Showing papers by "Nicola Maffulli published in 2010"

Sarcopenia: characteristics, mechanisms and functional significance

Abstract: Sarcopenia reflects a progressive withdrawal of anabolism and an increased catabolism, along with a reduced muscle regeneration capacity. Muscle force and power decline more than muscle dimensions: older muscle is intrinsically weak. Sarcopenic obesity (SO) among the elderly corroborates to the loss of muscle mass increasing the risk of metabolic syndrome development. Recent studies on the musculoskeletal adaptations with ageing and key papers on the mechanisms of muscle wasting, its functional repercussions and on SO are included. Neuropathic, hormonal, immunological, nutritional and physical activity factors contribute to sarcopenia. Selective fast fibre atrophy, loss of motor units and an increase in hybrid fibres are typical findings of ageing. Satellite cell number decreases reducing muscle regeneration capacity. SO promotes further muscle wasting and increases risk of metabolic syndrome development. The proportion of fast to slow fibres seems maintained in old age. In elderly humans, nuclear domain is maintained constant. Basal protein synthesis and breakdown show little changes in old age. Instead, blunting of the anabolic response to feeding and exercise and of the antiproteolytic effect of insulin is observed. Further understanding of the mechanisms of sarcopenia requires disentangling of the effects of ageing alone from those of disuse and disease. The causes of the greater anabolic resistance to feeding and exercise of elderly women need elucidating. The enhancement of muscle regeneration via satellite cell activation via the MAPK/notch molecular pathways seems particularly promising.

Biochemical markers of muscular damage.

Abstract: Muscle tissue may be damaged following intense prolonged training as a consequence of both metabolic and mechanical factors. Serum levels of skeletal muscle enzymes or proteins are markers of the functional status of muscle tissue, and vary widely in both pathological and physiological conditions. Creatine kinase, lactate dehydrogenase, aldolase, myoglobin, troponin, aspartate aminotransferase, and carbonic anhydrase CAIII are the most useful serum markers of muscle injury, but apoptosis in muscle tissues subsequent to strenuous exercise may be also triggered by increased oxidative stress. Therefore, total antioxidant status can be used to evaluate the level of stress in muscle by other markers, such as thiobarbituric acid-reactive substances, malondialdehyde, sulfhydril groups, reduced glutathione, oxidized glutathione, superoxide dismutase, catalase and others. As the various markers provide a composite picture of muscle status, we recommend using more than one to provide a better estimation of muscle stress.

How Successful are Current Ankle Replacements?: A Systematic Review of the Literature

Abstract: Total ankle arthroplasty provides an alternative to arthrodesis for management of ankle arthritis. What is the outcome of total ankle arthroplasty implants currently in use? We conducted a systematic literature search of studies reporting on the outcome of total ankle arthroplasty. We included peer-reviewed studies reporting on at least 20 total ankle arthroplasties with currently used implants, with a minimum followup of 2 years. The Coleman Methodology Score was used to evaluate the quality of the studies. Thirteen Level IV studies of overall good quality reporting on 1105 total ankle arthroplasties (234 Agility™, 344 STAR, 153 Buechel-Pappas™, 152 HINTEGRA®, 98 Salto™, 70 TNK, 54 Mobility™) were included. Residual pain was common (range, 27%–60%), superficial wound complications occurred in 0% to 14.7%, deep infections occurred in 0% to 4.6% of ankles, and ankle function improved after total ankle arthroplasty. The overall failure rate was approximately 10% at 5 years with a wide range (range, 0%–32%) between different centers. Superiority of an implant design over another cannot be supported by the available data. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Long-term health outcomes of youth sports injuries

