r = 0.70, respectively, p < 0.0001), a weak correlation with the 17-FFI (r = -0.30, p = 0.007), and high-to-moderate correlation with the physical functioning, bodily pain, physical role functioning, social functioning, role emotional, and vitality of the SF-36 (r = 0.75, r = 0.61, r = 0.52, r = 0.49, r = 0.40 and r = 0.34, respectively, p < 0.0001). CONCLUSION: The Italian version of the ATRS is a valid instrumentation to assess the functional limitations of Italian patients after Achilles tendon rupture. LEVEL OF EVIDENCE: III.

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PURPOSE: The main purpose of the present study was to determine long-term implant fixation of 15 unicompartmental knee arthroplasty (UKAs) with an all-poly tibial component using Roentgen stereophotogrammetric analysis (RSA) at a mean 10-year follow-up. The secondary purpose was to investigate whether the progressive loss of implant's fixation correlates with a reduction in Knee society score (KSS). METHODS: Fifteen non-consecutive patients with primary knee osteoarthritis received a UKA with an all-poly tibial component were assessed using KSS scores pre-operatively and post-operatively and RSA on day 2 after surgery, then at 3, 6, and 12 months and yearly thereafter. The mean last follow-up was 10 years. RESULTS: An increase in maximum total point motion (MTPM) values from 6 months to 1 year post-operatively was found respect to post-operative reference. Implants' displacement values were always <2 mm during the first 6 months, and then, two different trends were noticed in revised and non-revised implants. MTPM increase between 1 and 2 years of follow-up in non-revised UKAs was always <0.2 mm, whereas it was >0.2 mm in revised UKAs. A linear and negative correlation with statistical significance was found between MTPM and both clinical and functional KSS scores (p < 0.001). CONCLUSION: Also in a long-term follow-up evaluation, RSA is an effective tool to predict functional results after an all-poly UKA providing also a relevant predictive value at 1 year follow-up, and this can be very useful for both patients and surgeons. LEVEL OF EVIDENCE: Diagnostic studies, Level III.

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PURPOSE: Degenerative cartilage lesions present a negative joint environment, which may have a negative effect on the process of cartilage regeneration. The aim of this study is to analyze the clinical outcome obtained with the treatment for isolated degenerative knee cartilage lesions by second-generation arthroscopic autologous chondrocyte implantation (ACI). METHODS: Fifty-eight consecutive patients affected by focal degenerative chondral lesions of the femoral condyles and trochlea were treated by second-generation arthroscopic ACI. The mean age at surgery was 34.7 ± 9.1 years and the average defect size was 2.3 ± 0.9 cm(2). The patients were prospectively evaluated with IKDC, EQ-VAS, and Tegner scores preoperatively, at 2 and 6 years. RESULTS: A statistically significant improvement was observed in all scores from the basal evaluation to the final follow-up. The IKDC subjective score improved from 39.3 ± 13.6 to 68.8 ± 22.7 and 68.5 ± 23.9 at the 2- and 6-year follow-ups, respectively, with a significant improvement (P < 0.0005) and stable results over time; the same trend was confirmed by the EQ-VAS and Tegner scores. The worst results were found in patients with a low physical activity level, women, and those having undergone previous surgery, whereas the symptom duration before surgery did not influence the final outcome. The failure rate was 18.5%. CONCLUSIONS: Despite a significant improvement, the results were lower with respect to the outcome reported in different study populations, and the number of failures was markedly higher, too. Tissue-engineered cartilage implantation is a promising approach for the treatment of degenerative chondral lesions, but graft properties, besides mechanical and biochemical joint environment, have to be improved. LEVEL OF EVIDENCE: Case series, Level IV.

