Intraprosthetic dislocation (IPD) is a specific implant-related complication of dual mobility (DM) implants, which is defined as a dissociation of polyethylene (PE) liner from the femoral head. We report a unique case of  late IPD of a monoblock DM cup cemented into a well-fixed cementless acetabular shell for recurrent dislocation of total hip arthroplasty (THA). A 77-year-old woman was admitted to our department for acute right hip pain, functional impairment and inability to bear weight without any trauma. Three years earlier, she underwent revision THA for recurrent dislocation with a monoblock DM cup cemented into a well-fixed cementless acetabular shell according to the "double-socket" technique. Three months after that revision the patient experienced an anterior THA dislocation, which was managed by closed reduction under sedation in the emergency room. No additional episodes of prosthesis instability occurred. Upon admission, radiographic evaluation showed  right THA dislocation. X-rays performed  after closed reduction revealed eccentric positioning of the head inside the cup, and a direct contact between the metal head and the cup was revealed by subsequent CT scan, confirming the suspicion of IPD. The patient underwent revision surgery, during which the PE liner was found lodged within the cup in a subluxated position, disassembled from the inner head. Both the acetabular cup and modular femoral stem proved well-fixed and impossible to remove, therefore they were retained. The explanted DM components were replaced with new ones of the same size and, thanks to the femoral neck's modular nature, it was substituted with a longer one, which resulted in improved stability against intraoperative stress maneuvers. The postoperative course was uncomplicated. At 1-year follow-up, the patient had a good functional recovery.

BACKGROUND:The latest technology on far infrared radiations reflects the radiations emitted by the human body and induces an antalgic and anti-inflammatory effect without active ingredients. Our primary aim was to assess pain level modifications throughout the treatment period with two different types of patches, compared to a placebo. As secondary aims, we focused on addressing patients' quality of life and range of motion changes with each patch.METHODS:We assessed 54 patients with chronic lumbar back pain treated with FIT Therapy (far infrared technology) patch. Three different types of FIT Therapy patches (F4, F3, and placebo) were used according to the different power of action and patients allocated in a randomized fashion into the 3 arms of the study. Every single patient was assessed during the study using the VAS pain scale, the Roland Morris Disability Questionnaire for quality of life, and ROM for a total of 14 days.RESULTS:Only the F4 patch group significantly reduced pain level at T14 compared to the placebo group (p<0.05). Meanwhile, F3 showed only a non-significant decrease compared to placebo (p=0.254). In terms of lifestyle improvements, both F3 and F4 recorded a decrease on the RMDQ of 4 and 6 points, respectively.CONCLUSIONS:Currently, we still need further studies with longer follow-up to consider the FIT Therapy patches F4 a valid alternative as a "non-medicated pain relief", but it proved to have a role in alleviating painful symptoms and improving function in chronic lumbar back pain without adverse events.

The management of penetrating skeletal extremity trauma is a clinical challenge even for experienced surgeons. While the treatment of associated vascular injuries should be prioritized, there is still a lack of evidence regarding the management of foreign bodies in case of bone fractures or neurological injuries. Here we present a case of impalement of the right proximal humerus with a construction steel rod. The 54-year-old man was successfully treated without vascular, neurological, and thoracic sequelae. A review of the current literature about the most appropriate extrication sequences and soft tissue reconstruction following massive foreign body injuries was carried out.

