Showing papers by "Nicola Maffulli published in 2014"

Bone regenerative medicine: classic options, novel strategies, and future directions

Abstract: This review analyzes the literature of bone grafts and introduces tissue engineering as a strategy in this field of orthopedic surgery. We evaluated articles concerning bone grafts; analyzed characteristics, advantages, and limitations of the grafts; and provided explanations about bone-tissue engineering technologies. Many bone grafting materials are available to enhance bone healing and regeneration, from bone autografts to graft substitutes; they can be used alone or in combination. Autografts are the gold standard for this purpose, since they provide osteogenic cells, osteoinductive growth factors, and an osteoconductive scaffold, all essential for new bone growth. Autografts carry the limitations of morbidity at the harvesting site and limited availability. Allografts and xenografts carry the risk of disease transmission and rejection. Tissue engineering is a new and developing option that had been introduced to reduce limitations of bone grafts and improve the healing processes of the bone fractures and defects. The combined use of scaffolds, healing promoting factors, together with gene therapy, and, more recently, three-dimensional printing of tissue-engineered constructs may open new insights in the near future.

Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature.

Abstract: Purpose The aim of this study was to evaluate clinical outcome, rate of recurrence, complications, and rate of postoperative osteoarthritis in patients with anterior shoulder instability managed with Latarjet, Bristow, or Eden-Hybinette procedures. Methods A systematic review of the literature on management of anterior dislocation of the shoulder with glenoid bony procedures was performed. A comprehensive search of PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "dislocation," "treatment," "Latarjet," "Bristow," "bone loss," "Eden-Hybinette," "iliac," "bone," "block," "clinical," "outcome," and "Bankart." The following data were extracted: demographics, bone defects and other lesions, type of surgery, outcome measurement, range of motion (ROM), recurrence of instability, complications, and osteoarthritis. A quantitative synthesis of all comparative studies was performed to compare bone block procedures and Bankart repair in terms of postoperative recurrence of instability and osteoarthritis. Results Forty-six studies were included and 3,211 shoulders were evaluated. The mean value of the Coleman Methodology Score (CMS) was 65 points. Preoperatively, the injuries detected most were glenoid bone loss and Bankart lesions. The Eden-Hybinette procedure had the highest rate of postoperative osteoarthritis and recurrence. Pooled results from comparative studies showed that the bone block procedures were associated with a lower rate of recurrence when compared with Bankart repair (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.28 to 0.74; P = .002), whereas there was no significant difference between the 2 groups in terms of postoperative osteoarthritis ( P = .79). Conclusions The open Bristow-Latarjet procedure continues to be a valid surgical option to treat patients with anterior shoulder instability. Bone block procedures were associated with a lower rate of recurrence when compared with the Bankart repair. The Eden-Hybinette procedure has clinical outcomes very similar to the Bristow-Latarjet technique but has a higher rate of postoperative osteoarthritis and recurrence. An arthroscopic Bristow-Latarjet procedure seems to be better in terms of prevention of recurrence and rehabilitation, but randomized studies are needed to reach definitive conclusions. Level of Evidence Level IV, systematic review of Level II, III, and IV studies.

Obesity as a Risk Factor for Tendinopathy: A Systematic Review

Abstract: Purpose. In the last few years, evidence has emerged to support the possible association between increased BMI and susceptibility to some musculoskeletal diseases. We systematically review the literature to clarify whether obesity is a risk factor for the onset of tendinopathy. Methods. We searched PubMed, Cochrane Central, and Embase Biomedical databases using the keywords "obesity," "overweight," and "body mass index" linked in different combinations with the terms "tendinopathy," "tendinitis," "tendinosis," "rotator cuff," "epicondylitis," "wrist," "patellar," "quadriceps," "Achilles," "Plantar Fascia," and "tendon." Results. Fifteen studies were included. No level I study on this subject was available, and the results provided are ambiguous. However, all the 5 level II studies report the association between obesity measured in terms of BMI and tendon conditions, with OR ranging between 1.9 (95% CI: 1.1-2.2) and 5.6 (1.9-16.6). Conclusions. The best evidence available to date indicates that obesity is a risk factor for tendinopathy. Nevertheless, further studies should be performed to establish the real strength of the association for each type of tendinopathy, especially because the design of the published studies does not allow identifying a precise cause-effect relationship and the specific role of obesity independently of other metabolic conditions.

Management of primary acute anterior shoulder dislocation: systematic review and quantitative synthesis of the literature.

