PURPOSE: A new and more anatomical technique for SLAP II lesions repair is described. It consists in the reattachment of the medial aspect of the biceps anchor to the superior glenoid neck with a mattress stitch posterior and medial to the biceps anchor and a simple stitch placed anteriorly to the biceps. METHODS: From 2011 to 2012, 14 patients matching the inclusion criteria were selected for the study. A visual analogic scale, ROWE, UCLA, ASES and Constant scores were used to make evaluation. The passive ROM before surgery, at final follow-up, and the resumption of sports activities were analysed. RESULTS: The Constant, ASES, UCLA and ROWE scores passed from 64.6 (SD 13.9), 76.9 (SD 22.4), 28.4 (SD 23.8) and 53.6 (SD 20.6) to, respectively, 92.6 (SD 11.8), 108.3 (SD 8.5), 33.6 (SD 2.7) and 96.5 (SD 7.2) at final follow-up. Of the four patients who had participated in agonistic overhead athletics preoperatively, all of them were able to return to their preinjury level. No complications were observed in the present study. CONCLUSION: In our technique, the anatomy is respected leaving the articular aspect of the superior labrum loose and reinforcing the medial side. The clinical relevance of this work is that probably this technique could improve clinical results, giving a better mobility of the shoulder and a return to the same preoperative level in overhead athletes.

PURPOSE: We retrospectively analyzed our results in thoracolumbar and lumbar adolescent idiopathic scoliosis treated during adulthood. METHODS: Fifty-two thoracolumbar and 30 lumbar idiopathic scoliosis surgically treated were reviewed. Mean follow-up was 9.5 ± 6.6 years. All the subjects were analyzed by visual analog scale, Oswestry Disability Index (ODI), and SF-36 scores before and after surgery and at follow-up. The scoliotic curve, thoracic kyphosis, lumbar lordosis, pelvic incidence (PI), pelvic tilt (PT), sacral slope, and C7 plumb line were measured. For the statistical analysis, multivariate multiple regression models were formulated, considering as significative a P < 0.05. RESULTS: A statistically significant clinical and radiological amelioration was noted after surgery and at final follow-up. According to the logistic regression model, ODI was related to lumbar lordosis and spino-pelvic parameters at follow-up. The only determinant of failure was age. CONCLUSIONS: Spino-pelvic recovery is easier in patients aged less than 60 years with PI < 55° and PT < 25°.

Background: In the treatment of clavicle fractures, the choice of procedure depends on the possibility of restoring the anatomical functional integrity of the shoulder. Methods: We examined 71 patients (51 males and 20 females, mean age 38.9 years) who were affected by clavicle fracture sequelae. Demographic and clinical data and the site of the lesion were recorded for each partecipant. The dissatisfaction of the patient was determined by the presence of 1 or more affirmative answers on the Simple Shoulder Test. The Constant Shoulder Score was also included in the functional and clinical exams. We measured the length of the healthy clavicle and the previously fractured clavicle, and we expressed the difference in length in mm and in percentage shortening. We then examined the correlations between the shortening of the bone and the clinical and functional outcomes of the patients. Results: Sixty patients had a lesion of the diaphysis, 8 patients had a lesion of the lateral third of the clavicle, and 3 patients had a lesion of the medial third of the clavicle. The mean Constant Shoulder Score was 77.9, and 51 of the 71 patients were satisfied with their treatment. Radiography showed a mean clavicle shortening of 10 mm (mean percentage 6.5%). In the 20 dissatisfied patients, the mean clavicle shortening was 15.2 mm (9.7%). In these patients, we found a highly significant association between dissatisfaction with treatment and the amount of bone shortening, (p < 0.0001), as well as with a diaphyseal location (p < 0.05) and with the female sex (p = 0.004). No other variable related to the patient, the type of treatment or the fracture characteristics correlated with the treatment outcome. Conclusions: In the literature, measurements of the shortening of the bone segment following a fracture range between 15 and 23 mm, and marked shortening is correlated with the failure of conservative treatment. However, these data need to be reinterpreted in light of the physiological variability of the clavicle length, which ranges from 140 to 158 mm in the healthy population. Shortening of the bone by more than 9.7% should be the cut-off for predicting failure of conservative treatment.