3.1. Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358 3.2. Interspace involved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358 3.3. Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358 3.4. Injection procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359 Background: The aim of this paper is to analyze the effectiveness of corticosteroid injections (CI), in combination with or without a local anaesthetic, for Civinini-Morton's Syndrome to determine which protocol could be the most appropriate among conservative treatments. Methods: All selected articles were screened using a thorough database search of PubMed, EMBASE and SCOPUS to assess their suitability to the research focus. Results: Selection produced 10 articles as full-text, for a total of 590 patients, with a mean follow-up of 14 +/- 14.2 (range 3-48) months. Johnson satisfaction scale, resulting from 6 studies, scored 25.6% (range 5-38) and 39.4% (range 15-51.8), respectively completely satisfied and satisfied with minor reservations. Mean VAS, declared in 5 studies, decreased from 70.7 +/- 16.5 (range 67-89) to 33.4 +/- 7.6 (26-42.5) points (p < 0.01). Most common complication was skin depigmentation in 7 (2.6%) cases. Conclusions: CI appear to be a safe treatment allowing good results with a very low complications rate. A neuroma of 6.3 mm seems to be the cut-off size; below which CI could have best indications and be considered as an intermediate treatment between shoe modifications and more invasive procedures such as percutaneous alcoholization or surgery. Level of evidence: Level II, systematic review. (c) 2020 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

BACKGROUND This study aims to evaluate complications and early postoperative clinical outcomes of direct anterior approach (DAA) in total hip arthroplasty (THA). METHODS Ninety-one consecutive patients who underwent primary elective unilateral THA between January 2013 and December 2019 were identified. Collected data included age of patient, BMI, ASA score, EBL (estimated blood loss), LOS (length of stay), operating time, and intra/postoperative complications. The recorded complications included prolonged wound drainage without infection, superficial and deep infection, dislocation, periprosthetic fracture, aseptic loosening or failure of osteointegration and nervous damage. Any reoperation, with or without prosthetic component revision, was recorded. RESULTS Fourteen complications (15,4%) and 12 (13,18%) postoperative anemizations were observed in this series. No deep infection was reported. Most common complications were nerve damage (3/91;3,29%), greater trochanter fracture (3/91; 3,29%), and wound trouble (3/91; 3,29%). Two (2,19%) dislocations were reported. One (1,09%) intraoperative periprosthetic fracture was treated with cerclage wiring. One (1,09%) revision was needed for an acetabular mobilization. One patient (1,09%) had severe periprosthetic ectopic ossifications (Brooker 4), needing reintervention because of severe limitations of the range of motion (ROM). CONCLUSIONS Complications rate in this study with THA by DAA is comparable to those reported in literature. DAA is a safe, efficient procedure but it needs a steep learning curve. (www.actabiomedica.it).

Fourth generation ceramic bearings (BIOLOX delta, CeramTec AG; Phlochingen, Germany) were developed to reduce wear debris and improve fracture resistance. A case of a fourth generation head fracture in ceramic-on-polyethylene (COP) coupling after hip revision surgery is reported. A 58-year-old man was admitted to our department for increasing hip pain following a direct trauma which occurred during skiing activity 4 months before. Six years earlier, he had undergone a right cementless revision surgery with a 36-mm BIOLOX delta femoral head on polyethylene liner for metallosis and foreign body reaction after primary total hip replacement for hip osteoarthritis. At admission, radiological evaluation revealed a fracture of ceramic femoral head requiring a new revision surgery. Extensive synovectomy, lavage and capsulectomy were performed. Both acetabular cup and femoral stem were well fixed with no damage of trunnion, and therefore they were retained. A 36-mm internal diameter polyethylene acetabular liner was inserted along a 36-mm BIOLOX delta head with a BioBall adapter XL. The postoperative course was uncomplicated. At 1-year follow-up, the patient had a complete functional recovery. To our knowledge, BIOLOX delta ceramic femoral head fracture after COP hip revision surgery has not been previously reported.

A case of a 71-year-old man with femoral and tibial osteolysis and severe metallosis of the knee, resulting from abrasive wears of the metal components of a unicompartmental knee arthroplasty, that leaded to the rupture of the femoral component of the prosthesis is reported. An unicompartmental prosthesis, in a varus knee, was implanted in 2007. In March 2017, the patient felt that his knee was becoming increasingly unstable with pain and increasing disability. At clinical evaluation there was an effusion, 110° of flexion and - 10° of extension and a slight instability at the varus/valgus stress tests. BMI was 35. In a CT scan performed in June 2017 no signs of alteration were evident, but an X-Ray performed in January 2018 showed a rupture of the femoral component. A revision surgery was performed in February 2018. At the time of revision surgery, the synovitis and the metallosis were evident. A cemented total knee arthroplasty was performed. Samples of the fluid and surface did not show any bacterial growth. Histological examination confirmed the presence of a massive metallosis. The patient had a satisfactory rehabilitation. According to the literature, metallosis and rupture of the prosthetic components due to polyethylene wear after UKA is a common complication. In our case report the elevated BMI and varus knee accelerated the wear of the polyethylene. The aim of this case report is to enhance how an appropriate diagnosis (clinical and radiographic) and early treatment can lead to a successful result.

