Showing papers by "Nicola Maffulli published in 2012"

Platelet-Rich Plasma or Hyaluronate in the Management of Osteochondral Lesions of the Talus:

Abstract: Background: Nonoperative options for osteochondral lesions (OCLs) of the talar dome are limited, and currently, there is a lack of scientific evidence to guide management.Purpose: To evaluate the short-term efficacy and safety of platelet-rich plasma (PRP) compared with hyaluronic acid (HA) in reducing pain and disability caused by OCLs of the ankle.Study Design: Randomized controlled trial; Level of evidence, 2.Methods: Thirty-two patients aged 18 to 60 years were allocated to a treatment by intra-articular injections of either HA (group 1) or PRP (plasma rich in growth factors [PRGF] technique, group 2) for OCLs of the talus. Thirty OCLs, 15 per arm, received 3 consecutive intra-articular therapeutic injections and were followed for 28 weeks. The efficacy of the injections in reducing pain and improving function was assessed at each visit using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (AHFS); a visual analog scale (VAS) for pain, stiffness, and function; and the subje...

The FIFA 11+ Program Is Effective in Preventing Injuries in Elite Male Basketball Players A Cluster Randomized Controlled Trial

Abstract: >> Results: During the 9-month season, 23 (19%) of the 121 players included in the study sustained a total of 31 injuries (14 in the intervention group and 17 in the control group). In the intervention group, injury rates per 1000 athlete-exposures were lower than those in the control group, with statistical significance, for overall injuries (0.95 vs 2.16; P = .0004), training injuries (0.14 vs 0.76; P = .007), lower extremity injuries (0.68 vs 1.4; P = .022), acute injuries (0.61 vs 1.91; P\.0001), and severe injuries (0 vs 0.51; P = .004). The intervention group also had statistically significant lower injury rates for trunk (0.07 vs 0.51; P = .013), leg (0 vs 0.38; P = .007), and hip and groin (0 vs 0.25; P = .023) compared with the control group. There was no statistically significant difference in match injuries, knee injuries, ankle injuries, and overuse injuries between 2 groups. The most frequent acute injury diagnoses were ligament sprains (0.41 and 0.38 in the intervention and control groups, respectively; P\.006) and contractures (0.76 and 0.07 in the control and intervention groups, respectively; P \ .003).

Acute muscle strain injuries: a proposed new classification system

Abstract: Purpose To better define and classify acute muscle strain injuries. Methods Historically, acute muscle strains have been classified as grade I, II and III. This system does not accurately reflect the anatomy of the injury and has not been shown to reliably predict prognosis and time for return to sport. Results We describe an imaging (magnetic resonance or ultrasound) nomenclature, which considers the anatomical site, pattern and severity of the lesion in the acute stage. By site of injury, we define muscular injuries as proximal, middle and distal. Anatomically, based on the various muscular structures involved, we distinguish intramuscular, myofascial, myofascial/perifascial and musculotendinous injuries. Conclusions This classification system must be applied to a variety of muscle architectures and locations to determine its utility; additional studies are therefore needed prior to its general acceptance. Level of evidence V.

Physiopathology of intratendinous calcific deposition

Abstract: In calcific tendinopathy (CT), calcium deposits in the substance of the tendon, with chronic activity-related pain, tenderness, localized edema and various degrees of decreased range of motion. CT is particularly common in the rotator cuff, and supraspinatus, Achilles and patellar tendons. The presence of calcific deposits may worsen the clinical manifestations of tendinopathy with an increase in rupture rate, slower recovery times and a higher frequency of post-operative complications. The aetiopathogenesis of CT is still controversial, but seems to be the result of an active cell-mediated process and a localized attempt of the tendon to compensate the original decreased stiffness. Tendon healing includes many sequential processes, and disturbances at different stages of healing may lead to different combinations of histopathological changes, diverting the normal healing processes to an abnormal pathway. In this review, we discuss the theories of pathogenesis behind CT. Better understanding of the pathogenesis is essential for development of effective treatment modalities and for improvement of clinical outcomes.