Abstract: Injuries can counter the beneficial effects of sports participation at a young age if a child or adolescent is unable to continue to participate because of residual effects of injury. This paper reviews current knowledge in the field of long-term health outcomes of youth sports injuries to evaluate the evidence regarding children dropping out of sport due to injury, physeal injuries and growth disturbance, studies of injuries affecting the spine and knee of young and former athletes and surgical outcome of anterior cruciate ligament (ACL) reconstruction in children. Studies of dropping out of sport due to injury are limited primarily to gymnasts and implicate such injuries as ACL rupture and osteochondritis dissecans of the elbow joint in the early retirement of young athletes. Although most physeal injuries resolve with treatment and rest, there is evidence of disturbed physeal growth as a result of injury. Radiological findings implicate the effects of intense physical loading and injury in the development of spinal pathology and back pain during the growth of youth athletes; however, long-term effects are unclear. Follow-up studies of young athletes and adults indicate a high risk of osteoarthritis after meniscus or ACL injury. Prospective cohort studies with a follow-up into adulthood are needed to clarify the long-term health outcomes of youth sports injuries. Important to this research is meticulous documentation of injuries on injury report forms that include age-appropriate designations of the type of injury and accurate determination of exposure-based injury rates.

IOC consensus paper on the use of platelet-rich plasma in sports medicine

Abstract: PRP and its variant forms were originally used in clinical practice as an adjunct to surgery to assist in the healing of various tissues. PRP has also been used in prosthetic surgery to promote tissue healing and implant integration, and to control blood loss. 4 5 Furthermore, the application of activated PRP has an effect on pain and pain medication use following open subacromial decompression surgery. 5

Tendon augmentation grafts: a systematic review.

Abstract: Introduction: Several biomaterials are available to bridge large tendon defects or reinforce tenuous tendon repairs. Methods: We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases using various combinations of the commercial names of each scaffold and the keywords ‘tendon’, ‘rotator cuff’, ‘supraspinatus tendon’, ‘Achilles tendon’, ‘scaffold’, ‘biomaterials’, ‘extracellular matrix’, ‘substitute’, and ‘devices’ over the years 1966–2009. All articles relevant to the subject were retrieved, and their bibliographies hand searched for further references in the context to biomaterials for tendon repair. Results: Many biomaterials are available for tendon augmentation. Scanty evidence is available for the use of these scaffolds. Discussion: The emerging field of tissue engineering holds the promise to use biomaterials for tendon augmentation. Preliminary studies support the idea that these biomaterials have the ability to provide an alternative for tendon augmentation. However, available data are lacking to allow definitive conclusion on the use of biomaterials for tendon augmentation. Additionally, the prevalence of postoperative complications encountered with their use varies within the different studies. Conclusion: Rather than providing strong evidence for or against the use of these materials for tendon augmentation, this study instead generates potential areas for additional prospective investigation.

Functional anatomy of the Achilles tendon

Abstract: The Achilles tendon is the strongest and thickest tendon in the human body. It is also the commonest tendon to rupture. It begins near the middle of the calf and is the conjoint tendon of the gastrocnemius and soleus muscles. The relative contribution of the two muscles to the tendon varies. Spiralisation of the fibres of the tendon produces an area of concentrated stress and confers a mechanical advantage. The calcaneal insertion is specialised and designed to aid the dissipation of stress from the tendon to the calcaneum. The insertion is crescent shaped and has significant medial and lateral projections. The blood supply of the tendon is from the musculotendinous junction, vessels in surrounding connective tissue and the osteotendinous junction. The vascular territories can be classified simply in three, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. This leaves a relatively hypovascular area in the mid-portion of the tendon where most problems occur. The Achilles tendon derives its innervation from the sural nerve with a smaller supply from the tibial nerve. Tenocytes produce type I collagen and form 90% of the cellular component of the normal tendon. Evidence suggests ruptured or pathological tendon produce more type III collagen, which may affect the tensile strength of the tendon. Direct measurements of forces reveal loading in the Achilles tendon as high as 9 KN during running, which is up to 12.5 times body weight.

Novel Approaches for the Management of Tendinopathy

Abstract: Tendinopathy is a failed healing response of the tendon. Despite an abundance of therapeutic options, very few randomized prospective, placebo-controlled trials have been carried out to assist physicians in choosing the best evidence-based management. Eccentric exercises have been proposed to promote collagen fiber cross-link formation within the tendon, thereby facilitating tendon remodeling. Overall results suggest a trend for a positive effect of eccentric exercises, with no reported adverse effects. Combining eccentric training and shock wave therapy produces higher success rates compared with eccentric loading alone or shock wave therapy alone. The use of injectable substances such as platelet-rich plasma, autologous blood, polidocanol, corticosteroids, and aprotinin in and around tendons is popular, but there is minimal clinical evidence to support their use. The aim of operative treatment is to excise fibrotic adhesions, remove areas of failed healing, and make multiple longitudinal incisions in the tendon to detect intratendinous lesions and to restore vascularity and possibly stimulate the remaining viable cells to initiate cell matrix response and healing. New operative procedures include endoscopy, electrocoagulation, and minimally invasive stripping. The aim of these techniques is to disrupt the abnormal neoinnervation to interfere with the pain sensation caused by tendinopathy. Randomized controlled trials are necessary to better clarify the best therapeutic options for the management of tendinopathy.