Background and aim of the work: Osteoarthritis will become even more common in the near future since the average life span is steadily growing. Pain and loss of function are the main complaints reported by patients, inevitably leading towards a worsened daily life performance. New modern techniques have been developed with advanced cell based therapies. Mesenchymal stem cells (MSC) have the inner ability to mature into different types of cells depending on the stimuli they undergo. This technique has already been proven successful in the knee and, with this retrospective study, we would like to assess its feasibility in the hip joint. Methods:6 consecutive patients affected by hip osteoarthritis were treated by intra-articular injection of autologous adipose-derived MSC between June 2017 and June 2018. Our study included only patients with constant hip pain resistant conservative treatment and OA graded 0-2 on the Tonnis grading scale. All 6 patients were evaluated in the preoperative setting and at the 6 months post-operative mark. Results: The HHS showed an improvement from the pre-operative baseline mean value of 67.2±3.4 to the 84.6±6.3 post-operative value. Moreover, the WOMAC score dropped from a baseline score of 36.3±4.7 to 19.8±3.4 at 6 months’ post-op follow up visit. Conclusions: MSC Lipogems is a fairly easy technique. No adverse effects were recorded in our experience. Preliminary results showed a positive outcome according to all the grading systems used in this study even though a longer follow up is needed to validate this technique. (www.actabiomedica.it)

Background: Percutaneous alcoholization with phenol by electrostimulation guidance for the treatment of Morton's neuroma is proposed to determine a permanent chemical neurolysis. Methods: 115 patients for 125 Morton's neuromas were treated. Ten patients were affected by multiple neuromas. Visual Analogue Scale and AOFAS score were used for the clinical assessment. Results: The mean follow-up was 8,3 years. The pre-alcoholization VAS was 85.84 +/- 12.00, while at follow-up scored 28.85 +/- 31.35, showing a signi ficant decrease improving in 113/125 cases (90.4%). Treatment was considered successful with a reduction of the VAS value superior to 50% in 89 out of 125 patients (71.2%). The mean overall AOFAS score at-up was 85.09 +/- 13.41. Conclusions: Needle-electrode guided percutaneous alcoholization is an outpatient, minimally invasive procedure with low rate of complications. Better results of those obtained with traditional conservative treatments and comparable with those reported with other alcohols injections or surgical nerve excision were observed.

Introduction: The intricate linkage between Freezing of Gait (FoG) and postural control in Parkinson's disease (PD) is unclear. We analyzed the impact of FoG on dynamic postural control. Methods: 24 PD patients, 12 with (PD+FoG), 12 without FoG (PD-FoG), and 12 healthy controls, were assessed in ON state. Mobility and postural control were measured with clinical scales (UPDRS III, BBS, MPAS) and with kinematic and kinetic analysis during three tasks, characterized by levels of increasing difficulty to plan sequential movement of postural control: walk (W), gait initiation (GI) and sit-to-walk (STW). Results: The groups were balanced by age, disease duration, disease severity, mobility and balance. During STW, the spatial distribution of COP trajectories in PD+FoG patients are spread over medial-lateral space more than in the PD-FoG (p <.001). Moreover, the distribution of COP positions. in the transition between sit-to-stand and gait initiation, is not properly shifted toward the leading leg, as in PD-FoG and healthy controls, but it is more centrally dispersed (p <.01) with a delayed weight forward progression (p <.05). In GI task and walk task, COM and COP differences are less evident and even absent between PD patients. Conclusion: PD+FoG show postural control differences in STW, compared with PD-FoG and healthy. Different spatial distribution of COP trajectories, between two PD groups are probably due to a deficit to plan postural control during a more demanding motor pattern, such as STW.

