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Improving the management of irrigation schemes is a priority in the Mediterranean countries of the EU to achieve the objectives of the Water Framework Directive 2000/60EC. In the case of schemes based on open-channel networks for water conveyance and delivery, a limitation to the management efficiency is the huge number of gates that need to be controlled and regulated manually to adapt the flow to the actual irrigation water demand. Automated and coordinated gate regulation of large irrigation schemes has been successfully implemented in some areas of the world (e.g., NSW, Australia), but it implies huge public investments that are often unavailable. Opposite to this top–down approach, the Lombardy region (the largest irrigated region in the EU) has explored an approach based on funding small projects, which should demonstrate the potential of innovation in irrigation practice and foster the expansion of the most effective measures. In this paper, we analyze the effects of one of these projects, consisting in the substitution of a manual gate, controlling the supply of irrigation to a 150 ha irrigation district, with an automated, remotely controlled gate. Nine years of daily flow measurements at the district inlet, provided by the irrigation consortium that manages the gate, were compared with the rigid flow regulation that was applied when the inlet gate was manually regulated and with the irrigation water requirements simulated with a distributed agro-hydrological model widely used in the region for irrigation accounting and planning. The results show that the flexible regulation allowed by the new gate provided an average water saving of 12,000 m3/ha/year compared to the rigid regulation system. A further, though smaller, margin of improvement of 5000 m3/ha/year can be achieved with an optimal regulation that follows exactly the crop water requirements. A further interesting empirical evidence is that the simulation model fits very well the irrigation water requirements of the district using only easily accessible meteorological input data, without exploiting any information from ground or remote sensors to update soil moisture or crop developments during the season. This indicates that it could be effectively used, with very limited costs and effort, to support and improve the gate management. Finally, a preliminary economic analysis shows that the cost of the gate installation is sustainable, but the upscaling of this type of intervention to larger areas requires the support of public funding to cover approximately half of the cost of investment needed for the networking infrastructures.

Background Shoulder replacement (SR) constitutes the gold standard treatment for severe shoulder diseases, including osteoarthritis, rheumatoid arthritis, complex fractures, avascular necrosis and rotator cuff arthropathy. Although several countries have national registries, there is a lack of epidemiological data on SR. Sharing national statistics and correlating those to other countries could be helpful to compare outcomes and costs internationally. This paper aims to evaluate the trend of hospitalizations for SR (both first implants and revisions of anatomical and reverse prosthesis) in Italy from 2009 to 2019, based on the National Hospital Discharge Reports (S.D.O) provided by the Italian National Health Service (INHS). Moreover, the economic impact on the healthcare system of SR and SR revisions was assessed, providing a statistical prediction for the next ten years. Methods The data used in this paper were about patients who underwent Total Shoulder Replacement (TSR), Shoulder Hemiarthroplasty (SH) or Revision of shoulder joint replacement (RSR) from 2009 to 2019 in Italy. Information about patients was anonymous and included age, sex, days of hospitalization, procedures and diagnoses codes. Results From 2009 to 2019, 73,046 TSR and SH were performed in adult Italian residents, with a cumulative incidence of 13.6 cases per 100,000 adult Italian residents. While, 2,129 revisions of shoulder replacement were performed, with a cumulative incidence of 0.4 cases per 100,000 residents. Overall, females represented the majority of the cases (72.4% of patients who underwent TSR or SH and 59.1% of patients who underwent RSR). From 2009 to 2019, has been assessed an overall cost of 625,638,990€ for TSR or SH procedures in Italy. While, an overall cost of 9,855,141€ for RSR procedures in Italy was calculated. Conclusions The incidence of SR and RSR is expected to increase in the following years, constituting a burden for the healthcare systems. Overall, in Italy, the females represented the majority of patients. Further prospective studies on this topic in different countries can be con-ducted to make comparisons.

This case report describes the clinical progress of a 22-year-old male patient diagnosed with a consolidating Hill-Sachs lesion, treated with 18 sessions of Tissue Optimization Reparative (TO-Rpr) protocol, specific to Radio Electric Asymmetric Conveyor (REAC) technology. At baseline, the patient reported persistent pain with a numeric rating scale (NRS) score of 7 out of 10 and significant functional limitations of the shoulder (flexion 90°, abduction 70°, external rotation 20°), accompanied by bone marrow edema, tendinous alterations, and significant inflammation. The therapeutic protocol aimed to modulate tissue bioelectric activity to promote reparative processes and reduce inflammation. Follow-up MRI, performed four months after treatment, revealed complete resolution of bone marrow edema, normalization of tendinous structures, and reduced cortical irregularities. Clinically, flexion improved to 160°, abduction to 150°, and external rotation to 70°, with muscle strength restored to 5/5 and pain reduced to 0/10 on the NRS. This case highlights the role of REAC TO-Rpr treatment in managing complex joint lesions, showcasing its potential to significantly improve clinical and radiological parameters within a short timeframe.

