The clinical diagnosis of meniscal tear is not easy. Reliability of two clinical meniscal tests and magnetic resonance imaging.

Aim: to clarify the reliability of two clinical meniscal tests, McMurray's and Apley's and the MRI imaging, in order to establish how to reduce unjustified arthroscopies. Methods: 102 patients were selected out of 160. All patients were submitted to a triple clinical examination (by a young surgeon and two skilled surgeons), MRI and an arthroscopic procedure. The investigated clinical tests were McMurray's and Apley's test. The positivity or negativity of the tests and MRI were compared to arthroscopic findings. Arthroscopy is considered the gold standard for the diagnosis of meniscal lesions. We measured the length of the meniscal lesions in order to correlate it to the clinical findings. Results: From the clinical examination, we got the following data: McMurray's test: sensitivity 79.7%, specificity 78.5%, accuracy 79.4%, positive likelihood ratio 3.7, negative likelihood ratio 0.2. Apley's test: sensitivity 83.7%, specificity 71.4%, accuracy 80.3%, positive likelihood ratio 2.9, negative likelihood ratio 0.2. The composite assessment is strictly dependent on how the discordance of the two tests is evaluated. The assessment of the clinical tests was done even in relation to medial or lateral meniscal lesion. No statistical difference was found about the length of the meniscal tear. MRI gave the following results: sensitivity 78.3%, specificity 85.7%, accuracy 80.3%. Conclusions: If we use, as diagnostic means, McMurray's and Apley's clinical tests and MRI as imaging procedure, we have an accuracy of about 80%. It is important to keep in mind that it is not possible to have the absolute certainty of make a correct diagnosis in case of meniscal lesions. Patients, too, have to be informed about the risk of a negative arthroscopy

Can platelet-rich plasma be an alternative to surgery for resistant chronic patellar tendinopathy in sportive people? Poor clinical results at 1-year follow-up

Introduction and purpose: Patellar tendinopathy is a disease affecting particularly athletes. Platelet-rich plasma (PRP) injections have gained increasing interest for their potential benefits. Anyway, a tendon disease longer than 6 months should be considered as an indication for surgery. The aim of our study was to evaluate the efficacy of PRP in athletes with a severe chronic patellar tendinopathy longer than 6 months when surgery should be chosen. Methods: We enrolled 17 sport practitioners (19 patellar tendons) who did not want to undergo surgery and who are nonresponders to other conservative treatments. We treated them with PRP and calculated the results using the visual analog scale (VAS), the Victorian Institute of Sport Assessment-Patellar (VISA-P) score, and Tegner Activity Scale. Every test has been conducted at T0, T1 (4 months), and T2 (12 months). Results: We found a poor improvement at T1 and a clinical worsening at T2 through VAS. VISA-P showed a medium improvement both at T1 and T2. Tegner scale did not show improvements. Conclusions: Our study was not able to remove the doubts about the benefits of PRP in patellar tendinopathy, confirming ambiguous certainties. Further investigations are needed to assess its effectiveness

The emergency and delay management in total talus extrusion: Case report and review of literature after 24 months of follow up

Abstract Total talus extrusion is a rare and severe injury. It is burdened by many complications as avascular necrosis and osteomyelitis even if a proper debridement of extruded talus is performed. Few case reports or case series were published, and because of the rarity of this event, there are no guidelines for treatment. We report the first case on an octogenarian man providing a long-term follow-up performing contrast enhanced magnetic resonances. The authors report the case of an octogenarian man who fell from an olive tree reporting a total talus extrusion associated with the fracture of the medial malleolus. After an accurate debridement and washing of the wound, the talus was anatomically repositioned and the fracture was treated with an external fixator. The wound healed with difficulty after 12 months and the patient developed a chronic osteomyelitis of the talar dome and avascular necrosis of talar head. We followed the patient for 24 months performing contrast enhanced magnetic resonances and evaluating the development of the avascular necrosis. Even if we encountered these complications, the treatment allowed the patient to walk without pain, using a talus type shoe and one crutch. Although the literature suggests that an anatomic replacement of talus allows avoiding main complications, we deem that the patient's age is an important biological feature to consider in the prognostic stratification. Moreover, primary talectomy and tibio-calcaneal fusion should be reserved as a salvage procedure. Talus replacement allows an overall good outcome for the patients, retaining height, and allowing a good quality of life

Fixation of Posterior Malleolus in Trimalleolar Ankle Fractures: Anteroposterior Screw or Posterolateral Plate?