There is a complex interplay between the cells of the immune system and bone. These inter- actions are not only mediated by the release of cytokines and chemokines but also by direct cell-cell contact. Studies of intracellular signaling mechanisms in osteoclasts have revealed that numerous immunomodulatory molecules are involved in the regulation of bone metabolism. Recently, it was proposed that immunoreceptors found in the immune cells are also an essen- tial signal for osteoclasts activation, along with receptor activator of NF-icB (RANK) ligand (RANKL). Collectively, these and similar observations regarding cross-regulation between the immune and skeletal systems constitute the field of osteoimmunology. Here we briefly high- light core areas of interest and selected recent advances in this field.

Atypical femoral fractures are often associated with prolonged bisphosphonate use. The American Society for Bone and Mineral Research (ASBMR) has set the diagnosis criteria for atypical subtrochanteric and diaphyseal femoral fractures by classifying them according to their major and minor criteria. Prolonged bisphosphonate use is correlated with AFF, but the pathogenetic mechanism that causes this kind of fracture has not been defined yet. We describe simultaneous bilaterally femoral fractures in a 76-year-old woman.

The general principles of risk assessment as applied to whole foods, macroingredients, micronutrients, and chemicals that may be present in foods are described. Chemicals in food may be present due to their deliberate addition as technological additives, as residues from treatment of crops or food-producing animals with pesticides and veterinary drugs, as from carryover from their use as processing aids, as migrants from food packaging, or as contaminants due to natural occurrence or their presence as pollutants in the environment.

AIM OF THE STUDY:To evaluate the efficacy of plates and screws with angular stability in osteosynthesis of fractures of the distal radius.MATERIALS AND METHODS:We analyzed 52 patients undergone surgery for fracture of the distal radius at the Clinica Ortopedica dell'Università di Trieste; in half of the patients osteosynthesis was provided using Synthes' LCP plates, in the other half we utilized a multidirectional and angular stable plate ("Aptus Radius" by Medartis). Mean follow-up was 28 ± 10 months, patients were evaluated with DASH score (disability of arm shoulder and hand) and the modified Gartland Werley score.RESULTS:There were no significant differences between the two groups in terms of joint function, motility, volar and radial mean inclination.CONCLUSIONS:Based on clinical and radiological results using angular stability plates must be considered as the method of election in the treatment of fractures of the distal epiphysis of the radius; in particular, thanks to the broader technical capabilities that they allow, are particularly indicated in unstable fractures.

Balance and gait problems in patients with cerebellar degeneration lead to reduced mobility, loss of independence, and frequent falls. It is currently unclear, however, whether balance and gait capacities can be improved by training in this group of patients. Therefore, the aim of this study was to examine the effects of gait adaptability training on obstacle avoidance and dynamic stability during adaptive gait. Ten patients with degenerative cerebellar ataxia received 10 protocolized gait adaptability training sessions of 1 h each during 5 weeks. Training was performed on a treadmill with visual stepping targets and obstacles projected on the belt’s surface. As the primary outcome, we used an obstacle avoidance task while walking on a treadmill. We determined avoidance success rates, as well as dynamic stability during the avoidance manoeuvre. Clinical ratings included the scale for the assessment of ataxia (SARA), 10 m walking test, timed up-and-go test, berg balance scale, and the obstacle subtask of the emory functional ambulation profile (EFAP). Following the intervention, success rates on the obstacle avoidance task had significantly improved compared to pre-intervention. For successful avoidance, participants allowed themselves smaller stability margins in the sagittal plane in the (shortened) pre-crossing step. However, in the subsequent steps they returned to baseline stability values more effectively than before training. SARA scores and the EFAP obstacle subtask improved significantly as well. This pilot study provides preliminary evidence of a beneficial effect of gait adaptability training on obstacle avoidance capacity and dynamic stability in patients with cerebellar degeneration.

