Showing papers by "Nicola Maffulli published in 2015"

Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database

Abstract: Background Extracorporeal shock wave therapy (ESWT) is an effective and safe non-invasive treatment option for tendon and other pathologies of the musculoskeletal system.

Multidirectional Instability of the Shoulder: A Systematic Review.

Abstract: Purpose To analyze outcomes of surgical and conservative treatment options for multidirectional instability (MDI). Methods A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. A comprehensive search of the PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "multidirectional instability," "dislocation," "inferior instability," "capsulorrhaphy," "capsular plication," "capsular shift," "glenoid," "humeral head," "surgery," and "glenohumeral," over the years 1966 to 2014 was performed. Results Twenty-four articles describing patients with open capsular shift, arthroscopic treatment, and conservative or combined management in the setting of atraumatic MDI of the shoulder were included. A total of 861 shoulders in 790 patients was included. The median age was 24.3 years, ranging from 9 to 56 years. The dominant side was involved in 269 (58%) of 468 shoulders, whereas the nondominant side was involved in 199 (42%) shoulders. Patients were assessed at a median follow-up period of 4.2 years (ranging from 9 months to 16 years). Fifty-two of 253 (21%) patients undergoing physiotherapy required surgical intervention for MDI management, whereas the overall occurrence of redislocation was seen in 61 of 608 (10%) shoulders undergoing surgical procedures. The redislocation event occurred in 17 of 226 (7.5%) shoulders with open capsular shift management, in 21 of 268 (7.8%) shoulders with arthroscopic plication management, in 12 of 49 (24.5%) shoulders undergoing arthroscopic thermal shrinkage, and in 11 of 55 (22%) shoulders undergoing arthroscopic laser-assisted capsulorrhaphy. Conclusions Arthroscopic capsular plication and open capsular shift are the best surgical procedures for treatment of MDI after failure of rehabilitative management. Arthroscopic capsular plication shows results comparable to open capsular shift. Level of Evidence Level IV, systematic review of Level I to IV studies.

I.S.Mu.L.T - Rotator Cuff Tears Guidelines.

Abstract: Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.

Platelet-rich Plasma Modulates the Secretion of Inflammatory/Angiogenic Proteins by Inflamed Tenocytes

Abstract: Background Platelet-rich plasma therapies for tendinopathy appear to provide moderate pain reduction. However, the biological mechanisms behind the observed clinical effects remain poorly characterized.

Surgical management of irreparable rotator cuff tears

Abstract: In this prospective case control study, the effectiveness of surgical management of irreparable rotator cuff tears in terms of patient’s status and quality of life was evaluated in two groups of patients: one group receiving arthroscopic debridement associated with acromioplasty and bursectomy and the other receiving an arthroscopic partial repair of the rotator cuff tear. Sixty-eight patients (47 males and 21 females) undergoing arthroscopic shoulder surgery for massive irreparable rotator cuff tear were enrolled in our study. Patients were divided into two groups: Group AP (debridement associated with acromioplasty and bursectomy) and Group PR (partial repair). Pre- and post-operative range of motion (ROM), modified-UCLA shoulder score and strength measurement were performed. The RC-QOL was used at the time of the last follow-up to assess patients’ perception of their quality of life. The final follow-up was 7.8 (±2.3, range 5–9) years. ROM measures were significantly increased from pre- to post-operative evaluations, with significant intergroup differences (P < 0.001). The overall modified-UCLA shoulder score showed a mean pre-operative value of 7.6 ± 2.6 (95 % CI 6.7–8.5) for Group AP and 8.6 ± 4.1 (95 % CI 7.0–9.9) (n.s.) for Group PR. The post-operative values at the latest follow-up showed a statistically significant improvement in both groups [21.4 ± 3.7 (95 % CI 20.1–22.7) for Group AP and 28.8 ± 4.2 (95 % CI 27.3–30.2) for Group PR] (P < 0.0001), with a significant intergroup difference (P < 0.0001). The RC-QOL demonstrated a statistically significant difference between the groups [Group AP: 61.8 ± 6.1(95 % CI 59.6–63.9); Group PR: 71.2 ± 9.8 (95 % CI 67.7–74.6)] (P < 0.0002). Both techniques are effective in reducing patients’ symptoms, with higher functional outcomes for partial repair. However, the choice of which technique to undertake should take into account the patients’ features concerning the acromio-humeral interval and levels of daily activities. Therapeutic case–control study, Level III.

Acute compartment syndrome.

Abstract: Background acute compartment syndrome (ACS) is one of the few true emergencies in orthopedics and traumatology. It is a painful condition caused by the increase interstitial pressure (intracompart-mental pressure - ICP) within a closed osteofascial compartment which impair local circulation. It occurs most often in the legs, but it can affects also the arms, hands, feet, and buttocks. It usually develops after a severe injury such as fractures or crush injury, but it can also occurs after a relatively minor injury and it may be iatrogenic. Uncommon causes of ACS have been also described, that suggest surgeons to pay great attention to this serious complication. Diagnosing ACS is difficult in clinical practice, even among expert surgeons. Currently, the diagnosis is made on the basis of physical examination and repeated ICP measures. ICP higher than 30 mmHg of diastolic blood pressure is significant of compartment syndrome. Once diagnosis is made, fasciotomy to release the affected compartment should be performed as early as possible because delayed decompression would lead to irreversible ischemic damage to muscles and peripheral nerves. Conclusion acute compartment syndrome is a surgical emergency. There is still little consensus among authors about diagnosis and treatment of these serious condition, in particular about the ICP at which fasciotomy is absolutely indicated and the timing of wound closure. New investigations are needed in order to improve diagnosis and treatment of ACS.