Scaffolds in tendon tissue engineering

Abstract: Tissue engineering techniques using novel scaffold materials offer potential alternatives for managing tendon disorders. Tissue engineering strategies to improve tendon repair healing include the use of scaffolds, growth factors, cell seeding, or a combination of these approaches. Scaffolds have been the most common strategy investigated to date. Available scaffolds for tendon repair include both biological scaffolds, obtained from mammalian tissues, and synthetic scaffolds, manufactured from chemical compounds. Preliminary studies support the idea that scaffolds can provide an alternative for tendon augmentation with an enormous therapeutic potential. However, available data are lacking to allow definitive conclusion on the use of scaffolds for tendon augmentation. We review the current basic science and clinical understanding in the field of scaffolds and tissue engineering for tendon repair.

Systematic review and recommendations for intracompartmental pressure monitoring in diagnosing chronic exertional compartment syndrome of the leg.

Abstract: Objective Although all intracompartmental pressure (ICP) measurement, magnetic resonance imaging, and near-infrared spectroscopy seem to be useful in confirming the diagnosis of chronic exertional compartment syndrome (CECS), no standard diagnostic procedure is currently universally accepted. We reviewed systematically the relevant published evidence on diagnostic criteria commonly in use for CECS to address 3 main questions: (1) Is there a standard diagnostic method available? (2) What ICP threshold criteria should be used for diagnosing CECS? (3) What are the criteria and options for surgical management? Finally, we made statements on the strength of each diagnostic criterion of ICP based on a rigorous standardized process. Data sources We searched for studies that investigated ICP measurements in diagnosing CECS in the leg of human subjects, using PubMed, Score, PEDRO, Cochrane, Scopus, SportDiscus, Web of Knowledge, and Google Scholar. Initial searches were performed using the phrase, "chronic exertional compartment syndrome." The phrase "compartment syndrome" was then combined, using Boolean connectors ("OR" and "AND") with the words "diagnosis," "parameters," "levels," "localisation," or "measurement." Data extracted from each study included study design, number of subjects, number of controls, ICP instrument used, compartments measured, limb position during measurements, catheter position, exercise protocol, timing of measurements, mean resting compartment pressures, mean maximal compartment pressures, mean postexercise compartment pressures, diagnostic criteria used, and whether a reference diagnostic standard was used. The quality of studies was assessed based on the approach used by the American Academy of Orthopaedic Surgeons in judging the quality of diagnostic studies, and recommendations were made regarding each ICP diagnostic criteria in the literature by taking into account the quality and quantity of the available studies proposing each criterion. Main results In the review, 32 studies were included. The studies varied in the ICP measurement techniques used; the most commonly measured compartment was the anterior muscle compartment, and the exercise protocol varied between running, walking, and ankle plantarflexion and dorsiflexion exercises. Preexercise, mean values ranged from 7.4 to 50.8 mm Hg for CECS patients, and 5.7 to 12 mm Hg in controls; measurements during exercise showed mean pressure readings ranging from 42 to 150 mm Hg in patients and 28 to 141 mm Hg in controls. No overlap between subjects and controls in mean ICP measurements was found at the 1-minute postexercise timing interval only showing values ranging from 34 to 55.4 mm Hg and 9 to 19 mm Hg in CECS patients and controls, respectively. The quality of the studies was generally not high, and we found the evidence for commonly used ICP criteria in diagnosing CECS to be weak. Conclusions Studies in which an independent, blinded comparison is made with a valid reference standard among consecutive patients are yet to be undertaken. There should also be an agreed ICP test protocol for diagnosing CECS because the variability here contributes to the large differences in ICP measurements and hence diagnostic thresholds between studies. Current ICP pressure criteria for CECS diagnosis are therefore unreliable, and emphasis should remain on good history. However, clinicians may consider measurements taken at 1 minute after exercise because mean levels at this timing interval only did not overlap between subjects and controls in the studies we analyzed. Levels above the highest reported value for controls here (27.5 mm Hg) along with a good history, should be regarded as highly suggestive of CECS. It is evident that to achieve an objective recommendation for ICP threshold there is a need to set up a multi-center study group to reach an agreed testing protocol and modify the preliminary recommendations we have made.