Abstract: Purpose The aim of this study was to compare the clinical outcome of surgical versus conservative treatment of primary acute anterior dislocation of the shoulder. Methods A systematic review of published studies on the treatment of primary acute anterior dislocation of the shoulder was performed. Three investigators independently conducted the research. A comprehensive search of PubMed, MEDLINE, CINAHL, Cochrane Library, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "dislocation," "treatment," "acute," and "primary" over the years 1994 to 2013 was performed. The following data were extracted: demographics, soft tissue lesions and bone defects, outcome measurements, type of management, recurrence of instability, and complications. A quantitative synthesis of the literature was performed to compare surgery and conservative management and immobilization by internal and external in patients undergoing conservative treatment. Results Thirty-one studies were included in which 2,813 shoulders were evaluated. All patients sustained primary acute anterior shoulder dislocation. The mean Coleman Methodology Score (CMS) was 67 points (range, 19 to 84). Pooled results from comparative studies showed that the rate of recurrence was statistically significantly lower in the surgical group than in the conservative group (odds ratio, 12.71; 95% confidence interval [CI], 4.88 to 33.10; P P = .002). Conclusions Although limited, the available evidence from randomized controlled trials (RCTS) supports primary surgery in young adults engaged in highly demanding sports or job activities. There is lack of evidence to determine whether surgical or nonsurgical treatment is better for other categories of injury. Level of Evidence Level IV, systematic review of Level I to IV studies.

Platelet-rich plasma in the conservative treatment of painful tendinopathy: a systematic review and meta-analysis of controlled studies.

Abstract: Background Platelet-rich plasma (PRP) seeks to meet the multifaceted demand of degenerated tendons providing several molecules capable of boosting healing. Areas timely for developing research PRP is used for managing tendinopathy, but its efficacy is controversial. Sources of data Electronic databases were searched for clinical studies assessing PRP efficacy. Methodological quality was evaluated using the methods described in the Cochrane Handbook for systematic reviews. Areas of agreement Thirteen prospective controlled studies, comprising 886 patients and diverse tendons were included; 53.8% of studies used identical PRP protocol. Areas of controversy Sources of heterogeneity included different comparators, outcome scores, follow-up periods and diverse injection protocols, but not PRP formulation per se. Growing points Pooling pain outcomes over time and across different tendons showed that L-PRP injections ameliorated pain in the intermediate-long term compared with control interventions, weighted mean difference (95% CI): 3 months, -0.61 (-0.97, -0.25); 1 year, -1.56 (-2.27, -0.83). However, these findings cannot be applied to the management of individual patients given low power and precision. Research Further studies circumventing heterogeneity are needed to reach firm conclusions. Available evidence can help to overcome hurdles to future clinical research and bring forward PRP therapies.

Evidence-Based Surgical Management of Spondylolisthesis: Reduction or Arthrodesis in Situ

Abstract: Background: The role of reduction in the operative management of spondylolisthesis is controversial because of its potential complications, including neurologic deficits, prolonged operative time, and loss of reduction. The aim of this systematic review was to compare arthrodesis in situ and arthrodesis after reduction techniques with respect to clinical and radiographic outcomes and safety. Methods: We performed a comprehensive search of the PubMed, Ovid MEDLINE, Cochrane, CINAHL, Google Scholar, and Embase databases with use of the keyword ‘‘spondylolisthesis’’ in combination with ‘‘surgery,’’ ‘‘reduction,’’ ‘‘in situ,’’ ‘‘low back pain,’’ ‘‘high-grade,’’ ‘‘lumbar spine,’’ ‘‘lumbar instability,’’ and ‘‘fusion.’’ Results: Eight eligible studies, containing reportsof 165 procedures involving reduction followedby arthrodesis and 101 procedures involving arthrodesis in situ without reduction, were identified and included. The procedure involving reduction was associated with a significantly greater decrease in the percentage of slippage (p < 0.002) and slip angle (p < 0.003) compared with arthrodesis in situ. Pseudarthrosis was significantly more frequent in the arthrodesis in situ group compared with the reduction group (17.8% compared with 5.5%, p = 0.004). Neurologic deficits were not significantly more prevalent in the reduction group compared with the arthrodesis in situ group (7.8% compared with 8.9%, p = 0.8). Conclusions: On the basis on this review, the reduction of high-grade spondylolisthesis potentially improves overall spine biomechanics by correcting the local kyphotic deformity and reducing vertebral slippage. Reduction was not associated with a greater risk of developing neurologic deficits compared with arthrodesis in situ. Both procedures were associated with good clinical outcomes. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Epidemiology of the rotator cuff tears: a new incidence related to thyroid disease.

