OBJECTIVE:To assess the effectiveness of high-volume image-guided injection in the middle term in patients with recalcitrant patellar tendinopathy.DESIGN:Case series study; Level of evidence, 4.SETTING:All tertiary referrals, public, and private healthcare.PATIENTS:Forty-four patients (41 men and 3 women) with diagnosis of recalcitrant patellar tendinopathy were included.INTERVENTION:Tendon injection of a mixture of 10 mL of 0.5% bupivacaine hydrochloride, 62 500 international units of aprotinin, and 40 mL of normal saline solution.MAIN OUTCOME MEASURES:The Victorian Institute of Sport Assessment-patellar tendon (VISA-P), visual analogue scale, and Roles and Maudsley were assessed at baseline and at the last follow-up.RESULTS:The baseline VISA-P score of 46 ± 18.2 (range, 28-75) improved to 75.3 ± 19.2 (range, 68-100) by 15 months (P = 0.003). The mean pain visual analogue scale changed from 91 mm (range, 66-92 mm) before the injection to 28 mm (2-52 mm) (P = 0.01). Of 32 physically active patients, 23 (72%) had returned to sport at the same level practiced before the onset of symptoms. Thirty-five of the 44 patients (80%) rated their condition as good or excellent.CONCLUSIONS:High-volume injection at the interface between the deep surface of the patellar tendon and Hoffa body improves in the short-term symptoms and function of the knee.CLINICAL RELEVANCE:This procedure is minimally invasive, safe, and effective in the short term in athletes.

An internet survey was set up to assess the geriatric competence and perceived needs of 337 members of the Italian society of nephrology (SIN). The survey assessed how well aware nephrologists are of the typical geriatric conditions and needs of their elderly chronic kidney disease (CKD) patients. SIN associates were also questioned about their current use of comprehensive geriatric assessment, prescription of potentially nephrotoxic drugs, and screening for osteoporosis. The main finding is that CKD and dialysis are almost unanimously perceived as typically geriatric conditions, but knowledge and use of geriatric tools are scanty. While use of potentially inappropriate drugs is rare, almost half of the patients are not screened for osteoporosis. The significant clinical gaps observed could greatly impair the management of older CKD patients, and call for an urgent educational intervention.

Artificial Bee Colony (ABC) is a recent meta-heuristic approach. In this paper we face the problem of clustering by ABC and we model a further bee role in the colony, performed by inspector bee. This model conforms with real honey bee colony, indeed, in nature some bees among the foraging ones are called inspectors because they preserve the colony’s history and historical information related to food sources. We experiment inspector behavior in ABC and compare the solution to traditional clustering algorithm. Finally, the effect of colony size is investigated and experimental results are discussed.

This paper proposes a new formulation of Artificial Bee Colony (ABC) in order to address clustering problems. The proposed algorithm models the inspector bee within the colony. It is tested for some benchmarks and is adopted to a real-world problem in Transportation System domain. In particular, we propose a clustering problem for the identification of vehicle usage in Poste Italiane by grouping together those vehicles with same features as fuel economies, frequency and value of refueling activities.