Autologous growth factor injections in chronic tendinopathy: a systematic review

Abstract: Chronic degenerative tendinopathies are frequent and difficult to treat. Tendon healing and regeneration may be improved by injecting autologous growth factors obtained from the patient's blood. Autologous growth factors can be injected with autologous whole blood or platelet-rich plasma (PRP). Electronic databases were searched for prospective clinical trials on treatment with autologous growth factors of patients with chronic tendinopathy. Chronic tendinopathy in this study included wrist extensors, flexors, plantar fasciopathy and patellar tendinopathy. Studies examining the treatment of other tendinopathies were not identified. The Physiotherapy Evidence Database score was used to examine the methodological quality of the assessment, and a qualitative analysis was performed with the levels of evidence. There are many proposed treatment options for chronic tendinopathy. Treatments in the form of injections with autologous whole blood or PRP are increasingly used in clinical practice. There are high expectations of these regenerative injections, and there is a clear need for effective conservative therapies. All studies showed that injections of autologous growth factors (whole blood and PRP) in patients with chronic tendinopathy had a significant impact on improving pain and/or function over time. However, only three studies using autologous whole blood had a high methodological quality assessment, and none of them showed any benefit of an autologous growth factor injection when compared with a control group. At present, there is strong evidence that the use of injections with autologous whole blood should not be recommended. There were no high-quality studies found on PRP treatment. There is limited evidence to support the use of injections with PRP in the management of chronic tendinopathy. There is growing interest in the working mechanisms of autologous growth factors. The amount and mixture of growth factors produced using different cell separating systems are largely unknown and it is also uncertain whether platelet activation prior to injection is necessary. These variables should be taken into account when starting clinical studies. A good experimental model for studying tendinopathy would be helpful for basic research. Future clinical studies using a proper control group, randomization, blinding and validated disease-specific outcome measures for pain and function are needed.

Genetics and sports.

Abstract: Introduction: The limit of each individual to perform a given type of exercise depends on the nature of the task, and is influenced by a variety of factors, including psychology, environment and genetic make up. Genetics provide useful insights, as sport performances can be ultimately defined as a polygenic trait. Sources of data: We searched PubMed using the terms ‘sports’ and ‘genetics’ over the period 1990 to present. Areas of agreement: The physical performance phenotypes for which a genetic basis can be suspected include endurance capacity, muscle performance, physiological attitude to train and ability of tendons and ligaments to withstand injury. Genetic testing in sport would permit to identify individuals with optimal physiology and morphology, and also those with a greater capacity to respond/adapt to training and a lesser chance of suffering from injuries. Areas of controversy: Ethical and practical caveats should be clearly emphasized. The translation of an advantageous genotype into a champion’s phenotype is still influenced by environmental, psychological and sociological factors. Emerging areas for developing research: The current scientific evidence on the relationship between genetics and sports look promising. There is a need for additional studies to determine whether genome-wide genotyping arrays would be really useful and cost-effective. Since exercise training regulates the expression of genes encoding various enzymes in muscle and other tissues, genetic research in sports will help clarify several aspects of human biology and physiology, such as RNA and protein level regulation under specific circumstances.