Abstract: Background: in the last years the incidence of rotator cuff tears increased and one main cause still waiting to be clarified. Receptors for thyroid hormones in rotator cuff tendons suggest possible effects on tendons metabolism and status. We undertook a retrospective, observational cohort study of 441 patients who underwent arthroscopic and mini-open repair for non traumatic degenerative rotator cuff tears. Methods: all the patients, predominantly females (63%), were interview to assess the relationship (frequency for class age “20 yrs” and factor analysis) between lesions of the rotator cuff with the following variables: gender, thyroid disease, smoker, taking medications for diabetes, hypertension or high cholesterol; presence of associated conditions (diabetes, hypertension, hypercholesterolemia). Results: thyroid disease is highly frequently (until 63% for 60<80 yrs) in females group independent to the age. Conversely, males showed a high frequency for smoker 37<62% until 80 yrs and 50% hypercholesterolemia over 80 yrs for the clinical variable studied. Conclusions: this is the first clinical report that shown a relationship between thyroid pathologies and non-traumatic rotator cuff tear as increased risk factors.

Remplissage, Humeral Osteochondral Grafts, Weber Osteotomy, and Shoulder Arthroplasty for the Management of Humeral Bone Defects in Shoulder Instability: Systematic Review and Quantitative Synthesis of the Literature

Abstract: Purpose The aim of this study was to evaluate clinical outcomes, rate of recurrence, complications, and range of movement after remplissage, Weber osteotomy, humeral allograft reconstruction, shoulder arthroplasty, and hemiarthroplasty in patients with anterior or posterior shoulder instability associated with humeral bone loss. Methods A systematic review of published studies on the management of dislocation of the shoulder with humeral bony procedures was performed. A comprehensive search of the PubMed, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, Embase, and Google Scholar databases was performed using various combinations of the keywords "shoulder," "dislocation," "treatment," "remplissage," "hemiarthroplasty," "arthroplasty," "allograft," "osteotomy," "bone," "loss," "clinical," "outcome," and "Hill Sachs" since inception of the databases to 2014. The following data were extracted: demographic characteristics, bone defects and other lesions, type of surgery, outcome measurement, range of motion, recurrence of instability, and complications. Results Twenty-six studies were included, in which 769 shoulders were evaluated. The mean value of the Coleman Methodology Score was 69.2 points. Preoperatively, the most detected injuries were Hill-Sachs and Bankart lesions. Shoulder arthroplasty procedures had the highest rate of postoperative recurrence and the lowest scores for postoperative clinical outcomes. The combination of remplissage and Bankart procedures was associated with a lower rate of recurrence when compared with Bankart repair alone (odds ratio, 0.05; 95% confidence interval, 0.01 to 0.25; P = .0002). A high heterogeneity (I 2 = 85%) across the study results was found. Conclusions Arthroscopic remplissage is the safest technique for the management of patients with shoulder instability with humeral bone loss. Remplissage-Bankart procedures are associated with a lower rate of recurrence when compared with Bankart repair alone. Weber osteotomy, humeral allograft reconstruction, shoulder arthroplasty, and hemiarthroplasty are characterized by a high rate of recurrence, complications, and poor outcome scores. Level of Evidence Level IV, systematic review of Level II, III, and IV studies.

Minimally invasive versus open surgery for acute Achilles tendon rupture: a systematic review

Abstract: Introduction: This review provides a comprehensive description of clinical, functional outcomes, and complications after open and minimally invasive surgery for Achilles tendon ruptures. Sources of data: We systematically searched Medline (PubMED), EMBASE, CINHAL, Cochrane, Sports Discus and Google scholar databases using the combined keywords ‘open repair’, ‘percutaneous surgery’, ‘minimally invasive surgery ’‘ Achilles tendon rupture’, ‘complications’, ‘infections’, ‘wound disorders’ to identify articles published in English, Spanish, French and Italian. Areas of agreement: Twelve studies fulfilled our inclusion criteria. Six studies were retrospective, five were randomized controlled trials and one was a prospective investigation. Of a total of 781 patients, 375 underwent open repair and 406 percutaneous surgery. Different procedures were performed for open and minimally invasive repair. Areas of controversy: The range of motion was significantly greater after percutaneous repair than open surgery. The number of complications that occurred after open surgery was higher than after minimally invasive surgery.