Background: Multiple percutaneous longitudinal tenotomies have been successfully undertaken in runners with isolated midportion Achilles tendinopathy (nodular lesions <2.5 cm) without any sign of paratendinopathy. Hypothesis: In the long term, minimally invasive multiple tenotomies allow the patient to remain involved in middle- and long-distance running. Clinical and ultrasound (US) evidence of paratendinopathy is a negative prognostic factor. Study Design: Case series study; Level of evidence, 4. Methods: A total of 39 patients were reviewed at an average follow-up of 17 years (range, 15-22 years) after US-guided multiple percutaneous longitudinal tenotomies for chronic Achilles tendinopathy. The Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire was completed by each patient, maximum calf circumference and isometric plantarflexion strength of the gastrocsoleus complex were measured in both the affected and contralateral legs, and functional assessment was scored by the 4-point Boyden scale. Achilles tendon changes were also assessed according to the grayscale US grading system. Results: At the final follow-up, the maximum calf circumference and the strength in the operated leg were not significantly different than those measured preoperatively, but they were significantly lower than those on the contralateral side. This did not affect patients’ daily or sports activities. All patients had returned to their preinjury working occupation; 20 patients were still active in middle- and long-distance running, with an average current level of sport and function that was 60% ± 13% compared with baseline status (before onset of symptoms). Thirty of 39 patients (77%) reported good or excellent outcomes according to the Boyden assessment. On US assessment, the tendon was generally thicker than the contralateral asymptomatic tendon (average, 7.0 vs 8.7 mm, respectively; P = .003). There was no significant difference (P > .05) when comparing patients with good or excellent Boyden results versus those with fair or poor outcomes. The mean VISA-A score was 78.5, with no significant difference between patients with and without paratendinopathy on US assessment (P > .05). All of the patients who did not return to running or who gave up sports activities had signs of paratendinopathy. Conclusion: This approach to the management of midportion Achilles tendinopathy is safe, has a low cost, and is effective in the long term.

BACKGROUND:Lateral ankle sprains may result in pain and disability in the short term, decreased sport activity and early retirement from sports in the mid term, and secondary injuries and development of early osteoarthritis to the ankle in the long term.HYPOTHESIS:This combined approach to chronic lateral instability and intra-articular lesions of the ankle is safe and in the long term maintains mechanical stability, functional ability, and a good level of sport activity.STUDY DESIGN:Case series; Level of evidence, 4.METHODS:We present the long-term outcomes of 42 athletes who underwent ankle arthroscopy and anterior talofibular Broström repair for management of chronic lateral ankle instability. We assessed in all patients preoperative and postoperative anterior drawer test and side-to-side differences, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Kaikkonen grading scales. Patients were asked about return to sport and level of activity. Patients were also assessed for development of degenerative changes to the ankle, and preoperative versus postoperative findings were compared.RESULTS:Thirty-eight patients were reviewed at an average of 8.7 years (range, 5-13 years) after surgery; 4 patients were lost to follow-up. At the last follow-up, patients were significantly improved for ankle laxity, AOFAS scores, and Kaikkonen scales. The mean AOFAS score improved from 51 (range, 32-71) to 90 (range, 67-100), and the mean Kaikkonen score improved from 45 (range, 30-70) to 90 (range, 65-100). According to outcome criteria set preoperatively, there were 8 failures by the AOFAS score and 9 by the Kaikkonen score. Twenty-two (58%) patients practiced sport at the preinjury level, 6 (16%) had changed to lower levels but were still active in less demanding sports (cycling and tennis), and 10 (26%) had abandoned active sport participation although they still were physically active. Six of these patients did not feel safe with their ankle because of the occurrence of new episodes of ankle instability. Of the 27 patients who had no evidence of degenerative changes preoperatively, 8 patients (30%) had radiographic signs of degenerative changes (5 grade I and 3 grade II) of the ankle; 4 of the 11 patients (11%) with preexisting grade I changes remained unchanged, and 7 patients (18%) had progressed to grade II. No correlation was found between osteoarthritis and status of sport activity (P = .72).CONCLUSION:Combined Broström repair and ankle arthroscopy are safe and allow most patients to return to preinjury daily and sport activities.

BACKGROUND Chronic tears of the Achilles tendon can result in substantial loss of function. Those tears with a tendon gap of up to 6.5 cm can be treated surgically with use of an autologous peroneus brevis tendon graft. METHODS At an average follow-up period of 15.5 years after the surgery, we examined sixteen of twenty-two patients who had undergone peroneus brevis tendon graft reconstruction for a chronic Achilles tendon tear. Clinical and functional assessment was performed. RESULTS All sixteen patients were able to walk on tiptoe, and no patient used a heel lift or walked with a visible limp. The maximum calf circumference of the involved limb remained significantly decreased. The involved limb was significantly less strong than the contralateral one. One patient had developed a tendinopathy of the opposite Achilles tendon, one had developed a tendinopathy of the reconstructed tendon, and one had ruptured the contralateral Achilles tendon five years after the original injury. CONCLUSIONS The long-term results of treatment of chronic tears of the Achilles tendon by means of autologous peroneus brevis tendon grafting are encouraging. Patients retain good functional results despite permanently impaired ankle plantar flexion strength and decreased calf circumference.