Joint pathology and platelet-rich plasma therapies.

Abstract: Introduction: At the beginning of the new millennium, there was a breakthrough in platelet-rich plasma (PRP) therapy for tissue repair. The mechanisms governing the effects of this therapy in joint pathology remain largely unexplored. Areas covered: This review is primarily based on PubMed and Web of Knowledge searches with the terms osteoarthritis in combination with PRP, treatment, cartilage, synovium, platelets, inflammation and/or angiogenesis. This search was completed by a manual search for relevant studies. We mainly include papers from the last 5 years. The concept of dynamic reciprocity is used to shape understanding of the spatial relationship between cells and their microenvironments as well as between tissues within the joint. We describe the processes of joint injury and pathology relevant to the mechanism of action of PRP, and elaborate insights into how PRP components may influence inflammation, angiogenesis, cell death and cartilage chondroprotection. Expert opinion: PRP therapies are more...

Conservative management of patients with an osteoporotic vertebral fracture: a review of the literature

Abstract: Osteoporotic vertebral compression fractures (VCFs) are an increasing public health problem. Recently, randomised controlled trials on the use of kyphoplasty and vertebroplasty in the treatment of these fractures have been published, but no definitive conclusions have been reached on the role of these interventions. The major problem encountered when trying to perform a meta-analysis of the available studies for the use of cementoplasty in patients with a VCF is that conservative management has not been standardised. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing. In this review, we report the best evidence available on the conservative care of patients with osteoporotic VCFs and associated back pain, focusing on the role of the most commonly used spinal orthoses. Although orthoses are used for the management of these patients, to date, there has been only one randomised controlled trial published evaluating their value. Until the best conservative management for patients with VCFs is defined and standardised, no conclusions can be drawn on the superiority or otherwise of cementoplasty techniques over conservative management.

Epidemiology, genetics and biological factors of rotator cuff tears.

Abstract: Rotator cuff disease is among the most common musculoskeletal disorders with high direct and indirect costs in industrialized countries. Not all rotator cuff tears are symptomatic. Genetics has recently been investigated as a factor involved in the pathogenesis of rotator cuff pathology. Genetic factors seem to be involved in symptom presentation and tear progression. As rotator cuff disease is multifactorial, no single gene is directly involved in the pathology. Phenotypic expression of genetic susceptibility manifests at the level of ultrastructure of the tendon. Predisposing genes may also operate through apoptosis and regenerative capacity. Studies on cellular and molecular biology are more numerous, but still incomplete, and recently have focussed on the role of apoptosis in tendinopathy, analyzing its key mediators and cellular changes. Oxidative stress is responsible for reduction of collagen synthesis. Biological investigations have identified recently new risk factors. Preliminary reports introduced the possible role of glucose as a risk factor for rotator cuff tear. Further studies are required to fully clarify the genetic and biological factors involved in rotator cuff tears.

Conservative management of midportion Achilles tendinopathy: a mixed methods study, integrating systematic review and clinical reasoning.