Microfracture for chondral defects of the talus: maintenance of early results at midterm follow-up

Abstract: We determined whether the early improvement in symptoms and function after microfracture in the management of articular cartilage defects of the talus is maintained at mid term follow-up. Factors influencing outcome and postoperative magnetic resonance imaging were also evaluated. We performed data collection prospectively using the Hannover Scoring System for the ankle (HSS) and a Visual Analog Scale (VAS) for pain and function preoperatively, at 1 ± 0.1 year (45 ankles), 2 ± 0.4 years (45 ankles), and at an average of 5.8 ± 2.0 years (39 ankles) postoperatively. MRI was used to assess cartilage repair tissue based on the following variables: degree of defect repair and filling of the defect, integration to border zone, surface of the repair tissue, structure of the repair tissue and subchondral bone alterations. Comparing the outcome scores of the last follow-up to the previous follow-up points, the HSS and the VAS (pain, function and satisfaction) showed no deterioration. Four ankles, however, underwent further surgery to address the chondral defect and were regarded as failures. A body mass index greater than 25 kg/m2 and having severe post-traumatic cartilage damage appeared to be negative prognostic factors. Results for patients older than 50 years were not inferior to those in younger patients. Microfracture arthroplasty induces repair of localized articular cartilage defects of the talus maintaining the encouraging early results at mid term follow-up.

Posterior Thigh Muscle Injuries in Elite Track and Field Athletes

Abstract: Introduction: Posterior thigh muscle injuries in athletes are common, and prediction of recovery time would be of value.Hypothesis: Knee active range of motion deficit 48 hours after a unilateral posterior thigh muscle injury correlates with time to full recovery.Study Design: Cohort study (prognosis); Level of evidence, 2.Methods: One hundred sixty-five track and field athletes with acute, first-time, unilateral posterior thigh muscle injuries were prospectively evaluated regarding knee active range of motion deficit. This was compared with the uninjured side 48 hours after injury. A control group was also examined. Ultrasound was used to image the muscle lesion. All athletes were managed nonoperatively with the same rehabilitation protocol. The “full rehabilitation time” (interval from the injury to full athletic activities) was recorded.Results: Range of motion of the affected leg was decreased in the 165 injured athletes compared with the uninjured side and the control group. Sonography identified abn...

Tendon healing and platelet-rich plasma therapies

Abstract: Importance of the field: The therapeutic use of platelet-rich plasma (PRP) is an autologous biotechnology that relies on the local delivery of a wide range of growth factors and cytokines with the aim of enhancing tissue healing. Understanding both tendon healing and PRP therapies is an area of research that is critically important in developing optimal formulations and protocols to achieve the intended therapeutic effects.Areas covered in this review: We summarise recent information on the mechanisms inherent to the earliest response to tendon injury. We then describe the positive effect of PRP therapies on tendon healing. Research on tendinopathy has produced several biological hypotheses based on histopathological, biochemical and clinical findings showing that cell apoptosis, angiofibroblastic features or abnormal biochemical adaptations underlie the condition.What the reader will gain: The article provides insights into early healing mechanisms and the influence of PRP therapies on inflammation, cell...

Minimally Invasive Locked Plating of Distal Tibia Fractures is Safe and Effective

Abstract: Distal tibial fractures are difficult to manage. Limited soft tissue and poor vascularity impose limitations for traditional plating techniques that require large exposures. The nature of the limitations for traditional plating techniques is intrinsic to the large exposure required to approach distal tibia, a bone characterized by limited soft tissue coverage and poor vascularity. The locking plate (LP) is a new device for treatment of fractures. We assessed the bone union rate, deformity, leg-length discrepancy, ankle range of motion, return to preinjury activities, infection, and complication rate in 21 selected patients who underwent minimally invasive osteosynthesis of closed distal tibia fractures with an LP. According to the AO classification, there were 12 Type A, 5 Type B, and 4 Type C fractures. The minimum followup was 2 years (average, 2.8 years; range, 2–4 years). Two patients were lost to followup. Union was achieved in all but one patient by the 24th postoperative week. Four patients had angular deformity less than 7°. No patient had a leg-length discrepancy more than 1.1 cm. Five patients had ankle range of motion less than 20° compared with the contralateral side. Sixteen patients had not returned to their preinjury sporting or leisure activities. Three patients developed a delayed infection. We judge the LP a reasonable device for treating distal tibia fractures. The level of physical activities appears permanently reduced in most patients. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Rating scales for low back pain

Abstract: Introduction: During the past decades several rating scales have been developed to assess the functional status of patients with low back pain. Methods: We performed a search using the keywords ‘spine’ in combination with ‘scoring system’, ‘scale’, ‘scores’, ‘outcome assessment’, ‘low back pain’ and ‘clinical evaluation’. Results: Twenty-eight scoring systems are currently available for the evaluation of low back pain. Each of them evaluates low back pain using specific variables. All these scoring systems are presented. Discussion: Although many scoring systems have been used to evaluate the back function, we are still far from a single outcome evaluation system that is reliable, valid and sensitive to clinically relevant changes, taken into account both patients’ and physicians’ perspective and is short and practical to use. Conclusion: Further studies are required to evaluate the reliability, validity and sensitivity of the low back pain scoring systems used in the common clinical practice.