Purpose: To ascertain whether there are differences in the histopathological appearance of tendinopathic Achilles and patellar tendons.Methods: In males, we studied biopsies from tendinopathic Achilles (n ϭ 28; average age 34.1 years) and patellar tendons (n ϭ 28; average age 32.1), and Achilles tendons (n ϭ 21; average age 61.8 years) from deceased patients with no known tendon pathology, and patellar tendons (n ϭ 15; average age 28.3) from patients undergoing anterior cruciate ligament reconstruction.Haematoxylin-eosin stained slides were interpreted using a semi-quantitative grading scale (0: normal to 3: maximally abnormal) for fibre structure; fibre arrangement; rounding of the nuclei; regional variations in cellularity; increased vascularity; decreased collagen stainability; hyalinisation.All slides were assessed blindly twice, the agreement between two readings ranging from 0.170 to 0.750 (Kappa statistics). Results:The highest mean score of tendinopathic Achilles tendons was not significantly different from that of tendinopathic patellar tendons (11.6 Ϯ 5 and 10.4 Ϯ 3, respectively).The ability to differentiate between an Achilles tendon and a patellar tendon was low.Conclusions: Tendinopathic Achilles and patellar tendons show a similar histological picture.It was not possible to identify whether a specimen had been harvested from an Achilles or a patellar tendon on the basis of histological examination.The general pattern of degeneration was common to both tendinopathic Achilles and patellar tendons.A common, as yet unidentified, etiopathological mechanism may have acted on both these tendon populations.

BACKGROUND Chronic tears of the Achilles tendon with a tendon gap exceeding 6 cm are a surgical challenge. The purpose of this study is to report the long-term results of reconstruction of such chronic Achilles tendon ruptures with use of a free autologous gracilis tendon graft. METHODS Twenty-one patients underwent reconstruction of a chronic rupture of the Achilles tendon. Fifteen patients were available for clinical and functional assessment on the basis of anthropometric measurements, isometric strength testing, and the Achilles Tendon Total Rupture Score after a mean duration of follow-up of 10.9 years (range, eight to twelve years). RESULTS All fifteen patients were able to walk on the tiptoes, and no patient used a heel lift or walked with a visible limp. At an average of 10.9 years of follow-up, the maximum calf circumference of the operatively treated leg remained substantially decreased and the operatively treated limb was significantly weaker than the contralateral, normal limb. Two patients had developed tendinopathy of the contralateral Achilles tendon, one had developed tendinopathy of the reconstructed tendon, and one had ruptured the contralateral Achilles tendon eight years after the index tear. CONCLUSIONS The long-term results of treatment of chronic tears of the Achilles tendon with free gracilis tendon grafting showed that patients retained good functional results despite permanently impaired ankle plantar flexion strength and decreased calf circumference.

This is a prospective analysis on 30 physically active individuals with a mean age of 48.9 years (35 to 64) with chronic insertional tendinopathy of the tendo Achillis. Using a transverse incision, the tendon was debrided and an osteotomy of the posterosuperior corner of the calcaneus was performed in all patients. At a minimum post-operative follow-up of three years, the Victorian Institute of Sports Assessment scale - Achilles tendon scores were significantly improved compared to the baseline status. In two patients a superficial infection of the wound developed which resolved on antibiotics. There were no other wound complications, no nerve related complications, and no secondary avulsions of the tendo Achillis. In all, 26 patients had returned to their pre-injury level of activity and the remaining four modified their sporting activity. At the last appointment, the mean pain threshold and the mean post-operative tenderness were also significantly improved from the baseline (p < 0.001). In patients with insertional tendo Achillis a transverse incision allows a wide exposure and adequate debridement of the tendo Achillis insertion, less soft-tissue injury from aggressive retraction and a safe osteotomy of the posterosuperior corner of the calcaneum.

