Stefano Gumina

Background: The long head of the biceps tendon (LHBT) is a major contributor to shoulder pain in patients with rotator cuff tears (RCT), which is why tenotomy or tenodesis is commonly performed during RCT surgical repair. However, recent evidence highlights the importance of preserving the LHBT due to its potential role as an augmentative structure and stabilizer. Currently, no clear consensus or objective criteria exist to guide decisions about whether the LHBT should be sacrificed or preserved during rotator cuff repair. In this study, we compare clinical outcomes among patients with similar degrees of LHBT degeneration who were treated either with tenotomy (±tenodesis) or with debridement and radiofrequency ablation.Methods: We performed a retrospective comparative study. Group I was composed of 75 patients (mean age, 64.90±4.60; female, 46; male, 29) with large RCTs who underwent arthroscopic cuff repair associated with LHBT debridement and radiofrequency ablation for a Biceps Inflammation Section Integrity (BISI) score <5. Group II was composed of 86 patients (mean age, 65.70±3.58; female, 48; male, 38) with large RCTs who underwent arthroscopic cuff repair associated with LHBT tenotomy/tenodesis for a BISI score <5. All RC repairs were performed using a single-row technique with titanium anchors. Clinical outcomes were evaluated 1 year postoperatively using the Constant-Murley Score, the visual analog scale (VAS) for pain, and patient satisfaction surveys. Group comparisons were conducted using standard tests for continuous and categorical variables.Results: At the 1-year follow-up, the mean Constant scores were 76 in the preservation group and 78 in the tenotomy group, with no statistically significant difference (P=0.16). Both groups reported low pain levels (mean VAS, 2). Similar strength deficits and partial limitations in shoulder rotations were observed in both groups. Patient satisfaction rates were 79% vs 81%, respectively.Conclusions: Routine sacrifice of the LHBT during rotator cuff repair may not be necessary for mild to moderate degeneration (BISI <5). Biceps preservation may help maintain shoulder biomechanics and offer advantages for future revision surgeries.Level of evidence: III.

Scapholunate (SL) ligament injuries, if not properly treated, can compromise wrist biomechanics, leading to instability, scapholunate advanced collapse (SLAC) and progressive osteoarthritis. Depending on the severity of the injury, current repair techniques include either arthroscopic or open surgical approaches; however, the limited vascularization of the region often represents an obstacle to optimal ligament healing. This study aims to assess the feasibility of using a vascularized fascial flap based on the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) for biological augmentation of the scapholunate ligament. Five previously injected cadaveric upper limbs were dissected and flap dimensions, including length, width, and pedicle length, were measured using a millimeter-calibrated ruler by two independent operators. All flaps provided sufficient coverage, and the vascular pedicle length allowed tension-free positioning without vascular kinking. These findings demonstrate that a 1,2 ICSRA-based fascial flap is anatomically feasible for scapholunate ligament augmentation. It should be noted that this is a purely cadaveric study, and the technique has not yet been tested in vivo. The results suggest potential surgical applications, providing a vascularized biological option that may enhance ligament healing in future clinical studies.

Background: The mechanical performance assessment of orthopedic fixation systems is computationally and experimentally challenging due to the complex geometrical and mechanical features of bones. Non-contact experimental techniques, widely adopted in several engineering fields, is shown to overcome these issues. Objective: This work discusses a comparative experimental investigation into specimens mimicking healthy humerus bones and fractured bones subject to an innovative surgery procedure and to a classical technique referred to as the gold standard surgery. The new surgery consists in the installation of an external fixation mechanism that constrains, according to different spatial patterns, a certain number of titanium slender bars inserted and clamped into the fractured bones. Methods: The mechanical properties of artificial bones are characterized through compressive tests, while the morphology of the fracture surface is analyzed using a scanning electron microscope. A three-dimensional laser vibrometer is used to measure the resonance frequencies, mode shapes, damping ratios, and mechanical waves propagating from the actuators across the surface of the bones. Results: The results provide insights into which configuration of the fixator performs better for a fast recovery. Based on the observed dynamic behaviors, the optimal configuration of the fixator offers performance that is comparable to, or potentially better than, the gold standard surgical procedure. Conclusions: The novelty and feasibility of the adopted experimental approach paves the way towards the adoption of advanced non-contact techniques for the mechanical characterization of complex, non-homegenous and anisotropic materials and structures in biomedical applications enabling also data-driven models of the systems.