Abstract: Clinicians manage midportion Achilles tendinopathy (AT) using complex clinical reasoning underpinned by a rapidly developing evidence base. The objectives of the study were to develop an inclusive, accessible review of the literature in combination with an account of expert therapists’ related clinical reasoning to guide clinical practice and future research. Searches of the electronic databases, PubMed, ISI Web of Science, PEDro, CINAHL, EMBASE, and Google Scholar were conducted for all papers published from inception to November 2011. Reference lists and citing articles were searched for further relevant articles. Inclusion required studies to evaluate the effectiveness of any conservative intervention for midportion AT. Exclusion criteria included in vitro, animal and cadaver studies and tendinopathies in other locations (e.g. patella, supraspinatus). From a total of 3497 identified in the initial search, 47 studies fulfilled the inclusion criteria. Studies were scored according to the PEDro scale, with a score of ≥8/10 considered of excellent quality, 5–7/10 good, and ≤4/10 poor. The strength of evidence supporting each treatment modality was then rated as ‘strong’, ‘moderate’, ‘limited’, ‘conflicting’ or ‘no evidence’ according to the number and quality of articles supporting that modality. Additionally, semi-structured interviews were conducted with physiotherapists to explore clinical reasoning related to the use of various interventions with and without an evidence base, and their perceptions of available evidence. Evidence was strong for eccentric loading exercises and extracorporeal shockwave therapy; moderate for splinting/bracing, active rest, low-level laser therapy and concentric exercises (i.e. inferior to eccentric exercise). In-shoe foot orthoses and therapeutic ultrasound had limited evidence. There was conflicting evidence for topical glycerin trinitrate. Taping techniques and soft-tissue mobilization were not yet examined but featured in case studies and in the interview data. Framework analysis of interview transcripts yielded multiple themes relating to physiotherapists’ clinical reasoning and perceptions of the evidence, including the difficulty in causing pain while treating the condition and the need to vary research protocols for specific client groups — such as those with the metabolic syndrome as a likely etiological factor. Physiotherapists were commonly applying the modality with the strongest evidence base, eccentric loading exercises. Barriers to research being translated into practice identified included the lack of consistency of outcome measures, excessive stringency of some authoritative reviews and difficulty in accessing primary research reports. The broad inclusion criteria meant some lower quality studies were included in this review. However, this was deliberate to ensure that all available research evidence for the management of midportion AT, and all studies were evaluated using the PEDro scale to compensate for the lack of stringent inclusion criteria. Graded evidence combined with qualitative analysis of clinical reasoning produced a novel and clinically applicable guide to conservative management of midportion AT. This guide will be useful to novice clinicians learning how to manage this treatment-resistant condition and to expert clinicians reviewing their evidence-based practice and developing their clinical reasoning. Important areas requiring future research were identified including the effectiveness of orthoses, the effectiveness of manual therapy, etiological factors, optimal application of loading related to stage of presentation and how to optimize protocols for different types of patients such as the older patient with the metabolic syndrome as opposed to the athletically active.

Hamstring exercises for track and field athletes: injury and exercise biomechanics, and possible implications for exercise selection and primary prevention

Abstract: Hamstring strain injuries are the most prevalent muscle injuries in track and field (TF). These injuries often cause prolonged symptoms and a high risk of re-injury. Strengthening of the hamstring muscles has been recommended for injury prevention. The authors review the possible role of eccentric training in TF hamstring injury prevention and introduce exercise classification criteria to guide clinicians in designing strengthening programmes adapted to TF. The principles exposed may serve as a foundation for future development and application of new eccentric programmes to decrease the high incidence of this type of injury in other sports.

Remplissage Repair—New Frontiers in the Prevention of Recurrent Shoulder Instability A 2-Year Follow-up Comparative Study

Abstract: Background:An engaging Hill-Sachs lesion is a defect of the humeral head, large enough to cause locking of the humeral head against the anterior corner of the glenoid rim when the arm is at 90° of abduction and more than 30° of external rotation.Hypothesis:When Bankart lesions are associated with engaging Hill-Sachs defects, simultaneous Bankart repair and remplissage provide lower recurrence rates than does Bankart repair alone.Study Design:Cohort study; Level of evidence, 3.Methods:Fifty patients (36 men, 14 women) with combined engaging Hill-Sachs and Bankart lesions were evaluated, before and after arthroscopic management, at a minimum follow-up of 2 years. After imaging and arthroscopic assessment, 25 patients underwent remplissage and Bankart repair, and 25 patients received Bankart repair alone. Patients were evaluated using the UCLA, Constant, and Rowe scores, and range of motion was measured using a goniometer. Postoperatively, all patients underwent magnetic resonance imaging to assess the statu...

Management of the greater trochanteric pain syndrome: a systematic review.