Wound Complications from Surgeries Pertaining to the Achilles Tendon

Abstract: Background: A retrospective review of one surgeon’s practice was conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon. Methods: We evaluated the incidence of infection and other wound complications, such as suture reactions, scar revision, hematoma, incisional neuromas, and granuloma formation. Results: A total of 219 surgical cases were available for review (140 males and 70 females; mean ± SD age at the time of surgery, 46.5 ± 12.6 years; age range, 16–75 years). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, for a total complication rate of 10.0%. Six patients had more than one complication; therefore, the percentage of patients with complications was 7.3%. There were no hematomas. Seven patients had additional surgery after th...

Evaluation and management of injuries of the tibiofibular syndesmosis

Abstract: Introduction: Injury to the tibiofibular syndesmosis often arises from external rotation force acting on the foot leading to eversion of the talus within the ankle mortise and increased dorsiflexion or plantar flexion. Such injuries can present in the absence of a fracture. Therefore, diagnosis of these injuries can be challenging, and often stress radiographs are helpful. Magnetic resonance imaging scans can be a useful adjunct in doubtful cases. The management of syndesmotic injuries remains controversial, and there is no consensus on how to optimally fix syndesmosis. This article reviews the mechanism of injury, clinical features and investigations performed for syndesmotic injuries and brings the reader up-to-date with the current evidence in terms of the controversies surrounding the management of these injuries.

Characterization of age-related changes of tendon stem cells from adult human tendons

Abstract: Purpose The present study evaluated the presence of stem cells in hamstring tendons from adult subjects of different ages. The aim was to isolate, characterize and expand these cells in vitro, and to evaluate whether cell activities are influenced by age.

The child and adolescent athlete: a review of three potentially serious injuries

Abstract: The increased participation of children and adolescents in organized sports worldwide is a welcome trend given evidence of lower physical fitness and increased prevalence of overweight in this population. However, the increased sports activity of children from an early age and continued through the years of growth, against a background of their unique vulnerability to injury, gives rise to concern about the risk and severity of injury. Three types of injury–anterior cruciate ligament (ACL) injury, concussion, and physeal injury – are considered potentially serious given their frequency, potential for adverse long-term health outcomes, and escalating healthcare costs. Concussion is probably the hottest topic in sports injury currently with voracious media coverage and exploding research interest. Given the negative cognitive effects of concussion, it has the potential to have a great impact on children and adolescents during their formative years and potentially impair school achievement and, if concussion management is not managed appropriately, there can be long term negative impact on cognitive development and ability to resume sports participation. Sudden and gradual onset physeal injury is a unique injury to the pediatric population which can adversely affect growth if not managed correctly. Although data are lacking, the frequency of stress-related physeal injury appears to be increasing. If mismanaged, physeal injuries can also lead to long-term complications which could negatively affect ability to participate in sports. Management of ACL injuries is an area of controversy and if not managed appropriately, can affect long-term growth and recovery as well as the ability to participate in sports. This article considers the young athlete’s vulnerability to injury, with special reference to ACL injury, concussion, and physeal injury, and reviews current research on epidemiology, diagnosis, treatment, and prevention of these injury types. This article is intended as an overview of these injury types for medical students, healthcare professionals and researchers.

Arthroscopic-Assisted Latissimus Dorsi Transfer for the Management of Irreparable Rotator Cuff Tears: Short-Term Results.

Abstract: Background: Irreparable rotator cuff tears associated with shoulder functional impairment represent a challenge, especially in young and active patients. Latissimus dorsi muscle-tendon transfer is performed to replace the irreversibly lost contractile elements in patients with irreparable tears of the posterosuperior aspect of the rotator cuff. Methods: From 2008 to 2010, we enrolled twenty-seven patients (mean age, sixty years; range, forty-six to sixty-seven years) with irreparable, full-thickness rotator cuff tears involving at least two tendons who underwent arthroscopicassisted latissimus dorsi muscle-tendon transfer. Outcome measures included the Constant and Murley score, shoulder range of motion in external rotation, and muscle strength in forward elevation. The mean duration of follow-up was twentyseven months (range, twenty-four to thirty-six months). Results: There was a significant improvement (p < 0.05) in the mean Constant and Murley score, pain score, muscle strength in forward elevation, and range of motion in external rotation at the time of the last follow-up. There was no significant correlation between the mean preoperative range of motion, pain, and strength and the mean postoperative Constant and Murley score. There was no significant osteoarthritis progression and proximal migration of the humeral head after surgery in the time period studied. Conclusions: Arthroscopic-assisted latissimus dorsi muscle-tendon transfer at short-term follow-up is an effective alternative to open surgery for the management of painful irreparable posterosuperior rotator cuff tears refractory to conservative management. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The role of eccentric exercise in sport injuries