Background: To date, it is not well known which systemic pathologies most frequently afflict patients with rotator cuff tear (RCT) and whether the coexistence of two or more pathologies can affect the lesion size. Therefore, we analyzed our database relative to a large group of patients who recently underwent rotator cuff repair. Methods: A total of 527 patients with full-thickness RCT were enrolled. For each patient, we checked the presence of at least one of diabetes, venous system diseases, cardiovascular diseases, hypercholesterolemia, blood hypertension, thyroid diseases, and a smoking habit. Patients were subdivided according to risk factors into five groups, representing those who had zero, one, two, three, and four or more risk factors, respectively. Statistical analysis was performed. Results: In total, 37% of our patients had no risk factors; 28% had one risk factor (arterial hypertension, smoking habit, and hypercholesterolemia were the most frequent); 23% had two risk factors (the hypertension/hypercholesterolemia association was the most frequent); and 8% suffered from three pathologies (the diabetes/arterial hypertension/hypercholesterolemia association was the most frequent). Comparing the cuff tear severity in patients without and with at least one risk factor, we observed that tear size increased in those with at least one risk factor. Conclusions: A total of 63% of patients with rotator cuff tears were either smokers and/or had at least one pathology capable of altering the peripheral microcirculation. Hypertension and hypercholesterolemia were the most frequent. Tear severity significantly increased with the presence of at least one risk factor.

A fracture-related infection (FRI) is a severe complication of an orthopedic trauma, often leading to challenging treatments and poor outcomes. The surgical strategies are typically categorized into one-stage or two-stage procedures, with the use of systemic and local antibiotics being crucial for infection management. This study assessed the efficacy of an antibiotic-loaded hydrogel (ALH) applied over the internal fixation devices for treating FRIs, comparing the outcomes between the one-stage (OS) and two-stage (TS) reconstructions. This retrospective study included 17 patients with an FRI treated using the ALH at a single center. The patients were divided into OS and TS reconstruction groups. The data on demographics, surgical procedures, antibiotic regimens, and outcomes were collected. The primary and secondary outcomes included the infection cure rate, bone union, complications, and reoperation rates. Among the 17 patients (mean age 48.5 years, 16 males), infections were predominantly in the tibia, with 12 chronic and 5 acute cases. Seven patients had monomicrobial infections, and nine had multidrug-resistant pathogens. No significant differences were found between the OS and TS groups in terms of the infection cure rate, bone union, or complications. One patient in the OS group experienced an infection recurrence, and bone healing was achieved in all but one case. Additional complications included delayed wound closure in two cases and implant failure in one case, requiring a reoperation. The ALH demonstrated potential as an effective local antibiotic treatment for FRIs, particularly in the one-stage reconstructions, allowing for a safe application of internal fixation devices. However, further research with larger sample sizes and longer follow-ups is needed to validate these findings.

Background: Little is known about alterations of the rotator cuff (RC) macroscopic vasculature associated with medical conditions and/or habits that predispose a person to diseases of the peripheral microcirculation. The high frequency of cuff tear and re-tear in patients with diabetes, hypercholesterolemia, uncontrolled arterial hypertension, or metabolic syndrome may be due to tissue hypovascularity.Methods: The macroscopic vasculature of both the articular and bursal sides of the posterosuperior RC was evaluated arthroscopically in 107 patients (mean age, 58.2 years) with no RC tear. Patients were divided into three groups according to medical comorbidities and lifestyle factors (group I, none; group II, smokers and/or drinkers and one comorbidity; and group III, two or more comorbidities). Pulsating vessels originating from both the myotendinous and osteotendinous junctions were assessed as “clearly evident,” “poorly evident,” or “not evident.” Results: Groups I, II, and III comprised 36, 45, and 26 patients, respectively. Within the myotendinous junction, vessels were visualized in 22 group I patients (61%), 25 group II patients (55%), and 6 group III patients (23%) (P=0.007). Pulsating arterial vessels originating from the osteotendinous junction were seen in 42%, 36%, and 0% of patients, respectively (P<0.001). Within the bursal side of the RC, a dense anastomotic network was visualized (either clearly or poorly) in 94% (34), 80% (36), and 35% (9) of patients, respectively (P<0.001).Conclusions: The macroscopic vasculature of the RC is influenced by pre-existing diseases and lifestyle factors, which may impair peripheral microcirculation. Level of evidence: III.