Abstract: Introduction Greater trochanteric pain syndrome (GTPS) is a debilitating condition characterized by lateral hip pain located at or around the greater trochanter. Source of data We performed a comprehensive search of Pubmed, Medline, Ovid, Google Scholar and Embase databases, from inception of the database to 20th of June 2011, using a variety of keywords. We identified 52 relevant abstracts of articles published in peer-reviewed journals. Fourteen studies reporting the outcomes of patients undergoing conservative and surgical management of GTPS were selected. Areas of agreement Significant pain relief and improved outcomes were observed after conservative and surgical management of GTPS. The modified Coleman methodology score averaged 44.7 (range from 14 to 82), evidencing an overall low-to-moderate quality of the studies. Repetitive low-energy radial shock wave therapy and home training approach provide beneficial effect over months, with almost 80% success rate at 15 months. Areas of controversy Poor available data extracted from small studies do not allow definitive conclusions to be drawn on the best treatment for GTPS. Growing points Further multi-centre prospective studies are necessary to confirm the general validity of the findings reported. Areas timely for developing research Future research and trials should focus on the application and effectiveness of the various conservative modalities for management of GTPS. Conclusion The effectiveness of the various treatment modalities needs to be tested in carefully conducted randomized controlled trials.

Osteoporotic vertebral fractures: current concepts of conservative care

Abstract: Introduction: Osteoporotic vertebral compression fractures (VCFs) are a growing public health problem with important socio-economic effects in western countries. In the USA, 10 million people over 50 suffer from osteoporosis. In these patients, 1.5 million annual fractures have been registered, and 50% of these are vertebral compression. Sources of data: We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of the keywords 'osteoporosis', 'vertebral compression fractures', 'brace', 'bracing', 'orthosis', 'conservative management' and 'rehabilitation' over the years 1966- 2011. All articles relevant to the subject were retrieved, and their bibliographies were hand searched for further references in the context of conservative management of osteoporotic vertebral fractures. Areas of agreement: Conservative management for patients with osteoporotic vertebral fractures includes bed rest, pain medication, physiotherapy and bracing. Areas of controversy: A conservative management for patients with osteoporotic VCFs s has not been standardized. The utility of vertebral augmentation techniques has been questioned by recent randomized controlled trials. Growing points: Randomized controlled trials are being performed worldwide on vertebral augmentation techniques. Areas timely for developing research: Although spinal orthoses are commonly used for the management of patients with osteoporotic vertebral fractures, in the literature there is only one randomized controlled trial on bracing for this condition. While the best conservative management for subjects with osteoporotic VCFs s is not defined and standardized, no conclusions on the superiority of vertebral augmentation techniques over conservative management can be drawn.

Extracorporeal shock wave therapy in early osteonecrosis of the femoral head: prospective clinical study with long-term follow-up.

Abstract: Extracorporeal shock wave therapy (ESWT) may exert beneficial effects in avascular necrosis of femoral head (AVNFH). The current study evaluated the effectiveness of ESWT in reducing pain and in slowing down the progression of bone damage in 36 patients with unilateral AVNFH of stage Association Research Circulation Osseous (ARCO) I, II and III. At the beginning of the study, 10 hips were classified as stage I, 11 as stage II and 15 as stage III. Each treatment cycle included four sessions, with 2,400 impulses each administered at 0.50 mJ/mm2, at 48–72 h intervals. Follow-up examinations were scheduled at 3, 6, 12 and then 24 months. Clinical assessments included assessment of pain scores, Harris Hip Scores and Roles and Maudsley score. Plain radiographs and magnetic resonances of the hip were used to evaluate the size of the lesion, the extent of collapse of subchondral bone, and degenerative changes of the hip joint. Patients from ARCO stage I group and stage II group achieved significantly better results than patients from ARCO stage III group at all follow-up time points (p < 0.005). During the follow-up period, 10 of the 15 stage III ARCO patients received an arthroplasty. ARCO stages I and II lesions were unchanged on radiographs and on magnetic resonance images. ESWT in ARCO stages I and II may help to prevent progression of the area of avascular necrosis and manage pain.

Femoroacetabular impingement syndrome management: arthroscopy or open surgery?

Abstract: Purpose This review explores the scientific evidence for clinical, functional and imaging outcomes after surgical management of Femoroacetabular Impingement (FAI) syndrome, and assesses the methodological quality of the published literature reporting this issue.

Management of stiffness following total knee arthroplasty: a systematic review.