Abstract: Introduction: Sports injuries frequently involve tendons, muscles and ligaments. The variable outcome of surgery and medical treatment support early functional treatments. Eccentric exercise (EE) showed effectiveness in the management of Achilles tendinopathy (AT), patellar tendinopathy (PT) and lateral epicondyle tendinopathy (LET). Preliminary results of EE in other tendinopathies and sports injuries suggest its wide prescription in the sport rehabilitation field. Sources of data: A comprehensive search of PubMed, Web of Science, the Cochrane Collaboration Database, Physiotherapy Evidence Database (PEDro), Evidence Based Medicine (EBM) Search review, National Guidelines, Scopus and Google Scholar was performed using keywords such as ‘eccentric exercise’, ‘sports injuries rehabilitation’, ‘tendinopathy’, ‘hamstrings strain ’‘ adductor injuries 0 and ‘ACL reconstruction rehabilitation’. Areas of agreement: EE, alone or associated with other therapies, represents a feasible, cost-effective and successful tool in the treatment of well-known targets and might be promising in shoulder tendinopathy, adductor-related groin pain, hamstring strains, and ACL rehabilitation.

The role of eccentric exercise in sport injuries rehabilitation

Abstract: Introduction: Sports injuries frequently involve tendons, muscles and ligaments. The variable outcome of surgery and medical treatment support early functional treatments. Eccentric exercise (EE) showed effectiveness in the management of Achilles tendinopathy (AT), patellar tendinopathy (PT) and lateral epicondyle tendinopathy (LET). Preliminary results of EE in other tendinopathies and sports injuries suggest its wide prescription in the sport rehabilitation field. Sources of data: A comprehensive search of PubMed, Web of Science, the Cochrane Collaboration Database, Physiotherapy Evidence Database (PEDro), Evidence Based Medicine (EBM) Search review, National Guidelines, Scopus and Google Scholar was performed using keywords such as 'eccentric exercise', 'sports injuries rehabilitation', 'tendinopathy', 'hamstrings strain' 'adductor injuries' and 'ACL reconstruction rehabilitation'. Areas of agreement: EE, alone or associated with other therapies, represents a feasible, cost-effective and successful tool in the treatment of well-known targets and might be promising in shoulder tendinopathy, adductor-related groin pain, hamstring strains, and ACL rehabilitation. Area of controversy: The lack of standardization of protocols, the variable amount, quality and follow-up of studies, the different anatomy and pathophysiology of the therapeutic targets limit the evidence of applicability of EE to sports injuries. Growing points: The role of pathology and biomechanics in the response to EE should be further investigated.Areas timely for developing research. New randomized controlled trials should test the effectiveness of standardized EE regimens to various sites of sports injuries. Language: en

Development and validation of a new visa questionnaire (VISA-H) for patients with proximal hamstring tendinopathy

Abstract: Background There is a need for a patient-reported outcome (PRO) questionnaire to evaluate patients with proximal hamstring tendinopathy (PHT). Objective To develop a PRO questionnaire based on VISA questionnaire forms for patients with PHT. Methods Item generation, item reduction, item scaling and evaluation of the psychometric properties were used to develop a questionnaire to assess the severity of symptoms, function and ability to play sports in patients with PHT and healthy subjects. The final version, named Victorian Institute of Sport Assessment-Proximal Hamstring Tendons (VISA-H), consisted of eight questions that measured the domains of pain, function and sporting activity. The psychometric properties of a questionnaire were estimated in a population of non-surgical (n=20) and surgical (n=10) patients, as well as in healthy subjects (n=30). Results The VISA-H questionnaire displayed a high degree of internal consistency, with a Cronbach α of 0.84. (The test–retest reliability was high for all groups of participants with an intraclass correlation coefficient ranging from 0.90 to 0.95.) The VISA-H exhibited a high correlation with the Nirschl phase rating scale (r ranging from −0.75 to −0.89) and a generic tendon grading system proposed by Curwin and Stanish (r ranging from −0.70 to −0.88). Also, the responsiveness was higher for the VISA-H questionnaire with an area under the curve of 0.90 and a minimum clinically important difference of 22 points. Conclusions The VISA-H is a PRO questionnaire with high psychometric properties for measuring pain, function and sporting activity in patients with PHT.