The study design is retrospective. The aim is to describe our experience about the treatment of patients with neuromuscular scoliosis (NMS) using Cotrel-Dubousset instrumentation. Neuromuscular scoliosis are difficult deformities to treat. A careful assessment and an understanding of the primary disease and its prognosis are essential for planning treatment which is aimed at maximizing function. These patients may have pelvic obliquity, dislocation of the hip, limited balance or ability to sit, back pain, and, in some cases, a serious decrease in pulmonary function. Spinal deformity is difficult to control with a brace, and it may progress even after skeletal maturity has been reached. Surgery is the main stay of treatment for selected patients. The goals of surgery are to correct the deformity producing a balanced spine with a level pelvis and a solid spinal fusion to prevent or delay secondary respiratory complications. The instrumented spinal fusion (ISF) with second-generation instrumentation (e.g., Luque-Galveston and unit rod constructs), are until 1990s considered the gold standard surgical technique for neuromuscular scoliosis (NMS). Still in 2008 Tsirikos et al. said that "the Unit rod instrumentation is a common standard technique and the primary instrumentation system for the treatment of pediatric patients with cerebral palsy and neuromuscular scoliosis because it is simple to use, it is considerably less expensive than most other systems, and can achieve good deformity correction with a low loss of correction, as well as a low prevalence of associated complications and a low reoperation rate." In spite of the Cotrel-Dubousset (CD) surgical technique, used since the beginning of the mid 1980s, being already considered the highest level achieved in correction of scoliosis by a posterior approach, Teli et al., in 2006, said that reports are lacking on the results of third-generation instrumentation for the treatment of NMS. Patients with neuromuscular disease and spinal deformity treated between 1984 and 2008 consecutively by the senior author (G.D.G.) with Cotrel-Dubousset instrumentation and minimum 36 months follow-up were reviewed, evaluating correction of coronal deformity, sagittal balance and pelvic obliquity, and rate of complications. 24 patients (Friedreich's ataxia, 1; cerebral palsy, 14; muscular dystrophy, 2; polio, 2; syringomyelia, 3; spinal atrophy, 2) were included. According the evidence that the study period is too long (1984-2008) and that in more than 20 years many things changed in surgical strategy and techniques, all patients were divided in two groups: only hooks (8 patients) or hybrid construct (16 patients). Mean age was 18.1 years at surgery (range 11 years 7 months-max 31 years; in 17 cases the age at surgery time was between 10 and 20 years old; in 6 cases it was between 20 and 30 and only in 1 case was over 30 years old). Mean follow-up was 142 months (range 36-279). The most frequent patterns of scoliosis were thoracic (10 cases) and thoracolumbar (9 cases). In 8 cases we had hypokyphosis, in 6 normal kyphosis and in 9 hyperkyphosis. In 8 cases we had a normal lordosis, in 11 a hypolordosis and in 4 a hyperlordosis. In 1 case we had global T4-L4 kyphosis. In 8 cases there were also a thoracolumbar kyphosis (mean value 24°, min 20°-max 35°). The mean fusion area included 13 vertebrae (range 6-19); in 17 cases the upper end vertebra was over T4 and in 11 cases the lower end vertebra was over L4 or L5. In 7 cases the lower end vertebra was S1 to correct the pelvic obliquity. In 5 cases the severity of the deformity (mean Cobb's angle 84.2°) imposed a preoperative halo traction treatment. There were 5 anteroposterior and 19 posterior-only procedures. In 10 cases, with low bone quality, the arthrodesis was performed using iliac grafting technique while in the other (14 cases) using autologous bone graft obtained in situ from vertebral arches

The histopathological changes associated with rotator cuff tears include thinning and disorganization of collagen fibers, the presence of granulation tissue, increased levels of glycosaminoglycans, fibrocartilaginous metaplasia, calcification, fatty infiltration, and necrosis of the tendon margin with cell apoptosis. The biochemical changes include an increase in the expression of matrix metalloproteinases (MMPs) and a decrease in tissue inhibitor of metalloproteinases (TIMP) messenger ribonucleic acid expression. Histological evidence of tendinopathy has been found in patients with rotator cuff tear. Biochemical changes include significant increases in MMP1, MMP2, MMP3, and in TIMP1 and TIMP2 levels, not only at the lateral supraspinatus edge, but also in the macroscopically intact portion of the supraspinatus tendon and in the intact subscapularis. The tissue in the ruptured area of the supraspinatus tendon undergoes marked rearrangement at molecular levels. This involves the activity of MMP1, 2, and 3 and supports a critical role of MMPs in tendon physiology. Intact parts of the torn supraspinatus tendon can present the histopathological changes associated with rotator cuff tears. These findings suggest that biochemical changes can already occur in a macroscopically intact tendon and seem to point to a global degenerative process in the shoulder.