Background: The treatment of the third malleolus has evolved in recent years, and surgical treatment can be carried out with traditional percutaneous osteosynthesis using anteroposterior screws or ORIF with a posterolateral plate. Methods: Our study included 54 patients divided into two groups based on the intervention type (screw or plate). Instrumental assessments comprised pre- and post-operative X-rays and pre-operative CT scans to evaluate joint step-off. The mean follow-up duration was 1 year and 9 months. Results: Radiographic control revealed no loss of reduction or mobilization of the synthesis devices, and all patients achieved fracture healing. Articular step-off > 2 mm was observed in 21 patients (38.9%), including 4 in the plate group and 17 in the screw group, with a statistically significant likelihood of step-off presence in the latter. The mean AOFAS score was 90 points, negatively correlated with age, and lower in patients with joint step-off and a 15 degrees reduction in ROM. Conclusions: The management of posterior malleolus fractures has changed with anatomical studies and an understanding of ankle stability through CT scans. ORIF with a posterior plate is advantageous for anatomical reduction of the tibial plafond but is disadvantageous in terms of surgical invasiveness and technical difficulty

Tranexamic Acid in Pertrochanteric Femoral Fracture: Is it a Safe Drug or Not?

AbstractBackground:There is a high incidence of blood transfusion following hip fractures in elderly patients.Aim:The aim of this study is to evaluate the effectiveness and complications of use of tranexamic acid in proximal femur nailing surgery.Materials and methods:Our sample group consisted of 90 patients suffering from pertrochanteric fractures surgically treated with osteosynthesis with SupernailGT(LimaCorporate). The classification system AO/OTA was used to divide the fractures into 31A1 (n=45) and 31A2 (n=45). The patients were divided into two groups: 47 patients were administered 15 mg of tranexamic acid per kg (group A) and 43 patients were administered placebo (group B). Blood counts were monitored daily to evaluate the rate of anemia. As a safety criterion, we monitored the possible occurrence of vascular events, symptomatic or not, over the 8 weeks post-surgery. Markers predicting mortality and deep venous thrombosis (DVE) were also monitored (fibrinogen D-dimer).Results:Blood loss occurring post-surgery can be influenced by numerous factors that are not linked to the use or non-use of tranexamic acid. While closely monitoring hemoglobin levels daily, we observed that 42% of the patients in group A required blood transfusion as opposed to 60% in group B. The results of the markers predicting mortality (alpha1-acid glycoprotein; albumin LDL) and those of DVE were not statistically significant between the two groups in this study (p>0.05).Conclusion:Based on this study, the use of tranexamic acid was statistically significant in reducing post-surgery blood loss

Is it really advantageous to operate proximal femoral fractures within 48 h from diagnosis? – A multicentric retrospective study exploiting COVID pandemic-related delays in time to surgery

Objectives: Hip fractures in the elderly are common injuries that need timely surgical management. Since the beginning of the pandemic, patients with a proximal femoral fracture (PFF) experienced a delay in time to surgery. The primary aim of this study was to evaluate a possible variation in mortality in patients with PFF when comparing COVID-19 negative versus positive. Methods: This is a multicentric and retrospective study including 3232 patients with PFF who underwent surgical management. The variables taken into account were age, gender, the time elapsed between arrival at the emergency room and intervention, pre-operative American Society of Anesthesiology score, pre-operative cardiovascular and respiratory disease, and 10-day/1-month/6-month mortality. For 2020, we had an additional column, “COVID-19 swab positivity.” Results: COVID-19 infection represents an independent mortality risk factor in patients with PFFs. Despite the delay in time-to-surgery occurring in 2020, no statistically significant variation in terms of mortality was detected. Within our sample, a statistically significant difference was not detected in terms of mortality at 6 months, in patients operated within and beyond 48 h, as well as no difference between those operated within or after 12/24/72 h. The mortality rate among subjects with PFF who tested positive for COVID-19 was statistically significantly higher than in patients with PFF who tested. COVID-19 positivity resulted in an independent factor for mortality after PFF. Conclusion: Despite the most recent literature recommending operating PFF patients as soon as possible, no significant difference in mortality was found among patients operated before or after 48 h from diagnosis

Temporal changes in the epidemiology, management, and outcome from acute respiratory distress syndrome in European intensive care units: a comparison of two large cohorts