Sports Injuries in Young Athletes: Long-Term Outcome and Prevention Strategies

Abstract: Physical activity plays a significant role in the physical and emotional well-being of a child. In the past 15 to 20 years, there has been a dramatic increase in sports participation at a young age, which has offered numerous health benefits, including self-esteem, confidence, team play, fitness, agility, and strength. Children are playing sports at younger ages. This article assesses the long-term outcome of sports injuries in young athletes, with suggestions on how to prevent such injuries. There are no definitive epidemiological data on withdraw from sports activities due to injury in young athletes. Disturbed physeal growth as a result of injury can result in length discrepancy, angular deformity, or altered joint mechanics, and may cause significant long-term disability. Sequelae of Osgood-Schlatter lesion include painful ossicle in the distal patellar tendon. Fragmentation or separation of the apophysis appears to be the result of adaptive changes to the increased stress that occurs in overu...

Plantar fascia-specific stretching versus radial shock-wave therapy as initial treatment of plantar fasciopathy.

Abstract: Background: Whether plantar fascia-specific stretching or shock-wave therapy is effective as an initial treatment for proximal plantar fasciopathy remains unclear. The aim of this study was to test the null hypothesis of no difference in the effectiveness of these two forms of treatment for patients who had unilateral plantar fasciopathy for a maximum duration of six weeks and which had not been treated previously. Methods: One hundred and two patients with acute plantar fasciopathy were randomly assigned to perform an eight-week plantar fascia-specific stretching program (Group I, n = 54) or to receive repetitive low-energy radial shock-wave therapy without local anesthesia, administered weekly for three weeks (Group II, n = 48). All patients completed the seven-item pain subscale of the validated Foot Function Index and a patient-relevant outcome questionnaire. Patients were evaluated at baseline and at two, four, and fifteen months after baseline. The primary outcome measures were a mean change in the Foot Function Index sum score at two months after baseline, a mean change in item 2 (pain during the first few steps of walking in the morning) on this index, and satisfaction with treatment. Results: No difference in mean age, sex, weight, or duration of symptoms was found between the groups at baseline. At two months after baseline, the Foot Function Index sum score showed significantly greater changes for the patients managed with plantar fascia-specific stretching than for those managed with shock-wave therapy (p < 0.001), as well as individually for item 2 (p = 0.002). Thirty-five patients (65%) in Group I versus fourteen patients (29%) in Group II were satisfied with the treatment (p < 0.001). These findings persisted at four months. At fifteen months after baseline, no significant between-group difference was measured. Conclusions: A program of manual stretching exercises specific to the plantar fascia is superior to repetitive low-energy radial shock-wave therapy for the treatment of acute symptoms of proximal plantar fasciopathy. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Current treatment options for tendinopathy

Abstract: Importance of the field: Tendon disorders are frequent and are responsible for much morbidity, both in sport and the workplace. Although several therapeutic options are routinely used, very few well-conducted randomised prospective, placebo, controlled trials have been performed to assist in choosing the best evidence-based management.Areas covered in this review: We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases over the years 1966 – 2010 to review the best evidence-based options for the management of patients with tendinopathy.What the reader will gain: The reader will obtain information on the available medical and surgical therapies used to manage tendinopathy-related symptoms. The effectiveness of therapies, the length of management and the adverse effects are examined.Take-home message: Management of tendinopathy is often anecdotic and lacking well-researched scientific evidence. Teaching patients to control the symptoms may be more beneficial than leadin...