ABSTRACT: Aim of the study: the purpose of the study was to evaluate the differences in post-operative results of ACL reconstruction using as graft semitendinosus and gracil tendons or bone patellar tendon. Materials and Methods: 160 patients who underwent ACL reconstruction between January 1998 and January 2007, in our department were analyzed at the follow-up from 1 to 10 years (mean follow-up 5 years). These patients were treated using random one of the two grafts. They were divided into two groups of 80 patients each. In group A we used the bone patellar tendon bone (BPTB), while in group B we used the semitendinosus and gracilis tendon graft (STGD). In group A there were 47 men and 33 females, aged from 19 to 49 years (mean age: 27years 7months), in second group there were 51 men and 29 females, aged from 19 to 41 years (mean age: 25 years 5 months). To evaluate this study we used the International Knee Documentation Committee (IKDC), AP and LL x–rays and MRI of the knee. Results: there was not a significant statistical difference between the two groups. Clinical results were normal or almost normal in more than 90% of cases. In the subjective evaluation there was a smaller incidence of pain and symptoms into the second group and an higher incidence of pain to kneel into the first group. Imaging results showed that when LCA injury is associated to condral or meniscal damage, there is a worsening of x-ray features above all if the LCA reconstruction has been performed a long time after injury, even if condral or meniscal lesions are treated in the same surgery. Conclusion: Arthroscopic LCA can be performed using both grafts. STGD graft is preferable because it seems to avoid patellar tendon graft pathology. The ACL reconstruction with graft cannot reproduce completely the complex biomechanics of the knee so, even if it gives stability to the knee joint, it cannot prevent degenerative changes. The ACL rupture associated to cartilaginous or meniscal injury promotes the arthrosis. For the prevention of osteoarthrosis it is important to preserve the homeostasis of the joint more than single ACL reconstruction with graft. Key Words: anterior cruciate ligament – bone patellar tendon bone – semitendinosus and gracilis tendon graft.

BACKGROUND: Ceramic bearings in total hip arthroplasty (THA) have been introduced in clinical practice to minimize the problem of polyethylene particle-induced osteolysis. The aim of the study is to report the results of 68 consecutive alumina-on-alumina THAs done in 61 patients for avascular necrosis (AVN) of the femoral head. MATERIALS AND METHODS: In all implants a press-fit cup was used; it was combined with a 32-mm alumina head and with titanium-alloy stems. The mean age at surgery was 50 years. At an average follow-up of 13 years two hips have been revised, one for periprosthetic infection and one for excessive abduction of the cup. RESULTS: No revision for aseptic loosening is recorded; one anatomical cementless femoral stem had radiological evidence of definite aseptic loosening. No dislocations occurred, and no osteolysis was observed. CONCLUSIONS: The results support the application of alumina-alumina THA for long-lasting replacements.

Arthroscopic technique for lateral release is the most widely used procedure for the correction of recurrent dislocations of the patella. In the relevant literature, several complications of lateral release are described, but the spontaneous patellar tendon rupture has never been suggested as a possible complication of this surgical procedure. Patellar tendon rupture is a rather infrequent and often unilateral lesion. Nevertheless, in case of systemic diseases (LES, rheumatoid arthritis, and chronic renal insufficiency) that can weaken collagen structures, bilateral patellar tendon ruptures are described. We report a case of a 24-year-old girl with spontaneous rupture of patellar tendon who, at the age of 16, underwent an arthroscopic lateral release for recurrent dislocation of the patella. This is the first case of described spontaneous patellar tendon rupture that occurred some years after an arthroscopic lateral release.