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PURPOSE: The aim of this study was to analyze the clinical outcome obtained with arthroscopic second generation autologous chondrocyte implantation (ACI) associated with bone grafting for the treatment of knee osteochondritis dissecans (OCD) at medium term follow-up. METHODS: Thirty-four knees affected by symptomatic OCD grade III or IV on the ICRS (International Cartilage Repair Society) scale were treated and prospectively evaluated at 12, 24 months of follow-up, and at a final mean 6 ± 1 years of follow-up. The mean age at treatment was 21 ± 6 years. The average size of the defects was 3 ± 1cm(2). Patients were evaluated with IKDC, EQ-VAS, and Tegner scores. RESULTS: A statistically significant improvement in all scores was observed after the treatment. The IKDC subjective score improved from 38 ± 13 to 81 ± 20, and 91% of the knees were rated as normal or nearly normal in the objective IKDC at the final evaluation. EQ-VAS and Tegner scores showed a statistically significant linear trend of improvement over time passing from 52 ± 18 to 83 ± 14 and from 2 ± 1 to 5 ± 3, respectively, at 6 years' follow-up. A better outcome was obtained in men, sport active patients, and smaller lesions. CONCLUSIONS: Second generation ACI associated with bone grafting is a valid treatment option for knee OCD and may offer a good and stable clinical outcome at mean 6 years of follow-up. Further studies are needed to confirm the results over time, and determine if there is only a symptomatic improvement, or if this procedure may also prevent or delay further knee degeneration.

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BACKGROUND: Total hip replacement is considered the best option for treatment of displaced intracapsular fractures of the femoral neck (FFN). The size of the femoral head is an important factor that influences the outcome of a total hip arthroplasty (THA): implants with a 28 mm femoral head are more prone to dislocate than implants with a 32 mm head. Obviously, a large head coupled to a polyethylene inlay can lead to more wear, osteolysis and failure of the implant. Ceramic induces less friction and minimal wear even with larger heads. METHODS: A total of 35 THAs were performed for displaced intracapsular FFN, using a 32 mm alumina-alumina coupling. RESULTS: At a mean follow-up of 80 months, 33 have been clinically and radiologically reviewed. None of the implants needed revision for any reason, none of the cups were considered to have failed, no dislocations nor breakage of the ceramic components were recorded. One anatomic cementless stem was radiologically loose. CONCLUSIONS: On the basis of our experience, we suggest that ceramic-on-ceramic coupling offers minimal friction and wear even with large heads.

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Painful hip prosthesis is the most feared immediate and remote complication of a primary implant and usually represents the failure of one or more therapeutic moments. In cases of aseptic implant failure, the causes invoked may be represented by an incorrect indication, the quality of materials, local and general condition of the patient and especially from a bad joint biomechanics. In cases of septic loosening, however, the cause of failure to be found in the location of pathogens within the implant. In planning a revision is necessary to respect many important steps. They are represented by the exact identification of the causes of failure, the correct preoperative planning, by respecting the skin incisions, the proper choice of the prosthesis, planning the surgical technique, and finally by an appropriate rehabilitation program.In the evaluation of hip failure the first diagnostic step is to recognize exactly those aseptic and septic forms anyway to exclude the diagnosis of infection.

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The extracorporeal shock wave therapy (ESWT) is an extensively applied treatment for musculoskeletal disorders because it promotes bone repair. The aim of this study was to evaluate the direct effect of ESWT on murine osteoblasts to clarify the cellular mechanism that leads to the induction of osteogenesis. Osteoblasts in culture flasks were treated with ESWT pulses (500 impulses of 0.05 mJ/mm(2)) generated by an electromagnetic device. Using western blot analysis 3h after ESWT, an increased expression of Bax was found, indicating a fast pro-apoptotic effect of treatment on some of the osteoblasts. Activation of the cyclin E2/CDK2 is the complex that regulates the G1-S transition and is essential for cell proliferation. It was evident 24 to 72h after treatment, indicating a proliferative stimulus. A decreased expression of osteoprotegerin (OPG) and receptor activator NF kappa B ligand (RANKL) 24 and 48h after ESW, followed by a later increase of OPG, paired with a much smaller increase of RANKL, was evident by real-time polymerase chain reaction (PCR). The decreased RANKL/OPG ratio suggests inhibition of osteoclastogenesis. We can conclude that ESWT induces bone repair through the proliferation and differentiation of osteoblasts and the reduction of their secretion of pro-osteoclastogenic factors.