Background Several reconstruction procedures have been proposed to manage recurrent dislocation of the superior tibiofibular joint. Hypothesis Reconstruction of the superior tibiofibular joint using a gracilis tendon autograft is effective in recurrent dislocation of the superior tibiofibular joint. Study Design Case series; Level of evidence, 4. Methods Eight patients with recurrent dislocation of the superior tibiofibular joint without anatomical predisposing factors and who practiced sports were included in the study. Evaluation included the modified Cincinnati rating system and the Kujala score, anthropometry, plain radiography, and isokinetic dynamometry. Results The average follow-up was 44 ± 13 months. The mean modified Cincinnati score increased from 54 preoperatively to 92 (P = .01). The mean Kujala scores increased from 48 preoperatively to 85 (P = .05). The muscle volume of the thigh of the operated limb remained less well developed than the muscle volume of the nonoperated limb (P = .05). Significant isokinetic strength differences were found between the operated and the contralateral limb (P = .02) even at the latest follow-up. Conclusion Gracilis autograft for posttraumatic instability of the superior tibiofibular joint is a safe, reliable management option for recurrent dislocation of the superior tibiofibular joint in patients without any predisposing factors.

BACKGROUND:Several medial patellofemoral ligament reconstruction procedures have been proposed to manage recurrent patellar dislocation.HYPOTHESIS:Reconstruction of the medial patellofemoral ligament using a hamstring graft with a 2 transverse patellar tunnels technique is an effective treatment for recurrent patellar dislocation in patients without any evident predisposing factors.STUDY DESIGN:Case series; Level of evidence, 4.METHODS:Twenty-eight patients with chronic patellar instability without any anatomic predisposing factors, experiencing recurrent unilateral patellar dislocation, were included in the study. Evaluation included the modified Cincinnati and the Kujala scores, anthropometry, plain radiography, and isokinetic dynamometry.RESULTS:The average follow-up was 3.1 years (range, 2.5-4 years). The mean modified Cincinnati score increased from 52 preoperatively to 89 (P = .001). The mean Kujala scores increased from 45 preoperatively to 83 (P = .03). The muscle volume of the thigh of the operated limb increased with time, but remained less well developed than the nonoperated limb (P = .04). The mean Insall-Salvati index was 1.1 (range, 0.9-1.2) preoperatively and remained within normal range (1.1 [range, 0.9 to 1.2]) (P = .07), at latest follow-up. Significant isokinetic strength differences were found between the operated and the contralateral limbs (.05 < P < .006), even at the latest follow-up. Three patients experienced a new patellar dislocation.CONCLUSION:Medial patellofemoral ligament reconstruction using hamstring tendon passed through a double patellar transverse bony tunnel technique is a safe, reliable management option for recurrent patellar dislocation in patients without any predisposing anatomic factors.

BACKGROUND:Recurrent patellar dislocations are common injuries in children and adolescents. The subjective and functional results of soft tissue surgical management in a population that was skeletally immature at the time of surgery have not been reported. HYPOTHESIS:The 3-in-1 procedure is an effective treatment for recurrent patellar dislocation in skeletally immature patients. STUDY DESIGN:Case series; Level of evidence, 4. METHODS:Twenty-five skeletally immature patients (age at operation, 13.5 +/- 3.8 years) who were practicing sports and suffering from recurrent unilateral patellar dislocation were included in the study and followed until skeletal maturation. Clinical evaluation included the modified Cincinnati rating system and the Kujala score, anthropometry, plain radiography, and isokinetic dynamometry. RESULTS:The average follow-up was 3.8 years (range, 2.5-6 years). The mean modified Cincinnati score increased from 51.7 +/- 12.6 preoperatively to 94.3 +/- 10.8 (P < .02), while the mean Kujala scores increased from 52.4 +/- 12.7 preoperatively to 93.8 +/- 14.2 (P < .02). The Insall-Salvati index remained essentially unchanged, being 1.04 +/- 0.2 preoperatively and 1.02 +/- 0.3 at latest follow-up. Significant differences were found between the operated and the contralateral limb in the various isokinetic strength variables at all angular velocities measured at the latest follow-up (.05 < P < .0042). CONCLUSION:The 3-in-1 procedure is a safe, reliable management option for recurrent patellar dislocation in skeletally immature patients. Side-to-side differences in isokinetic strength and in anthropometric indices persist despite subjective success of the procedure.