Abstract: article i nfo Aim: The aim of the study was to systematically evaluate the outcome of four main modalities of treatment for arthrofibrosis that develops subsequent to a total knee arthroplasty (TKA), namely manipulation under anesthesia (MUA), arthroscopic debridement, open surgical release and revision TKA. Materials and methods: A computerised search was conducted for relevant studies published from 1975 on- wards in all the major databases and various search engines. A total of twenty-five studies were selected, representing a total of 798 patients. Studies that passed the inclusion criteria were then subjected to quality assessment using the Newcastle-Ottawa Scale. On assessment, the 25 studies scored a total of 77 stars out of a possible 125. Two studies were prospective in design, while the remaining case series were retrospective in nature. The primary outcome measures assessed were increase in range of movement (ROM) and the Knee Society Score (KSS) at final follow-up. Results: Our results showed that manipulation under anesthesia (MUA) had a mean increase in ROM of 38.4°, arthroscopic release had a mean increase of 36.2°, open surgical release had a mean increase of 43.4° and revision TKA had a mean increase of 24.7°. No significant differences were found in the KSS of the four treatment modalities. Our analysis suggests that open surgical release would be the most beneficial option for patients who are fit to undergo secondary surgery if their lifestyle requires a higher ROM for activities of daily living. However, there were methodological limitations as majority of the papers were case series, which decreased the quality of the evidence available.

Neovascularization in Achilles tendinopathy: have we been chasing a red herring?

Abstract: The concept of neovascularization in tendin- opathy seems to have gained nearly mythological propor- tions and quasi-religious state: it is considered of diagnostic and prognostic value, related to clinical out- come, and the exclusive target of some therapeutic inter- ventions. However, we question whether these assumptions are based on scientific evidence, and we come to the conclusion that, in the light of recent well-performed research, it seems that detecting neovessels has no addi- tional value for the diagnosis, no firmly confirmed prog- nostic value, and no proven relation with symptoms. The role of neovascularization in this field should be re-thought. Level of evidence V.

Free gracilis tendon graft for reconstruction of chronic tears of the Achilles tendon.

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

Genetic susceptibility to aseptic loosening following total hip arthroplasty: a systematic review

Abstract: Introduction: Aseptic loosening is the most common cause of total hip arthroplasty (THA) failure and revision surgery. Genetic polymorphisms could be determinant factors for implant loosening. Source of data: We performed a comprehensive search of Medline, CINAHL, Googlescholar, Embase and Cochrane databases, using various combinations of the keyword terms ‘aseptic loosening’, ‘gene’, ‘hip arthoplasty’, ‘genetics’, ‘loosening’. Twelve studies detailing the genetic investigation of patients with aseptic loosening of a THA were identified. Areas of agreement: SNPs of GNAS1, TNF-238 A allele, TNF-a promoter (-308G!A) transition, IL6-174 G allele, interleukin (IL)-6 (-597) and (-572), MMP1-promoting gene, C/C genotype for the MMP1, MT1-MMP, MMP-2, transforming growth factor-beta1 signal sequence (29T!C) transitions, A/A genotype for the OPG-163, and MBL were overexpressed in patients with aseptic loosening and periprosthetic osteolysis. Areas of controversy: Data from single centre studies do not allow one to compare the results of different studies. Conclusion: Several gene pathways and genes contribute to the genetic susceptibility to aseptic loosening following THA. Further studies will enhance the understanding of prosthesis failure, and may inform and direct pharmaceutical interventions. Growing points: Further multi-centre prospective studies are necessary to confirm the general validity of the findings reported. Single-centre findings should be replicated in other centres and populations to open new avenues for pre-surgical genetic testing and to investigate immune response modulation in THA. Areas timely for developing research: Research in this field could lead to better understanding of mechanisms behind aseptic osteolysis, and improve the results of THA.

Sparing the anterior cruciate ligament remnant: is it worth the hassle?