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Few cases of hip fracture in pregnant women affected by transient osteoporosis of the femoral head have been reported in the literature, but its real incidence seems to be underestimated. During pregnancy, osteoporosis manifests itself with an insidious onset of hip pain and limp without any trauma or infective episode in clinical history. Its clinical course is characterized by spontaneous recovery a few weeks to several months after delivery. This article describes the case of a 35-year-old woman with a sudden onset of bilateral hip pain during the last trimester of her first pregnancy; she had neither history of steroid therapy nor alcohol abuse; her body temperature and serological parameters were normal. Bilateral transient osteoporosis of the femoral heads was suspected and confirmed by magnetic resonance imaging. Fifteen days postpartum, she was admitted to our clinic with a displaced femoral neck fracture. A cementless total hip arthroplasty was performed to quickly begin a rehabilitative program. She underwent antiresorptive therapy with alendronic acid 70 mg/week and vitamin D for 3 months. Three months after the fracture, a dual-energy x-ray absorptiometry scan showed osteopenia (T-score, -1.5). Risedronic acid 35 mg/week and vitamin D were then prescribed. The last physical examination at 3 months postoperatively revealed a gradual recovery of the autonomy in activities of daily life.

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We report a study of 85 Symax femoral stems that were followed at regular intervals with radiographs at 6, 12, 24 and 36 months. The radiological migration of each stem was measured using the computer-assisted EBRA -FCA method. In 30 cases in which the EBRA method did not provide a complete measurement another computer-assisted method (Roman version 1.7) was employed. In all cases the distal migration of the stems was minimal, The threshold migration value used to define the stability of a stem was 1.5 mm at 24 months. The mean migration within the first two years was -0.17 mm (+/- 0.3) at 6 months, -0.31 mm (+/- 0.4) at 12 months and -0.45 mm (+/- 0.5) at 24 months. Only two cases exceeded the threshold limit of 1.5 mm at the two-year follow-up, but both values were lower than 2 mm. In the 25 cases which reached three-year follow-up the mean distal migration was -0.84 (+/-0.7). In four of them the subsidence exceeded 1.5 mm, but only one exceeded 2 mm. These data represent a positive predictive factor for the minimal risk of future aseptic loosening.

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In soccer players, lower extremity stress fractures are common injuries and are the result of repetitive use damage that exceeds the intrinsic ability of the bone to repair itself. They may be treated conservatively but this may cause long-term complications, such as delayed union, muscle atrophy and chronic pain. Stress fractures that fail to respond to this management require surgical treatment, which is also not without risks and complications. Extracorporeal shock wave therapy (ESWT) has been used successfully on fracture complications, such as delayed union and nonunion. As such, we want to examine ESWT in the management of stress fractures. In this article, we present a retrospective study of 10 athletes affected by chronic stress fractures of the fifth metatarsus and tibia that received three to four sessions of low-middle energy ESWT. At the follow-up (8 wk on average), the clinical and radiography results were excellent and enabled all players to gradually return to sports activities. These reports show that ESWT is a noninvasive and effective treatment for resistant stress fractures in soccer players.

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Osteoporotic fractures represent one of the most common cause of disability and one of the major voice in the health economic budget in many countries of the world. Fragility fractures are especially meta-epiphyseal fractures, in skeletal sites with particular biomechanic characteristic (hip, vertebrae), complex and with more fragments, with slow healing process (mineralization and remodeling) and co-morbidity. The healing of a fracture in osteoporotic bone passes through the normal stages and concludes with union of the fracture although the healing process is prolonged. Fractures in the elderly osteoporotic patients represent a challenge to the orthopaedic surgeons. Osteoporosis does not only increase the risk of fracture but also represents a problem in osteofixation of fractures in fracture treatment. The major technical problem that surgeons face, is the difficulty to obtain a stable fixation of an implant due to osteoporotic bone. The load transmitted at the bone-implant interface can often exceed the reduced strain tolerance of osteoporotic bone.IN THE TREATMENT OF OSTEOPOROTIC FRACTURES IT IS IMPORTANT TO CONSIDER DIFFERENT ASPECTS: general conditions of elderly patient and comorbidity, the reduced muscular and bone mass and the increased bone fragility, structural modifications as medullary expansion.The aim of surgical treatment is to obtain a stable fixation that reduces pain and permits an early mobilization.