Purpose. To report the middle term outcome in male and female patients who underwent surgery for chronic recalcitrant Achilles tendinopathy. Methods. We tried to match each of the 58 female patients with a diagnosis of tendinopathy of the main body of the Achilles tendon with a male patient with tendinopathy of the main body of the Achilles tendon who was within two years of age at the time of operation. A match accordingly was possible for 41 female subjects. Results. Female patients were shorter and lighter than male patients. They had similar BMI, lower calf circumference, similar side-to-side calf circumference differences, and greater subcutaneous body fat than men. Of the 41 sedentary patients, only 25 reported an excellent or good result. Of these, three had undergone a further exploration of the Achilles tendon. The remaining patients could not return to their normal levels of activity despite prolonged supervised post-operative physiotherapy, with cryotherapy, massage, ultrasound, pulsed magnetic, and laser therapy. Conclusion. Females experience more prolonged recovery, more complications, and a greater risk of further surgery than males with recalcitrant Achilles tendinopathy.

Purpose. To translate and adapt the English VISA-A questionnaire to Italian, to perform reliability and validity evaluations of the Italian VISA-A version in patients with tendinopathy of the main body of the Achilles tendon. Methods. The VISA-A English version was translated into Italian by a bilingual orthopaedic surgeon. The back translation of the Italian version into English was performed by another bilingual orthopaedic surgeon. The original version was compared with the back translation. The VISA-A-I questionnaire was then administered to 50 male athletes (average age 26.4, range 18-49 years) with a diagnosis of tendinopathy of the main body of the AT. For test-retest evaluation, the 50 patients were asked to complete the questionnaire at first examination, and 30 minutes following the end of this examination. Results. The kappa statistics for 50 patients was 0.80 (range 0.7-0.86). There were no significant differences between the scores immediately after the consultation and 30 minutes later. Conclusions. Italian and the English versions of the VISA-A questionnaire evaluate the same aspects of clinical severity in patients with tendinopathy of the main body of the Achilles tendon.

Purpose. To translate and adapt the English VISA-P questionnaire to Italian and to perform reliability and validity evaluations of the Italian VISA-P version in patients with patellar tendinopathy. Methods. The VISA-P English version was translated into Italian by a bilingual orthopaedic surgeon. The back translation of the Italian version into English was performed by another bilingual orthopaedic surgeon. The original version was compared with the back translation. The VISA-P-I questionnaire was then administered to 25 male athletes (average age 27.9, range 18-32 years) with a diagnosis of patellar tendinopathy. For test-retest evaluation, the 25 patients were asked to complete the questionnaire at first examination, and 30 minutes following the end of this examination. Results. The kappa statistics for 25 patients was 0.78. There were no significant differences between the scores immediately after the consultation and 30 minutes later. Conclusions. Italian and the English versions of the VISA-P questionnaire evaluate the same aspects of clinical severity in patients with patellar tendinopathy.