Abstract Glenohumeral instability is an intrinsic pathological condition of the shoulder, owing to its ample range of mobility that predisposes this joint to a somewhat limited degree of stability. Several techniques have been employed for the treatment of instability. Among these, one is the Latarjet procedure, recommended for cases of substantial bone deficit on the humeral head or on the anterior region of the glenoid. Such technique gives generally good, long-term results, considering the low incidence of recurrence. However, potential complications such as glenohumeral arthrosis, absorption of the bone block, breakage, malpositioning or mobilization of the screws, infections, neurological or vascular complications can be serious. Moreover, as a result of further severe trauma, the shoulder can become again globally unstable. In such cases, the question arises of which technique to employ in surgical revision, since the Latarjet procedure determines substantial subversion of glenohumeral anatomy. The aim of the study was the analysis of arthroscopical treatment after failure of a Latarjet procedure and to describe the related definitive results. During the period between January 2000 and June 2007, we treated 17 patients (18 shoulders) using arthroscopy, following failure of an open Latarjet surgical procedure. One patient was operated bilaterally. Clinical revision according to the Constant Score, ROWE, ASES, UCLA and the VAS scale for pain evaluation was carried out during follow-up examination after an average period of 5 years and 9 months (min. 2 years-max. 9 years) from latest surgery. The system of evaluation according to the Constant Score indicated an average score of 78.4/100 at follow-up examination; UCLA indicated 27.2/35; ASES 99.6/120; ROWE 75.2/100. With regard to pain, the VAS Scale indicated an average score of 2.9/10. As criteria for relapse, we considered classic cases of dislocation and subluxations, or sprains with subluxation, and subjectively experienced apprehension and pain to a degree that seriously inhibited the patient's daily life. The incidence of relapse following the final surgical operation (taking into consideration both frank dislocations and subluxations) was 16.7%. At clinical revision, one patient showed dislocation due to relatively modest trauma approximately 1 year following the second surgery (5.6%). Episodes of subluxation or sprains continued in 2 shoulders (11.1% relapse). In 11 cases (61%), return to sports activities was achieved. Arthroscopy technique using anchors and sutures can, in selected cases, lead to satisfactory results, allowing, by means of minimal surgical invasion, identification and treatment also of intra-articular lesions, where associated.

The association between thyroid disorders and musculoskeletal diseases has long been suspected, but it is still debated whether they have a role in the pathogenesis of shoulder diseases. In vivo and in vitro studies describe the role of thyroid hormones in bone, cartilage and tendon biology. Retrospective studies and case reports suggest that thyroid diseases should be considered as risk factors and hold prognostic value in some of the most common causes of shoulder pain. Thus, it is advisable to search for underlying thyroid disorders in these patients. The pathophysiologic mechanisms by which thyroid hormone imbalance affects the onset, progression and response to treatment of these diseases are yet to be thoroughly defined and demand further studies.

STUDY DESIGN: Prospective observational study. OBJECTIVE: To assess (1) the evolution of vertebral bone marrow edema (VBME) in patients with A1 vertebral compression fractures (VCFs) conservatively treated and (2) the relationship between VBME and clinical symptoms, evaluated as Visual Analogue Scale (VAS) back pain and Oswestry Disability Index (ODI). SUMMARY OF BACKGROUND DATA: VBME is a marker of acute-subacute vertebral fractures. Little is known about the evolution of VBME in conservatively managed VCFs, as well as its clinical meaning. METHODS: 82 thoracic or lumbar VCFs (21 post-traumatic; 61 osteoporotic VCFs), type A1 according to the AOSpine thoracolumbar spine injury classification system, in 80 patients were treated with C35 hyperextension brace for 3 months, bed rest for the first 25 days. Patients with osteoporotic fractures also received antiresorptive therapy and vitamin D supplementation. At 0 (T0), 30 (T1), 60 (T2), and 90 (T3) days, patients underwent magnetic resonance imaging evaluation and clinical evaluation, using VAS for pain and ODI.The paired t test was used to compare changes within groups at each follow-up versus baseline. The unpaired t test after ANOVA (analysis of variance) was used to compare the 2 groups at each follow-up.The association between VBME area, VAS score, and ODI score was analyzed by the Pearson correlation test. The tests were 2-tailed with a confidence level of 5%. RESULTS: A significant VBME mean area, VAS, and ODI scores reduction was recorded at 60 and 90-days follow-ups versus baseline. A positive correlation between VBME reduction and clinical symptoms improvement (VAS and ODI scores improvement) was found in both traumatic and osteoporotic VCFs. CONCLUSION: In benign A1 VCFs conservatively managed, VBME slowly decreases in the first 3 months of magnetic resonance imaging follow-up. This VBME reduction is related to clinical symptoms improvement.