Abstract: Introduction Anterior cruciate ligament (ACL) rupture is the most common surgically treated ligament injury. Many efforts have been taken to reconstruct it as anatomically as possible to restore knee stability and, possibly, prevent knee osteoarthritis. Sources of data A literature search was performed using the isolated or combined keywords 'ACL augmentation remnant', 'ACL reconstruction and remnant and stump', 'ACL reconstruction and remnant and stump preserving and stability' and 'ACL remnant complete tear' with no limit regarding the year of publication. We identified seven published studies. Areas of agreement The ACL remnant might accelerate the vascularization and the ligamentization of the graft and contribute to faster graft innervation leading to a better proprioception. Areas of controversy The role of the ACL remnant is debated, because, although it may increase the risk of impingement and the formation of cyclops lesion, its preservation can improve proprioception, biomechanical functions and vascularity. However, the current assessment methods to assess proprioception, vascularization and the ligamentization do not lead to hard evidence that preservation of the remnant confers clinically relevant advantages over its excision. Growing points The ACL remnant has been demonstrated in experimental studies to have a role in improving revascularization, ligamentization and reinnervation of the graft, but these findings are still not supported by clinical findings. A more direct way to assess proprioceptive function after ACL reconstruction and appropriately conducted powered and rigorously prospective randomized double-blind studies comparing the clinical outcomes of excising the remnant to leaving it in situ are necessary.

Immediate and short-term effects of exercise on tendon structure: biochemical, biomechanical and imaging responses

Abstract: Introduction Tendons are metabolically active structures, and their biochemical, biomechanical and structural properties adapt to chronic exercise. However, abnormal adaptations may lead to the development of tendinopathy and pain. Acute and subacute adaptations might contribute to tendon pathology. Sources of data A systematic search of peer-reviewed articles was performed using a wide range of electronic databases. A total of 61 publications were selected. Areas of agreement Exercise induces acute responses in collagen turnover, blood flow, glucose, lactate and other inflammatory products (e.g. prostaglandins and interleukins). Mechanical properties are influenced by activity duration and intensity. Acute bouts of exercise affect tendon structure, with some of the changes resembling those reported in pathological tendons. Areas of controversy Given the variation in study designs, measured parameters and outcomes, it remains debatable how acute exercise influences overall tendon properties. There is discrepancy regarding which investigation modality and settings provide optimal assessment of each parameter. Growing points There is a need for greater homogeneity between study designs, including subject consortium and age, exercise protocols and time frames for parameter assessing. Areas timely for developing research Innovative methods, measuring each parameter simultaneously, would allow a greater understanding of how and when changes occur. This methodology is key to revealing pathological processes and pathways that alter tendon properties according to various activities. Optimal tendon properties differ between activities: more compliant tendons are beneficial for slow stretch shortening cycle (SSC) activities such as countermovement jumps, whereas stiffer tendons are considered beneficial for fast SSC movements such as sprinting.

Pre-cooling for endurance exercise performance in the heat: a systematic review

Abstract: Background Endurance exercise capacity diminishes under hot environmental conditions. Time to exhaustion can be increased by lowering body temperature prior to exercise (pre-cooling). This systematic literature review synthesizes the current findings of the effects of pre-cooling on endurance exercise performance, providing guidance for clinical practice and further research.

Biological Strategies to Enhance Healing of the Avascular Area of the Meniscus

Abstract: Meniscal injuries in the vascularized peripheral part of the meniscus have a better healing potential than tears in the central avascular zone because meniscal healing principally depends on its vascular supply. Several biological strategies have been proposed to enhance healing of the avascular area of the meniscus: abrasion therapy, fibrin clot, organ culture, cell therapy, and applications of growth factors. However, data are too heterogeneous to achieve definitive conclusions on the use of these techniques for routine management of meniscal lesions. Although most preclinical and clinical studies are very promising, they are still at an experimental stage. More prospective randomised controlled trials are needed to compare the different techniques for clinical results, applicability, and cost-effectiveness.

Conservative treatment and rotator cuff tear progression.