Favorable Outcome of Percutaneous Repair of Achilles Tendon Ruptures in the Elderly

Abstract: Percutaneous repair of Achilles tendon (AT) ruptures reportedly reduces the risk of rerupture compared to nonoperative treatment and reduces the risk of wound infection compared to open surgery. We retrospectively reviewed the postoperative Achilles tendon total rupture score (ATRS), and the maximum calf circumference in 35 patients over 65 years of age who sustained an acute tear of the AT and underwent percutaneous repair of the AT. There were 26 men and nine women with a mean age at operation of 73.4 ± 8.7 years (range, 65–86 years). Of the 35 recruited patients, we report on 27 patients for whom we have a full data set. The minimum followup was 49 months (mean, 88 months; range, 49–110 months). The ATRS had a postoperative average rating of 69.4 ± 14 (range, 56–93). All patients were able to bear weight fully on the affected limb by the eighth postoperative week. The data suggest that percutaneous repair of the AT is a suitable option for patients older than 65, producing similar outcomes when compared to percutaneous repair in younger patients of previous reports. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Autologous platelet-rich plasma: a revolution in soft tissue sports injury management?

Abstract: Platelet-rich plasma (PRP) therapy is an emerging technology that aims to improve the process of tissue repair through local delivery of autologous bioactive agents to influence critical physiological mechanisms such as inflammation, angiogenesis, or extracellular matrix synthesis. These biological properties have prompted the therapeutic administration of PRP in orthopedics and sports medicine. Given its biocompatibility and healing properties, percutaneous injections of PRP are used in athletes to treat tendon and muscle injuries. Studies of varying levels of evidence have demonstrated the safety and beneficial effects of PRP in these applications, but standardization of the methods of plasma preparation and procedures for application is necessary for further advancements. Continued efforts to identify factors that influence the biological response to PRP treatment may yield new formulations tailored to each specific application. The growing emphasis on an evidence-based approach in the sports medicine setting demands additional research efforts before incorporating this technology in routine clinical care.

Triglycerides and total serum cholesterol in rotator cuff tears: do they matter?

Abstract: Objective In this study, the serum triglycerides and total serum cholesterol levels in patients with rotator cuff tear were determined. Design Frequency-matched case-control study. Setting University teaching hospital. Participants 240 individuals who were operated on at our institution were included in the study. 120 patients (45 men and 75 women; mean age 64.86 years, range 40 to 83 years) who underwent arthroscopic repair of a rotator cuff tear were included in group 1. 120 patients (45 men and 75 women; mean age 63.91 years, range 38 to 78 years) who underwent arthroscopic meniscectomy for a meniscal tear and had no evidence of shoulder pathology were included in group 2 (control group). These patients were frequency-matched by age (within 3 years) and sex with patients of group 1. Main outcome measures Measurement of serum triglyceride and total cholesterol concentrations. Results When comparing the two groups, there was no difference either in serum triglyceride concentration or total serum cholesterol concentration. Conclusions There appears to be no association between serum triglyceride concentration and total serum cholesterol concentration in rotator cuff tears.

Temporal sequence of greyscale ultrasound changes and their relationship with neovascularity and pain in the patellar tendon

Abstract: Objective Ultrasound (US) imaging has revealed distinct types of greyscale abnormalities in the patellar and Achilles tendons, including diffusely thickened tendons and tendons containing a hypoechoic region. The relationship between these greyscale abnormalities and their clinical relevance is unknown. This study investigated the temporal sequence in greyscale abnormalities as well as the relationship between greyscale abnormalities, Doppler flow and pain. Methods Patellar tendon pain (single leg decline squat test) and ultrasound imaging (greyscale (normal, diffuse thickening, hypoechoic), presence of Doppler flow) were assessed bilaterally among 58 volleyball players at monthly intervals during a 5-month season. The probability of transition between the greyscale ultrasound groups was calculated for each month and totalled over the season (prospective) and the relationship between these groups and the presence and intensity of pain and the presence of Doppler flow were investigated (cross-sectional investigation). Results Tendons with normal US were more likely to transition to diffuse thickening than to a hypoechoic region. Tendons containing a hypoechoic region were more likely to transition to diffuse thickening rather than to a normal US appearance. Hypoechoic regions were more likely to be painful (59%) and contain Doppler flow (42%) than tendons with diffuse thickening (pain in 43% and Doppler flow in 6%). Conclusions The transitions identified between normal, diffusely thickened tendons and those containing a hypoechoic region suggests that these greyscale US changes may represent different phases of tendon pathology. Tendons containing a hypoechoic region are more likely to be painful and contain Doppler flow than diffusely thickened tendons.