Abstract PurposeSince the critical shoulder angle (CSA) is considered a risk factor for shoulder pathology and the intra- and inter-rater variabilities in its calculation are not negligible, we developed a deep learning model that calculates it automatically and accurately.MethodsWe used a dataset of 8467 anteroposterior x-ray images of the shoulder annotated with 3 landmarks of interest. A Convolutional Neural Network model coupled with a spatial to numerical transform (DSNT) layer was used to predict the landmark coordinates from which the CSA was calculated. The performances were evaluated by calculating the Euclidean distance between the ground truth coordinates and the predicted ones normalized with respect to the distance between the first and the second points, and the error between the CSA angle measured by a human observer and the predicted one.ResultsRegarding the normalized point distances, we obtained a median error of 2.9%, 2.5%, and 2% for the three points among the entire set. Considering CSA calculations, the median errors were 1° (standard deviation 1.2°), 0.88° (standard deviation 0.87°), and 0.99° (standard deviation 1°) for angles below 30°, between 30° and 35°, and above 35°, respectively.DiscussionThese results demonstrate that the model has the potential to be used in clinical settings where the replicability is important. The reported standard error of the CSA measurement is greater than 2° that is above the median error of our model, indicating a potential accuracy sufficient to be used in a clinical setting.

Purpose The purpose of this study was to evaluate clinical outcomes and tendon integrity on magnetic resonance imaging (MRI) of chronic posterosuperior rotator cuff tears treated with single-row tensionless repair and subacromial balloon spacer as protection with a minimum follow-up of 2 years. The hypothesis of this study was that this procedure would have acceptable clinical outcomes and tendon-healing rate without increased complications. Methods This is a retrospective study of patients with chronic posterosuperior rotator cuff tears repaired with a single-row technique protected with a subacromial balloon device. Patients were followed up for a minimum of 2 years. Clinical outcomes were evaluated with American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Numerical Rating Scale (NRS) for pain. MRI study was obtained likewise after at least 2 years to assess tendon-healing rate. Statistical comparison was performed between pre-operative and at least 2-year clinical and imaging follow-up. Results Thirty-two patients were included in the study with a mean follow-up of 27 ± 7 (range 24–48). The mean age of this cohort was 58 ± 6 (range 41–66) including 15 males and 17 females. The tear size was on average 2.3 cm (range 2–4) and a mean of 2.1 triple-loaded anchors were used (range 2–3). The ASES score significantly increased from a mean of 39 ± 12 points to a mean of 89 ± 12 at the final follow-up ( P  < 0.001). Similarly, pain significantly reduced from a mean pre-operative NRS of 6.8 ± 1.4 to 0.8 ± 1.5 at the final follow-up ( P  < 0.001). MRI scans showed that repair occurred in 26 patients (81.3%). Significant higher ASES score was reached at final follow-up in patients with a “healed” (Sugaya I–III) tendon when compared to patients with an evidence of tendon discontinuity on MRI study (Sugaya IV–V), 93 ± 9 and 74 ± 13, respectively ( P  < 0.001). Conclusions Arthroscopic repair of chronic posterosuperior rotator cuff tears using a single-row tensionless repair and subacromial spacer as protection resulted in an 81.3% of tendon integrity at a mean follow-up of 27 months. Clinical outcomes and pain scores significantly improved without severe complications reported after a minimum follow-up of 2 years. Level of evidence III.

Purpose There is ongoing debate regarding the optimal surgical treatment of irreparable rotator cuff tears (IRCT). This study aimed to assess within the Italian health care system the cost-effectiveness of subacromial spacer as a treatment modality for patients with IRCT. Methods An expected-value decision analysis was created comparing costs and outcomes of patients undergoing arthroscopic subacromial spacer implantation, rotator cuff repair (RCR), total shoulder arthroplasty, and conservative treatment for IRCTs. A broad literature search provided input data to extrapolate and inform treatment success and failure rates, costs, and health utility states for these outcomes. The primary outcome assessed was an incremental cost-effectiveness ratio (ICER) of subacromial spacer implantation versus shoulder arthroplasty, RCR, and conservative treatment. Results Subacromial spacer is favorable over both arthroscopic partial repair and shoulder arthroplasty since it costs less than both options and increases effectiveness by 0.06 and 0.10 quality-adjusted life years (QALYs), respectively. While conservative treatment is the least costly management strategy, subacromial spacer results in a gain of 0.05 QALYs for the additional cost of 522 €, resulting in an ICER of 10,440 €/QALY gain, which is below the standard willingness to pay ratio of $50,000 USD. Strategies with an ICER of less than 50,000 USD are considered to be cost-effective. Conclusions Based on the available evidence and reasonably conservative assumptions, subacromial spacer is likely to provide a safe, effective, and cost-effective option for patients with massive IRCTs. Furthermore, this cost-effectiveness analysis may ultimately serve as a guide for development of health care system and insurer policy as well as clinical practice.