Abstract: There is no definite consensus on the best management for patients with rotator cuff tears. No randomized controlled studies have compared the outcome of surgical versus conservative treatment. The described successful rate of conservative treatment varies widely, from 33 to 92%. Even though current evidence is not sufficient to allow definitive conclusions on conservative treatment of rotator cuff tears, non-operative management is often recommended in such patients. Prognostic factors seem to be clinical presentation, duration of symptoms and tear size. The best programme for conservative treatment is not defined. Physical therapy consists of stretching and strengthening exercises. The characteristics of exercise programmes are not standardized. In clinical practice, intra-articular injections are commonly used for treatment of shoulder pain. Systemic pharmacotherapy for patients with shoulder pain consists of non-steroidal anti-inflammatory drugs. Recently, cyclo-oxygenase-2-selective inhibitors have been introduced for management of shoulder pain. To date, few randomized controlled trials are available on conservative management of rotator cuff tears, and therefore further studies are required to clarify its role in such patients.

Errors of level in spinal surgery An evidence-based systematic review

Abstract: Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery.

Synthetic augmentation in massive rotator cuff tears.

Abstract: Massive rotator cuff tears represent a great challenge in orthopaedic. They are associated with persistent defects, weakness, and poor outcomes and can cause an uncoupling of forces across the glenohumeral joint, with unstable shoulder kinematics. In the last few years, a notable interest has emerged to develop new treatment strategies that provide effective mechanical reinforcement of rotator cuff repair and stimulate and enhance the patient’s intrinsic healing potential. Tissue engineering techniques using novel scaffold materials offer potential alternatives for managing massive irreparable rotator cuff tears. Synthetic scaffolds, manufactured from chemical compounds, have gained much interest to bridge massive rotator cuff tears. Preliminary studies support the idea that synthetic scaffolds can provide an alternative for rotator cuff augmentation with an enormous therapeutic potential. Despite the growing clinical use of synthetic scaffold devices for rotator cuff repair, there are numerous questions related to their indication, surgical application, safety, mechanism of action, and efficacy that remain to be clarified or addressed. We review the current basic science and clinical understanding of synthetic scaffolds for massive rotator cuff repair, reporting the preclinical and clinical studies carried out to date in this field. We underline the benefits and limitations of the available synthetic scaffolds for augmentation of rotator cuff tears, and discuss the implications of these literature data on the future directions for the use of these scaffolds in tendon repair procedures.

Stem cells and gene therapy for cartilage repair.

Abstract: Cartilage defects represent a common problem in orthopaedic practice. Predisposing factors include traumas, inflammatory conditions, and biomechanics alterations. Conservative management of cartilage defects often fails, and patients with this lesions may need surgical intervention. Several treatment strategies have been proposed, although only surgery has been proved to be predictably effective. Usually, in focal cartilage defects without a stable fibrocartilaginous repair tissue formed, surgeons try to promote a natural fibrocartilaginous response by using marrow stimulating techniques, such as microfracture, abrasion arthroplasty, and Pridie drilling, with the aim of reducing swelling and pain and improving joint function of the patients. These procedures have demonstrated to be clinically useful and are usually considered as first-line treatment for focal cartilage defects. However, fibrocartilage presents inferior mechanical and biochemical properties compared to normal hyaline articular cartilage, characterized by poor organization, significant amounts of collagen type I, and an increased susceptibility to injury, which ultimately leads to premature osteoarthritis (OA). Therefore, the aim of future therapeutic strategies for articular cartilage regeneration is to obtain a hyaline-like cartilage repair tissue by transplantation of tissues or cells. Further studies are required to clarify the role of gene therapy and mesenchimal stem cells for management of cartilage lesions.

Platelet plasma rich products in musculoskeletal medicine: Any evidence?

Abstract: Platelet Reach Plasma (PRP) is considered to accelerate muscle and tendon healing and allow early return to elite competition, and it is often recommend as best practice for management of musculoskeletal injuries. Even though several growth factors abundant in PRPs have been extensively studied in tissue regeneration, the key factors are yet unknown. Given our rudimentary knowledge of the mechanism of action of the PRPs, it is challenging to use this technology to promote early healing, and produce improved and accelerated functional recovery. We prompt researchers to undertake appropriately powered level I studies with adequate and relevant outcome measures and clinically appropriate follow up.