Upper cervical spine injuries: indications and limits of the conservative management in Halo vest. A systematic review of efficacy and safety.

Abstract: Introduction The integrity of the upper cervical spine is essential for survival and function, because of the neurovascular structures contained within its bony elements. Fractures of the upper cervical spine (C1–C2) are frequent. This systematic review assesses the efficacy and safety of the conservative management in Halo vest for patients with upper cervical spine fractures. Materials and methods Two reviewers independently identified studies in English, by a systematic search of CINAHL, Embase, Medline, HealthSTAR, and the Cochrane Central Registry of Controlled Trials, from inception of each database to 28 January 2010, using various combinations of the keywords terms “odontoid fractures”, hangman's fractures”, “axis fractures”, “axis”, “atlas”, “Jefferson fractures”, “C1 arch fractures”, “C1 fractures”, “C2 fractures”, “cervical spine”, “injuries”, “fracture”, “trauma”, “neck injury”, “surgery”. Results A total of 43 citations were obtained. An additional 4 papers were obtained from the reference list of the studies included. The 47 studies that were included described a total of 1078 patients with C1–C2 fractures managed by halo fixator. Conclusions The halo fixator has a well defined place in the management of fractures of the cervical spine. Clearly, studies of higher level of evidence, for instance large randomised trials, should be conducted, even though the available evidences suggest that management of upper cervical spine facture with halo fixator is safe and effective.

Temporal sequence of greyscale ultrasound changes and their relationship with neovascularity and pain in the patellar tendon.

Abstract: Objective Ultrasound (US) imaging has revealed distinct types of greyscale abnormalities in the patellar and Achilles tendons, including diffusely thickened tendons and tendons containing a hypoechoic region. The relationship between these greyscale abnormalities and their clinical relevance is unknown. This study investigated the temporal sequence in greyscale abnormalities as well as the relationship between greyscale abnormalities, Doppler flow and pain. Methods Patellar tendon pain (single leg decline squat test) and ultrasound imaging (greyscale (normal, diffuse thickening, hypoechoic), presence of Doppler flow) were assessed bilaterally among 58 volleyball players at monthly intervals during a 5-month season. The probability of transition between the greyscale ultrasound groups was calculated for each month and totalled over the season (prospective) and the relationship between these groups and the presence and intensity of pain and the presence of Doppler flow were investigated (cross-sectional investigation). Results Tendons with normal US were more likely to transition to diffuse thickening than to a hypoechoic region. Tendons containing a hypoechoic region were more likely to transition to diffuse thickening rather than to a normal US appearance. Hypoechoic regions were more likely to be painful (59%) and contain Doppler flow (42%) than tendons with diffuse thickening (pain in 43% and Doppler flow in 6%). Conclusions The transitions identified between normal, diffusely thickened tendons and those containing a hypoechoic region suggests that these greyscale US changes may represent different phases of tendon pathology. Tendons containing a hypoechoic region are more likely to be painful and contain Doppler flow than diffusely thickened tendons.

Supination-External Rotation Ankle Fractures Stability a Key Issue

Abstract: Stability is a key issue in treating supination-external rotation ankle fractures, but we do not know how it affects functional outcome and subsequent development of radiographic osteoarthritis. With a systematic literature review, we identified 11 clinical studies (Level IV evidence) published in peer-reviewed journals reporting on at least 10 ankles. Followup was at least 1 year. Two authors independently scored the quality of the studies using the modified Coleman Methodology Score; the mean score was 58 of 100, with substantial agreement between the two examiners. Four studies used a general health assessment questionnaire. Several literature limitations (debatable fracture stability criteria, few cohort studies with heterogeneous methodology, small patient numbers and limited followup in some studies) do not allow definitive conclusions. Of 213 stable fractures treated nonoperatively, 2.8% of ankles had radiographic osteoarthritis develop (18 years’ mean followup) and 84% were free of symptoms. The incidence of radiographic osteoarthritis in 420 unstable fractures treated operatively was 20.9% at 5.5 years versus 65.5% at 6.8 years in 137 ankles treated nonoperatively. The complication rate in 355 operatively treated fractures was 10.4%. A medial malleolus fracture, female gender, older age, higher American Society of Anesthesiologists grade, smoking, and lower educational level negatively influenced general health outcome, physical function, and pain. Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Platelet-rich plasma: any substance into it?