Purpose The aim of this study is to evaluate the return to sport after surgical treatment of shoulder injuries in professional goalkeepers in relationship with the mechanism of injury and the pattern of related shoulder lesions. Methods Twenty-six shoulders in nineteen elite male professional soccer goalkeepers were retrospectively analyzed considering multiple diseases (instability, rotator cuff, biceps or other tendon injuries). Data was collected for injury modality and context, pathological findings, surgical procedures, time, level of return to sport, and complications. Results The mechanism of injury was “mild trauma without contact” in 46% of the cases and 54% of injuries happened during training. 11 patients (42%) reported multiple pattern lesions and 9 patients (35%) classic anterior instability lesions. The mean time for return to differentiated training and unrestricted sport activity was 14 and 20.2 weeks, respectively. 15 athletes (62.5%) reported 100% return to sport, 4 (16.7%) to 90%, 1 (4.2%) to 85%, 3 (12.5%) to 80% and 1 athlete to 50%, stopping professional activity. 21% of the cases reported the persistence of some shoulder symptoms. 3 cases experienced a new injury. Patients with classic anterior instability had significantly lower age (30.7 vs 19.8 years, P =  0.001), experienced injury in different context and reported symptoms more frequently compared to multiple lesion patients (4/8 vs 0/10, P =  0.011). Conclusion Professional elite goalkeepers which required shoulder surgery for different causes demonstrated high-rate level of return to play despite the persistence of mild symptoms. The high frequency of multiple lesions, patients’ characteristics, injury context and mechanism, increase the concern for injuries in overstressed shoulder for this category of sport. Level of evidence IV.

Cells and tissues work like batteries, positively charged by potassium ions and negatively charged by chloride ions. The difference in potential gradient generates an ionic flux, and this, in turn, generates a current that develops endogenous bioelectric fields (EBFs), which are fundamental for all cellular life processes, including reparative phenomena. In damaged tissues, the ionic flow is altered and, consequently, the production of EBFs is altered. This determines an alteration of the reparative processes. In previous studies, the reparative and regenerative treatments of radio electric asymmetric conveyer (REAC) technology have been shown to favor and accelerate the reparative processes of injured tissues, inducing the recovery of ionic flows and EBFs. The purpose of this report is to illustrate the clinical efficacy of REAC treatments for reparative tissue optimization on muscle injuries, even in those with a severity of third degree.

Facial injuries are often caused by accidental traumas and can be devastating, as their aesthetic outcomes can impact the social relationships and self-esteem of the patient. The reparative processes can be delayed and hindered by the alteration of the endogenous bioelectric activity (EBA) in the damaged tissues, caused by the trauma. In fact, the proper maintenance and generation of EBA is a prerequisite for the cellular health of any tissue and the alteration of EBA determines the inhibition of any cellular repair process, affecting even the cellular differentiation processes. The radio electric asymmetric conveyer (REAC) technology for neurobiological stimulation treatments was designed precisely to restore EBA in both superficial and deep tissues. The two cases of facial trauma presented in this report were treated with the noninvasive treatment of reparative tissue optimization (TO-RPR) applied with REAC technology. The results showed that the REAC TO-RPR treatment can quickly and safely optimize the reparative processes of the tissues, inducing a homogeneous, synchronized, and coordinated recovery, regardless of the type and the aging of the injured tissue and the severity and depth of the lesions.

The shoulder enjoys the widest range of motion of all the joints in the human body, therefore requires a delicate balance between stability and motility. The glenohumeral joint is inclined to fall into two main instability categories: macro and micro. Macroinstability can be traumatic or atraumatic, with anterior or posterior dislocation of the humeral head. Microinstability falls within the broader section of acquired instability in overstressed shoulder caused by repeated joint stress. Anterior traumatic instability is the most frequent entity and a relatively common injury in young and athletic population. While shoulder instability is a clinical diagnosis, imaging impacts the patient management by detailing the extent of injury, such as capsulo-labral-ligamentous tears, fracture, and/or dislocation, describing the predisposing anatomic conditions and guide the therapetic choice. The aim of this comprehensive review is to cover the imaging findings of shoulder instability by different imaging techniques.