Purpose Fracture-related infections (FRI) pose a difficult management problem, as they require numerous surgical interventions and extended antibiotic treatments, especially when a multidrug-resistant organism is involved, with a paucity of available literature that provides guidance. Results A 42-year-old male presents an open diaphyseal tibia and fibula fracture, complicated by soft tissue necrosis and infections caused by extensively drug-resistant Acinetobacter baumannii (XDR-Ab). Initially treated with a damage control external fixator, the patient underwent multiple surgical procedures, including radical debridement, negative pressure wound therapy, external fixator revisions and reconstructive surgery using a latissimus dorsi free flap. The emergence of colistin resistance in the Acinetobacter baumannii strain led to the compassionate use of cefiderocol, finally achieving clinical cure. Conclusions This case report is one of the firsts that highlights the potential efficacy of cefiderocol in treating challenging bone and joint infections sustained by XDR-Ab. The successful outcome also emphasizes the importance of a comprehensive, multidisciplinary approach in achieving favorable results in complex FRI.

This work discusses a comparative experimental investigation into specimens mimicking healthy humerus bones and fractured bones subject to an innovative surgery procedure and to a classical technique defined as the gold standard surgery. The new surgery technique consists in the installation of an external fixation mechanism (fixator) that constrains in defined positions a certain number of titanium slender bars inserted and clamped to the fractured bones according to different spatial patterns. The mechanical properties of the material constituting the artificial bones are obtained by means of compressive tests while a SEM imaging is employed to characterize the morphology of the fracture surface. A 3D laser vibrometer is employed to acquire the resonance frequencies and the associated operational deflection shapes of the specimens subject to piezoelectric actuation. The same experimental configurations are employed to acquire the mechanical waves propagating from the actuators across the surface of the bones. The analysis of the results provides insights into which configuration of the fixator performs better for a fast recovery using as references the healthy bones and the gold standard surgery. The experimental campaign paves also the way towards the adoption of advanced techniques employed for the mechanical characterization of materials and structures in biomedical applications with the additional aim of extracting data-driven models of the systems.

Periprosthetic joint infections (PJI) are among the most difficult complications to treat in orthopaedic surgery. Debridement, antibiotics, and implant retention (DAIR) represent an efficient strategy for acute PJI, especially when resorbable local antibiotic carriers and coatings are used. The aim of this pilot study was to evaluate the difference between using antibiotic-loaded hydrogel (ALH) and calcium sulphate (CS) beads in the DAIR procedure. We analysed 16 patients who had been treated since 2018 for acute PJI, namely eight patients with knee PJI (50%), seven with hip PJI (43.7%), and one with shoulder PJI (6.2%). Nine patients were treated with the Debridement, Antibiotic Coating and Retention of the Implant (DACRI) method, while seven were treated with the Debridement, Antibiotic Pearls, Retention of the Implant (DAPRI) method. We found no significant differences between the two groups in terms of age, sex, the American Society of Anesthesiologists risk score, Charlson Comorbidity Index, localisation, days from onset to diagnosis and pathogenesis. Furthermore, no differences were found between the DACRI and DAPRI groups in terms of infection control (15 patients, 93.75% with p = 0.36) and last C-Reactive Protein values (p = 0.26), with a mean follow-up of 26.1 ± 7.7 months. Treatment for one patient affected by knee Candida albicans PJI in the DACRI group was not successful. In conclusion, DAPRI and DACRI appear to be safe and effective treatments for PJIs. This evidence will encourage the development of new clinical research into local carriers and coatings for use in acute implant-associated infections.

Rotator cuff tear is a common shoulder injury that compromises both function and quality of life. Despite the prevalence of the injury and advancements in repair techniques, a significant percentage of these repairs fail. This review aims to explore the multifactorial reasons behind this failure, including the degenerative nature of the rotator cuff tendon, inherent and extrinsic factors, and the role of hypoxia in tissue degeneration. Additionally, it elucidates potential strategies for improving healing outcomes.