Platelet-rich plasma injections for chronic plantar fasciopathy: a systematic review

Abstract: Introduction: There is an increasing interest in platelet-rich plasma (PRP) injection as a treatment for chronic plantar fasciopathy (PF). We wished to evaluate the evidence for the use of PRP in PF/fasciitis.

Supervised training and home-based rehabilitation in patients with stabilized ankylosing spondylitis on TNF inhibitor treatment: a controlled clinical trial with a 12-month follow-up:

Abstract: Objective:To assess the 12-month’s follow-up effects on pain, mobility, and physical function outcomes of a supervised training and home-based rehabilitation for ankylosing spondylitis patients stabilized with TNF-inhibitor therapy.Design:Controlled clinical trial (sequentially determined allocation) with 12-months’ follow-up.Setting:Patients’ homes.Subjects:A total of 69 subjects were allocated to either a rehabilitation programme (rehabilitation group, n = 22), an educational-behavioural programme (educational group, n = 24), and to neither programme (control group, n = 23).Interventions:Rehabilitation programme included supervised training and home exercises (stretching, strengthening, aerobic, chest, and spine/hip joint flexibility exercises); educational-behavioural programme included information on ankylosing spondylitis, pain and stress mechanisms, and control.Main measures:Spinal pain intensity, Bath Ankylosing Spondylitis Metrology Index, Bath Ankylosing Spondylitis Functional Index, Bath Ankylos...

Surgical management of partial tears of the anterior cruciate ligament

Abstract: Partial anterior cruciate ligament (ACL) tears involving the posterolateral (PL) bundle can lead to rotatory laxity of the knee, while tears involving the anteromedial (AM) bundle result in abnormal anteroposterior laxity of the knee. In this systematic review, we examine the best evidence on the management of partial tears of the ACL. A comprehensive search of several databases was performed from the inception of the database to December 2011, using various combinations of keywords focusing on clinical outcomes of human patients who had partial tears of ACL and who had undergone ACL augmentation. We evaluated the methodological quality of each article using the Coleman Methodology Score. Ten articles published in peer-reviewed journals were identified (392 males and 242 females), with a mean modified Coleman methodology of 66.1 ± 10.2. Only two studies compared standard ACL reconstruction and augmentation techniques. No study has a sample large enough to allow establishing guidelines. Validated and standardized proprioception assessment methods should be used to report outcomes. Imaging outcomes should be compared to functional outcomes, and a control group consisting of traditional complete ACL reconstruction should be present. There is a need to perform appropriately powered randomized controlled trials presenting clinical outcome with homogeneous score systems to allow accurate statistical analysis. ACL augmentation technique, preserving the intact AM or PL bundle of the ACL, is encouraging but currently available evidences are too weak to support his routine use in clinical practice. Systematic review, Level IV.

Total Knee Arthroplasty After High Tibial Osteotomy

Abstract: High tibial osteotomy may be indicated in the treatment of varus knee in young, active patients. The preservation of proprioception and native joint and biomechanics is crucial for functional recovery in these patients. However, deterioration of initial good results can occur with time. In such cases, revision with total knee arthroplasty is indicated. However, this is a more surgically demanding option compared with a primary prosthesis. Accurate preoperative planning is mandatory to decrease the risk of intraoperative complications. A precise surgical technique, which is crucial to improving functional outcomes, includes hardware removal, joint exposition, tibial deformities due to previous osteotomy, and managing soft tissue mismatches. Possible technical challenges and surgical solutions exist for each of these aspects. However, several studies report lower functional results compared with primary implants. Thus, patients should be informed before high tibial osteotomy about its failure rate, the difficult surgical aspects of an additional prosthesis, and less satisfactory clinical results.

High volume image-guided Injections for patellar tendinopathy: a combined retrospective and prospective case series.

Abstract: Background: the aim was to quantify the effect of a novel high volume-image guided injection (HVIGI) technique for recalcitrant patellar tendinopathy (PT). Methods: twenty patients (8 prospective; 12 retrospective) with ultrasonographically confirmed proximal PT were recruited. A HVIGI under ultrasound guidance of 10 ml 0.5% Bupivacaine, 25 mg Hydrocortisone and 30 ml normal saline at the interface of the patellar tendon and Hoffa’s fat pad was administered. A standardised eccentric loading rehabilitation protocol was prescribed. Results: the VISA-P score improved from 45.0 to 64.0 (p<0.01) for all subjects, likely to be clinically significant. There was no statistically significant difference between the increase in the retrospective group of 19.9 (± 23.5) and the prospective of 16.4 (± 11.3) p = 0.7262.5% of prospective subjects agreed that they had significantly improved, with 37.5% returning to sport within 12 weeks. Conclusions: HVIGI should be considered in the management of recalcitrant PT. Randomised controlled trials are warranted.