NTRODUCTION: Kyphoplasty and percutaneous vertebroplasty are two effective procedures for osteoporotic vertebral compression fractures, but there have been few publications on their use in non-osteoporotic forms. B-Twin(®) vertebral body reconstruction is a new minimally invasive vertebral body reconstruction technique developed for non-osteoporotic vertebral compression fractures of the thoracolumbar junction and lumbar spine. OBJECTIVES: The present study describes this novel technique and assessed efficacy compared to a conservative method. PATIENTS AND METHODS: Inclusion criteria were: Magerl type A1.2 non-osteoporotic thoracolumbar or lumbar spinal compression fractures in patients aged over 18 years, free of neurologic compromise. Patients were randomized to management by corset (group 1) or by the B-Twin(®) spacer (group 2). Follow-up used a visual analog scale (VAS) to assess pain, the Oswestry Disability Index (ODI) and, on radiology, the vertebral (VK) and regional (RK) kyphosis angles and anterior and medial height indices at baseline, 3 months and 12 months. RESULTS: Group 1 comprised 26 patients; group 2 comprised 24 patients, with 44 implants. In group 1, mean VK was 10.7° (± 1.73°) at baseline, 11.9° (± 1.56°) at 3 months and 12.3° (± 1.6°) at 12 months. Mean RK was respectively 9.7° (± 0.97°), 11.10° (± 1.07°) and 11.8° (± 1.27). Mean medial height (medial-to-posterior [MH/PH] height ratio was respectively 0.75 [±0.05], 0.70 [±0.06] and 0.65 [±0.04]). Mean anterior height (anterior-to-posterior [AH/PH] height ratio) was respectively 0.79 [± 0.06], 0.76 [± 0.05] and 0.73 [± 0.05]). Mean VAS score was respectively 8.6 (± 0.52), 3.8 (± 0.82) and 2.3 (± 0.83). In group 2, mean VK was 13.8° (± 0.47°) at baseline, 4.88° (± 0.65°) at 3 months and 4.88° (± 0.65°). Mean RK was respectively 9.82° (± 1.67°), 4.47° (± 0.86°) and 4.82° (± 0.98°). Mean MH/PH ratio was respectively 0.69 (± 0.05), 0.86 (± 0.03) and 0.86 (± 0.03). Mean AH/PH ratio was respectively 0.73 (± 0.04), 0.90 (± 0.03) and 0.90 (± 0.03). Mean VAS score was 8.88 (± 0.47) at baseline, 2 (± 1) at 1-day post-surgery, 1.71 (± 0.88) at 3 months and 1.12 (± 0.23) at 12 months. The increase in vertebral body height in patients managed by B-Twin(®) was maintained at 6 and 12 months (P<0.0001). The study showed better results with the vertebral spacer than on conservative treatment, with a 95% reduction in bed-rest: 4-6 weeks in the conservative group vs. 2-3 days in the surgical group. CONCLUSIONS: The vertebral body reconstruction technique provided anatomic vertebral body reconstruction and quick return to household activity without resort to a corset. Deformity was durably reduced. At 12-month follow-up, pain reduction and stasis were achieved. The risk of injected cement leakage was slight.

OBJECTIVE: To assess (1) the evolution of VBME in patients with A1 VCFs conservatively treated and (2) the relationship between VBME and clinical symptoms, evaluated as VAS (Visual Analogue Scale) Back Pain and ODI (Oswestry Disability Index). SUMMARY OF BACKGROUND DATA: Vertebral Bone Marrow Edema (VBME) is a marker of acute/sub-acute vertebral fractures. Little is known about the evolution of VBME in conservatively managed vertebral compression fractures (VCFs), as well as its clinical meaning. METHODS: 82 thoracic or lumbar VCF (21 post-traumatic; 61 osteoporotic VCFs), type A1 according to AOSpine Thoracolumbar Spine Injury Classification System, in 80 patients were treated with C35 hyperextension brace for three months, bed rest for the first twenty-five days. Patients with osteoporotic fractures also received Antiresorptive therapy and vitamin D supplementation. At 0 (T0), 30 (T1), 60 (T2) and 90(T3) days, patients underwent MRI evaluation and clinical evaluation, using VAS for Pain and ODI.The paired t test was used to compare changes within groups at each follow-up versus baseline. The unpaired t test after ANOVA was used to compare the two groups at each follow-up.The association between VBME area, VAS score, ODI score was analyzed by the Pearson Correlation test. The tests were two-tailed with a confidence level of 5%. RESULTS: A significant VBME mean area, VAS and ODI scores reduction was recorded at 60- and 90-days follow-ups versus baseline. A positive correlation between VBME reduction and clinical symptoms improvement (VAS and ODI scores improvement) was found both in traumatic and osteoporotic VCFs. CONCLUSION: In benign A1 VCFs conservatively managed, VBME slowly decreases in the first 3 months of MRI follow-up. This VBME reduction is related to clinical symptoms improvement.