Background: Mortality rates for patients with ARDS remain high. We assessed temporal changes in the epidemiology and management of ARDS patients requiring invasive mechanical ventilation in European ICUs. We also investigated the association between ventilatory settings and outcome in these patients. Methods: This was a post hoc analysis of two cohorts of adult ICU patients admitted between May 1–15, 2002 (SOAP study, n = 3147), and May 8–18, 2012 (ICON audit, n = 4601 admitted to ICUs in the same 24 countries as the SOAP study). ARDS was defined retrospectively using the Berlin definitions. Values of tidal volume, PEEP, plateau pressure, and FiO2 corresponding to the most abnormal value of arterial PO2 were recorded prospectively every 24 h. In both studies, patients were followed for outcome until death, hospital discharge or for 60 days. Results: The frequency of ARDS requiring mechanical ventilation during the ICU stay was similar in SOAP and ICON (327[10.4%] vs. 494[10.7%], p = 0.793). The diagnosis of ARDS was established at a median of 3 (IQ: 1–7) days after admission in SOAP and 2 (1–6) days in ICON. Within 24 h of diagnosis, ARDS was mild in 244 (29.7%), moderate in 388 (47.3%), and severe in 189 (23.0%) patients. In patients with ARDS, tidal volumes were lower in the later (ICON) than in the earlier (SOAP) cohort. Plateau and driving pressures were also lower in ICON than in SOAP. ICU (134[41.1%] vs 179[36.9%]) and hospital (151[46.2%] vs 212[44.4%]) mortality rates in patients with ARDS were similar in SOAP and ICON. High plateau pressure (> 29 cmH2O) and driving pressure (> 14 cmH2O) on the first day of mechanical ventilation but not tidal volume (> 8 ml/kg predicted body weight [PBW]) were independently associated with a higher risk of in-hospital death. Conclusion: The frequency of and outcome from ARDS remained relatively stable between 2002 and 2012. Plateau pressure > 29 cmH2O and driving pressure > 14 cmH2O on the first day of mechanical ventilation but not tidal volume > 8 ml/kg PBW were independently associated with a higher risk of death. These data highlight the continued burden of ARDS and provide hypothesis-generating data for the design of future studies

Where should analgesia lead to? Quality of life and functional recovery with tapentadol

Lorenzo Panella,1 Giuseppe Rinonapoli,2 Stefano Coaccioli31Rehabilitation Department, ASST Pini-CTO, 20100 Milan, Italy; 2Dipartimento di Scienze Chirurgiche, s.c. Ortopedia e Traumatologia Università di Perugia. Ospedale S.Maria della Misericordia, 06100 Perugia, Italy; 3Department of Medicine, Sezione di Clinica Medica e Anatomia Patologia, 05100 Terni, ItalyAbstract: Chronic pain is a major health-care problem worldwide, affecting more than one out of five adults in Europe. Although multiple analgesic agents have been extensively investigated in terms of clinical response and tolerability profile, few studies have focused on the impact of these therapies on patients’ quality of life (QoL). Of note, improvement in QoL, together with functional recovery, has been recognized since the late 1990s as two main goals of analgesic therapy. Tapentadol is a novel analgesic molecule that synergistically combines two mechanisms of action, μ-opioid receptor agonism and norepinephrine reuptake inhibition, and for which multiple literature data are available that confirm its efficacy and safety in controlling pain. This narrative review summarizes the information available on the impact of tapentadol on QoL, with the aim to provide clinicians with a comprehensive overview of the analgesic effects of tapentadol prolonged release beyond the reduction of pain.Keywords: pain, quality of life, tapentado

Tapentadol in the treatment of osteoarthritis: pharmacological rationale and clinical evidence

Giuseppe Rinonapoli,1 Stefano Coaccioli,2 Lorenzo Panella31Dipartimento di Scienze Chirurgiche, s.c. Ortopedia e Traumatologia Università di Perugia, Ospedale S. Maria della Misericordia, 06100 Perugia, Italy; 2Department of Medicine, Sezione di Clinica Medica e Anatomia Patologia, Terni, Italy; 3Rehabilitation Department, ASST Pini-CTO, Milan, ItalyAbstract: Osteoarthritis (OA) is the most prevalent joint disease in older people worldwide. Pain owing to OA is considered one of the most frequent causes of chronic pain; however, current pharmacological approaches have some limitations in terms of efficacy and safety. Of note, descending inhibitory pain pathways are often disrupted in chronic OA pain, and pharmacotherapies targeting those pathways – eg, those that block norepinephrine reuptake may be more appropriate for managing chronic pain than pure μ-opioid receptor (MOR) agonists. Tapentadol is an analgesic molecule, which combines two synergistic mechanisms of action, MOR, and norepinephrine reuptake inhibition. This narrative review will briefly discuss the mechanisms contributing to the onset and maintenance of pain in OA patients; clinical data on the use of tapentadol in this setting will then be presented and commented.Keywords: osteoarthritis, pain, tapentado