A frequent problem in Orthopedic surgery is represented by periprosthetic fractures in Total Hip Arthroplasty (THA). The incidence of this pathology has interested 1,5% in primary THA and till 6-8% in revision prosthesis during last 10 years. About this contest, the authors performed a study on 24 patients (6 males; 18 females) surgically treated for periprosthetic femoral fracture at the Orthopedic and Traumatologic Clinic, University of Trieste, Italy, in the period from January 2006 to December 2011. Periprosthetic fractures were classified following guide-lines of the Vancouver Classification System. Even the choice of treatment was based on Vancouver Classification System, on patient clinical conditions and patients age.

AIM OF THE STUDYTo compare unicompartmental knee arthroplasty with "all poly" tibial component and "metal back" from a clinical and functional point of view.MATERIALS AND METHODSWe evaluated prospectively 50 patients who underwent unicompartmental knee replacement at the Orthopedic Clinic of the University of Trieste. Patients were split into two groups (A and B); in patients from group A has been implanted a Mitus prosthesis (Link) with "all poly" tibial component, in patients from Group B has been implanted an Allegretto prosthesis (Zimmer) with a "metal back" tibial component. The mean follow-up was 36 months. All patients were evaluated using the Knee Society Score.RESULTSThe mean preoperative Knee Society Score (objective and functional) was found to be respectively 48 and 49 or the group A and group B; post-operative score was found to be of 95 and 94 respectively for Group A and group B. The average post-operative ROM was 125 degrees (range, 85-140 degrees) for group A and 130° (range 90°-145°) for group B.CONCLUSIONSNo differences were found between implants with "all poly" tibial component (thickness to be used must be greater than 6 mm) and those with the "metal back". We believe that to achieve positive results over time is important the carefully selection of the patients and the accurate positioning of components.

Purpose of review The increased age observed in most countries, with the associated higher rates of chronic illnesses and cancer, and a diffuse sedentary lifestyle, will increase the number of patients with clinically relevant anabolic resistance, sarcopenia and its complications. The need for solutions to this major health issue is, therefore, pressing. Recent findings The metabolic derangements and other consequences associated with sarcopenia can be slowed or even prevented by specific nutritional interventions. New evidence is available about the efficacy of omega-3 fatty acid dietary supplementation to improve protein metabolism and counteract anabolic resistance through indirect effects. Studies show that the anabolic stimuli from substrates (e.g. amino acids or proteins), hormones (e.g. insulin) and/or physical activity in skeletal muscle can be enhanced by long-term fish oil administration. Summary The review of data from recent studies on this topic suggests that dietary omega-3 fatty acid supplementation, in association with an anabolic stimulus, could potentially provide a safe, simple and low-cost intervention to counteract anabolic resistance and sarcopenia. This intervention may contribute to prevent cachexia and disabilities. Supplementation should be given in the earlier stages of sarcopenia (e.g. precachexia). Further research should, however, be performed to better understand the mechanisms involved and the best dosage and timing of administration.

AIM OF THE STUDY:The injury of the radial nerve is not uncommon in humeral shaft fractures. These lesions may be of different types and levels and their treatment changes depending on traumatic characteristic. The authors present a case report of a patient affected by a closed shaft humeral fracture, consequence of an high energy trauma, associated with motor palsy of the radial nerve in which an open surgical revision was performed. The nerve appeared medially displaced and entrapped within the fracture fragments and the fibrous tissue around the lesion and showed signs of posttraumatic suffering without disruption. The nerve was repositioned in its anatomical site after neurolysis and intramedullary nailing of the humeral fracture. The fracture healed after 4 months with full recovery of motor function of the radial nerve.We believe that, in shaft fractures of the humerus with radial nerve deficits, it is imperative to perform surgical exploration of the conditions of the radial nerve itself, in order to obtain a recovery of its functionality.