The cubital tunnel: a radiologic and histotopographic study

Abstract: Summary Entrapment of the ulnar nerve at the elbow is the second most common compression neuropathy in the upper limb. The present study evaluates the anatomy of the cubital tunnel. Eighteen upper limbs were analysed in unembalmed cadavers using ultrasound examination in all cases, dissection in nine cases, and microscopic study in nine cases. In all cases, thickening of the fascia at the level of the tunnel was found at dissection. From the microscopic point of view, the ulnar nerve is a multifascicular trunk (mean area of 6.0 ± 1.5 mm2). The roof of the cubital tunnel showed the presence of superimposed layers, corresponding to fascial, tendineous and muscular layers, giving rise to a tri-laminar structure (mean thickness 523 ± 235 μm). This multilayered tissue was hyperechoic (mean thickness 0.9 ± 0.3 mm) on ultrasound imaging. The roof of the cubital tunnel is elastic, formed by a myofascial trilaminar retinaculum. The pathological fusion of these three layers reduces gliding of the ulnar nerve during movements of the elbow joint. This may play a role in producing the symptoms typical of cubital tunnel syndrome. Independent from the surgical technique, decompression should span the ulnar nerve from the triceps brachii muscle to the flexor carpi ulnaris fascia.

Metallic or bioabsorbable interference screw for graft fixation in anterior cruciate ligament (ACL) reconstruction

Abstract: Background: Approximately 100 000 anterior cruciate ligament (ACL) reconstructions are performed in the USA each year. Interference screw fixation is considered the standard for rigid fixation of the graft and provides higher fixation strength compared with other devices such as staples or buttons. The present study summarizes the latest evidence comparing the effectiveness of the available classes of interference screws for fixation of ACL grafts.

Thyroid hormones increase collagen I and cartilage oligomeric matrix protein (COMP) expression in vitro human tenocytes.

Abstract: Background: we previously demonstrated the presence of high levels of thyroid hormones (THs) receptors isoforms in healthy tendons, their protective action during tenocyte apoptosis, and the capability to enhance tenocyte proliferation in vitro. In the present study we tested the ability of THs to influence ECM protein tenocyte secretion in an in vitro system. Methods: primary tenocyte-like cells were cultivated for 1, 7 and 14 days in the presence of T3 or T4 individually or in combination with ascorbic acid (AA). Results: THs (T3 or T4) in synergism with AA increase significantly the total collagen production after 14 days. THs in synergism with AA increase significantly the expression of collagen I,biglycan and COMP, after some days. Conclusion: THs play a role on the extra cellular matrix of tendons, enhancing in vitro the production of several proteins such as collagen I, biglycan and COMP. THs receptors are active on human tenocytes, and can play a role in tendon ailments.

Use of platelet-rich plasma for patellar tendon and medial collateral ligament injuries: best current clinical practice.

Abstract: Platelet-rich plasmas (PRPs) are complex molecular therapies prepared from the patient's own blood through minimal manipulation. Clinical studies examining the efficacy of PRPs to manage patellar tendinopathy and medial collateral ligament (MCL) injuries have been reviewed. We found three controlled trials, two of them randomized, and seven case series in the management of patellar tendinopathy. In addition, three other randomized studies showed that PRPs help to regenerate the patellar tendon harvest site for anterior cruciate ligament reconstruction and to reduce patellar donor site morbidity. On the other hand, the use of PRP in MCL injuries is reported in a single case study. Seven of the 11 studies used leukocyte and PRP which was buffered in four studies. Seven of the 11 studies applied two or three injections. Given the heterogeneity of PRP protocols and the paucity of high-quality data, the most effective approach to guide clinical decisions regarding patellar tendinopathy cannot be deduced from the present published studies.

Assessment of the Effectiveness of Extracorporeal Shock Wave Therapy (ESWT) For Soft Tissue Injuries (ASSERT): An Online Database Protocol.