Abstract: Autologous platelet-rich plasma (PRP) is perceived to accelerate healing in muscu loskeletal injuries. PRP is increasingly used in situations that require rapid return-to play, which, in the professional sports arena, translates to fame and money. It is astonishing but understandable that the most influential stimulus for PRP therapy in the USA, years after the method had been popularised in Europe, was a February 2009 article in the lay press.1 Human blood platelet counts are approx imately 200 000/ml. PRP is an autologous concentration of human platelets above this in a small volume of plasma.2 Reports vary regarding the platelet concentration and different growth factors present in the PRP concentrate. Also, there are many preparation protocols, kits, centrifuges and methods to trigger platelet activation before use. The same is true for application methods, including using injectable activated PRP liquid concentrate versus implanting a fibrin scaffold, optimal timing of injection and the specific volume to use. Almost every major manufacturer in the orthopaedic and sports medicine world markets a different commercial kit. Some claim to produce a better quantity and quality of PRP than their competitors from the same amount of blood from the same patient. Costs vary tremendously: a commercial kit yields a PRP concentrate at the cost of several hundred dollars, but inhouse non-automatised techniques produce a PRP concentrate for approximately US$10. Each method to concentrate platelets leads to a different product with different biology and potential uses,3 with a high variation (3 to 27-fold) in growth factor concentration and in the kinetics of release.3,–,5 Most techniques yield a PRP concentrate of approximately 10% of the blood volume taken (eg, 20 ml of whole blood would result in approximately 2 ml of PRP). These differences might be of relevance to clinical management, …

Effect of dihydrotestosterone on cultured human tenocytes from intact supraspinatus tendon.

Abstract: The role of hormones in the pathogenesis of tendinopathy is not well recognised, even though the use of anabolic steroids is correlated with a higher incidence of spontaneous tendon ruptures. The aim of this study was to investigate the effects of dihydrotestosterone (DHT) on human tenocyte cultures from the intact supraspinatus tendon of male subjects. Cultured human tenocytes were seeded into culture plates at a density of 5 × 104 cells per well and incubated for 24 h. Then, 10−9 M–10−7 M DHT or Dulbecco’s modified Eagle’s medium (DMEM) only (control) was added to the culture plate wells. Cell morphology assessment and cell proliferation tests were performed 48, 72 and 96 h after DHT treatment. DHT-treated tenocytes showed an increased proliferation rate at DHT concentration higher than 10−8 M. Differences in cell numbers between control and DHT-treated cells were statistically significant (P < 0.05) after 48 and 72 h of treatment with DHT concentrations of 10−8 and 10−7 M. The tenocytes treated with DHT (10−8 and 10−7 M) became more flattened and polygonal compared to control cells that maintained their fibroblast-like appearance during the experiment at each observation time. In conclusion, in vitro, progressive increasing concentration of DHT at doses greater than 10−8 M had direct effects on male human tenocytes, increasing cell number after 48 and 72 h of treatment, and leading to a dedifferentiated phenotype after 48 h of treatment. This effect can be important during tendon-healing and repair, when active proliferation is required. Our results represent preliminary evidence for a possible correlation between testosterone abuse and shoulder tendinopathy.

Low-Energy Extracorporeal Shock Wave Therapy as a Treatment for Medial Tibial Stress Syndrome

Abstract: Results: One month, 4 months, and 15 months from baseline, success rates for the control and treatment groups according to the Likert scale were 13% and 30% (P < .001), 30% and 64% (P < .001), and 37% and 76% (P < .001), respectively. One month, 4 months, and 15 months from baseline, the mean numeric rating scale for the control and treatment groups were 7.3 and 5.8 (P < .001), 6.9 and 3.8 (P < .001), and 5.3 and 2.7 (P < .001), respectively. At 15 months from baseline, 40 of the 47 subjects in the treatment group had been able to return to their preferred sport at their preinjury level, as had 22 of the 47 control subjects.