Serum deprivation induced in human lymphoblastoid Raji cells oxidative stress‐associated apoptotic death and G0/G1 cell cycle arrest. Addition into culture medium of the immunomodulatory protein Seminal vesicle protein 4 (SV‐IV) protected these cells against apoptosis but not against cycle arrest. The antiapoptotic activity was related to: (1) decrease of endocellular reactive Oxygen species (ROS) (2) increase of mRNAs encoding anti‐oxidant enzymes (catalase, G6PD) and antiapoptotic proteins (survivin, cox‐1, Hsp70, c‐Fos); (3) decrease of mRNAs encoding proapoptotic proteins (c‐myc, Bax, caspase‐3, Apaf‐1). The biochemical changes underlaying these effects were probably induced by a protein tyrosine kinase (PTK) activity triggered by the binding of SV‐IV to its putative plasma membrane receptors. The ineffectiveness of SV‐IV to abrogate the cycle arrest was accounted for by its downregulating effects on D1,3/E G1‐cyclins and CdK2/4 gene expression, ppRb/pRb ratio, and intracellular ROS concentration. In conclusion, these experiments: (1) prove that SV‐IV acts as a cell survival factor; (2) suggest the involvement of a PTK in SV‐IV signaling; (3) point to cell cycle‐linked enzyme inhibition as responsible for cycle arrest; (4) provide a model to dissect the cycle arrest and apoptosis induced by serum withdrawal; (5) imply a possible role of SV‐IV in the survival of hemiallogenic implanting embryos. J. Cell. Physiol. 212:610–625, 2007. © 2007 Wiley‐Liss, Inc.

Purpose To ascertain whether there are differences in the histopathological appearance of tendinopathic Achilles and patellar tendons. Methods In males, we studied biopsies from tendinopathic Achilles (n = 28; average age 34.1 years) and patellar tendons (n = 28; average age 32.1), and Achilles tendons (n = 21; average age 61.8 years) from deceased patients with no known tendon pathology, and patellar tendons (n = 15; average age 28.3) from patients undergoing anterior cruciate ligament reconstruction. Haematoxylineosin stained slides were interpreted using a semi-quantitative grading scale (0: normal to 3: maximally abnormal) for fibre structure; fibre arrangement; rounding of the nuclei; regional variations in cellularity; increased vascularity; decreased collagen stainability; hyalinisation. All slides were assessed blindly twice, the agreement between two readings ranging from 0.170 to 0.750 (Kappa statistics). Results The highest mean score of tendinopathic Achilles tendons was not significantly different from that of tendinopathic patellar tendons (11.6 ± 5 and 10.4 ± 3, respectively). The ability to differentiate between an Achilles tendon and a patellar tendon was low. Conclusions Tendinopathic Achilles and patellar tendons show a similar histological picture. It was not possible to identify whether a specimen had been harvested from an Achilles or a patellar tendon on the basis of histological examination. The general pattern of degeneration was common to both tendinopathic Achilles and patellar tendons. A common, as yet unidentified, etio-pathological mechanism may have acted on both these tendon populations.

Objective To report the outcome of surgery for chronic recalcitrant Achilles tendinopathy in nonathletic and athletic subjects. Design Case-control study. Setting University teaching hospitals. Patients We matched each of the 61 nonathletic patients with a diagnosis of tendinopathy of the Achilles tendon with an athletic patient with tendinopathy of the main body of the Achilles tendon of the same sex and age (±2 years). A match was possible for 56 patients (23 males and 33 females). Forty-eight nonathletic subjects and 45 athletic subjects agreed to participate. Interventions Open surgery for Achilles tendinopathy. Main Outcome Measure Outcome of surgery, return to sport, complication rate. Results Nonathletic patients were shorter and heavier than athletic patients. They had greater body mass index, calf circumference, side-to-side calf circumference differences, and subcutaneous body fat than athletic patients. Of the 48 nonathletic patients, 9 underwent further surgery during the study period, and only 25 reported an excellent or good result. Of the 45 athletic subjects, 4 underwent further surgery during the study period, and 36 reported an excellent or good result. The remaining patients could not return to their normal levels of activity. In all of them, pain significantly interfered with daily activities. Conclusions Nonathletic subjects experience more prolonged recovery, more complications, and a greater risk of further surgery than athletic subjects with recalcitrant Achilles tendinopathy.