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It has been at least two decades since the introduction of Extracorporeal Shock-Wave Treatment (ESWT) for the treatment of non-unions; despite conflicting opinions in the literature, it is recently achieving good results also in acute fractures. This paper reports Authors' clinical experience with electromagnetic shock-waves in the treatment of delayed unions and fresh fractures. Nonunion cases experienced remarkable successful results at an average of 8-10 weeks after ESWT; high success rate is been also found for the acute fractures. It can be concluded that this therapy constitutes an important aid in treatment of non-unions and can be useful also in fresh bone fractures.

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Bilateral patellae fractures represent a rare entity, accounting for approximately 2.9% of all lesions interesting in this anatomical district. In most cases found in the published work, they are described as stress fractures or as complications of chronic diseases such as osteoporosis, renal failure and secondary hyperparathyroidism. Although many pathogenetic mechanisms have been supposed, none have been proved for certain. Insufficiency fractures of the patellae are rare events and no data has been published on their incidence. We present a case of bilateral fracture of the patellae due to an indirect trauma occurring in an 85-year-old patient affected by Parkinson's disease, osteoporosis and diffuse degenerative osteoarthritis. X-ray of the knees (anteroposterior and lateral) and magnetic resonance imaging evaluation confirmed the fractures. The patient was treated conservatively. She had a good result, returning to her previous autonomous ambulation. This case is unusual because there was no direct trauma to the knees because of bilaterality, but confirmed previous observations about insufficiency fractures of patellae in the presence of comorbidity. Insufficiency fractures of patellae can be an insidious condition in elderly people. Prepatellar pain, a common symptom in the relapse phase of degenerative arthritis of the knee, should not be underestimated, particularly in patients with diseases influencing metabolism of bone and with an elevated risk of fall. A periodical clinical and instrumental follow up should be done in these patient. Moreover, we underline the necessity of a multidisciplinary approach.

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In this article we report a case of bizarre paraosteal osteochondromatous proliferation (BPOP), also known as Nora's lesion, arising on the distal phalanx of the fifth finger of the hand in a young-adult subject. In this paper, we discuss the possible therapeutic programme related to the grade of severity of the clinical features and underline the rarity of this lesion and the difficulty of diagnosis, which is exclusively histological.

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Quickly evolutive skin necrosis and deep infection after total knee arthroplasty (TKA) are not uncommon. Several predisposing factors, such as immunosuppression, malnutrition, steroid use, rheumatoid arthritis, multiple scars, and vascular disease can be involved in the onset of wound complications, as well as long tourniquet time and early knee flexion. Skin necrosis after TKA can be treated in different ways, including local wound care, debridement, and soft tissue coverage with muscle or skin grafts. This article presents a rare case of skin necrosis occurring in a patient without any other apparent risk factor after TKA. A 78-year-old woman affected by primary osteoarthritis of the right knee who had no comorbidities and who had already undergone TKA for primary osteoarthritis on the left knee underwent a cemented TKA. Three days postoperatively, she developed a fever and wound problems, which soon after turned into skin necrosis. This complication was first treated surgically with a debridement of the wound with antibiotic therapy and local wound care, then with vacuum-assisted closure (Kinetic Concepts Inc, San Antonio, Texas) therapy and soft tissue coverage using skin grafting. She had a complete recovery in the next 3 months; the skin grafting was well tolerated and the range of motion and functional outcome were good.

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