Abstract: Background Soft tissue injuries and tendinopathies account for large numbers of chronic musculoskeletal disorders. Extracorporeal shockwave therapy (ESWT) is popular, and effective in the management of chronic tendon conditions in the elbow, shoulder, and pain at and around the heel. Methods/Design Ethical approval was granted from the South East London Research Ethics Committee to implement a database for the Assessment of Effectiveness of Extracorporeal Shock Wave Therapy for Soft Tissue Injuries (ASSERT) to prospectively collect information on the effectiveness of ESWT across the UK. All participants will give informed consent. All clinicians follow a standardised method of administration of the ESWT. The primary outcome measures are validated outcome measures specific to the condition being treated. A Visual Analogue Score for pain and the EuroQol will be completed alongside the condition specific outcome tool at baseline, 3, 6, 12 and 24 months post treatment. Discussion The development of the ASSERT database will enable the evaluation of the effectiveness of ESWT for patients suffering from chronic conditions (plantar fasciopathy, tennis elbow, Achilles tendinopathy, greater trochanter pain syndrome and patellar tendinopathy). The results will aid the clinicians in the decision making process when managing these patients.

Medial tibial pain pressure threshold algometry in runners

Abstract: Pressure algometry (PA) may provide an objective and standardised tool in assessing palpation pain over the tibia. The purpose of this study was to analyse the intra-rater repeatability of PA and to determine whether tibial tenderness in healthy runners differ from runners with medial tibial stress syndrome (MTSS). Pressure algometry was performed on 20 asymptomatic runners (40 legs) and 9 MTSS patients (14 symptomatic legs) at standardised locations along the medial border of the tibia. Intra-rater reliability was assessed in 10 randomly selected asymptomatic runners through repeated measurements 2 weeks later. Intra-rater reliability was moderate to excellent (ICC 0.53–0.90) in asymptomatic runners. Pain pressure threshold (PPT) was significantly reduced at 2/9–5/9 of the distance from the medial malleolus to the medial tibial condyle (p = 0.002–0.022). There was evidence of a statistically significant association between both height and weight, and PPT from the 3/9 (r = 0.416, p = 0.008) to 7/9 (r = 0.334, p = 0.035) and 3/9 (r = 0.448, p = 0.004) to 6/9 (r = 0.337, p = 0.034) area, respectively. In both MTSS patients and healthy runners, there was evidence of lower PPT in females compared to males (p = 0.0001–0.049) and a negative association between age and PPT (p = 0.001–0.033). MTSS patients had significantly lower PPT at the 3/9 site (p = 0.048) compared to asymptomatic runners. Pain pressure threshold algometry can be incorporated into MTSS clinical assessment to objectively assess pain and monitor progress. The presence of reduced medial tibial PPT in asymptomatic runners suggests that clinicians may not need to await resolution of medial tibia tenderness before allowing return to sport in MTSS patients. III.

Can local corticosteroid injection in the retrocalcaneal bursa lead to rupture of the Achilles tendon and the medial head of the gastrocnemius muscle

Abstract: Purpose The purpose of the study is to explain the cause–effect relationship in three patients who reported combined ruptures of the Achilles tendon and the gastrosoleus complex 6 months after they had received corticosteroids injections for the management of retrocalcaneal bursitis.

Histopathological scores for tissue-engineered, repaired and degenerated tendon: a systematic review of the literature.

Abstract: Purpose: This systematic review analyzes histological scoring systems for degenerative tendon-enthesis changes, ex vivo tendon-enthesis repair and tissue-engineered tendon-enthesis repair. A secondary aim is to establish the validity and applicability of these scores to find a comprehensive and validated histological scoring system for the evaluation of tendon-enthesis tissue. Methods: We performed a systematic review of the literature by analyzing the following databases: PubMed, Embase, Medline, CINAHL, and Cochrane. The methodology of the study was developed according to the PRISMA guidelines. Results: Twenty-seven articles, describing a total of 9 scores for tendinopathy, 6 scores for tendon ruptures, and 12 scores for tendon regeneration were included. For enthesis changes, 4 studies describe a total of 3 scores for enthesopathy and 1 scores for enthesis regeneration. The Movin score and its modifications seem be the more comprehensive to assess the degenerative changes; the Soslowsky score, the Watkins score, the Novel scoring system and the Burssens score seem be the more comprehensive to assess tendon repair process. Only the Matthys score assesses the histological changes in enthesopathies, and the modified Watkins score has been well applied to assess enthesis repair. Conclusion: The assessment of tendon-enthesis structure can be performed with several histological scoring systems previously published in literature. However, no studies have been performed to validate these score in research settings. Further experimental and clinical studies should be developed to provide a comprehensive and validated scoring system for the histological assessment of tendon-enthesis repair.