Muscle and tendon injuries: the role of biological interventions to promote and assist healing and recovery.

Abstract: Purpose: To summarize clinical studies after platelet-rich plasma (PRP) therapy for tendinopathy, plantar fasciopathy, and muscle injuries; to review PRP formulations used across studies; and to identify knowledge deficits that require further investigation. Methods: After a systematic review in PubMed, we identified clinical studies assessing PRP efficacy in tendon and muscle during the past decade. We standardized data extraction by grouping studies based on anatomic location; summarized patient populations, PRP formulations, and clinical outcomes; and identified knowledge deficits that require further investigation. Results: Overall, 1,541 patients had been treated with PRP in 58 clinical studies; of these, 26 addressed upper limb tendinopathies and 32 addressed the lower limb (810 patients and 731 patients treated with PRP, respectively). The quality of research is higher for the upper limb than for the lower limb (23 controlled studies, of which 17 are Level I, v 19 controlled studies, of which 6 are Level I, respectively). Patients have been treated mostly with leukocyte-plateleterich plasma, except in the arthroscopic management of the rotator cuff. The safety and efficacy of PRP for muscle injuries has been addressed in 7 studies including 182 patients. Differences across results are mainly attributed to dissimilarities between tissues and different stages of degeneration, numbers of PRP applications, and protocols. Conclusions: Given the heterogeneity in tendons and tendinopathies, currently, we are not able to decide whether PRP therapies are useful. Despite advances in PRP science, data are insufficient and there is a clear need to optimize protocols and obtain more high-quality clinical data in both tendinopathies and muscle injuries before making treatment recommendations. Level of Evidence: Level IV, systematic review of Level I through IV studies.

No difference between unicompartmental versus total knee arthroplasty for the management of medial osteoarthtritis of the knee in the same patient: a systematic review and pooling data analysis.

Abstract: Introduction: One-third of patients with knee osteoarthritis (OA) has involvement of only one compartment, especially the medial one. Sources of data: We performed a comprehensive search of studies comparing unicompartmental knee arthoplasty (UKA) and total knee arthroplasty (TKA) in the same patient on PubMed, OVID/Medline, Cochrane, CINAHL, Google scholar and Embase databases.

A polymorphism at the translation start site of the vitamin D receptor gene is associated with the response to anti-osteoporotic therapy in postmenopausal women from Southern Italy

Abstract: The present study investigated the effect of two single nucleotide polymorphisms (SNPs) of the vitamin D receptor (VDR) gene, rs1544410 A/G and rs2228570 C/T, in modulating bone mineral density (BMD) and the response to treatment with bisphosphonates or strontium ranelate in postmenopausal osteoporosis (PMO). Four hundred eighteen postmenopausal women from Southern Italy treated with bisphosphonates or strontium ranelate for three years were enrolled and stratified according to their genotype. Changes in BMD were expressed as the delta t-score (Δt-score). Allelic frequencies for rs1544410 A/GSNP were 11.2% AA, 50.0% GA and 38.8% GG; for rs2228570 C/TSNP were 54.8% CC, 39.5% TC and 5.7% TT. TT carriers showed a lower t-score than TC and CC (both p < 0.02) genotypes and were more responsive to the therapy when compared to both TC (p < 0.02) and CC (p < 0.05) carriers. Specifically, TT carriers receiving alendronate demonstrated a significant improvement of the Δt-score compared to TC and CC (both p < 0.0001) carriers. After adjustment for confounders, the Δt-score showed evidence of a statistically significant positive association with TT in all treatments considered. Therapy response was independent of rs1544410 A/G SNP; instead, rs2228570 C/TSNP was associated with a better response to antiresorptive treatment, thus suggesting that the therapy for PMO should be personalized.

Metatarsalgia and Morton's Disease: Comparison of Outcomes Between Open Procedure and Neurectomy Versus Percutaneous Metatarsal Osteotomies and Ligament Release With a Minimum of 2 Years of Follow-Up.

Abstract: The present study compared the clinical results of open neurectomy versus a percutaneous procedure for Morton's disease. This was a retrospective study comparing the functional results after 2 surgical procedures: open neurectomy and a percutaneous procedure (with deep transverse metatarsal ligament release and distal metatarsal osteotomies). The present study included 52 patients (26 in each group), and the mean follow-up period was 4 (range 2 to 7) years. The patient evaluation criteria included the presence of painful symptoms of Morton's disease, American Orthopaedic Foot and Ankle Society (AOFAS) functional scale score, patient satisfaction, and delay for recovery. Percutaneous treatment of Morton's disease and open neurectomy produced complete relief of pain in 25 of 26 patients in each group. At the latest follow-up visit, the mean AOFAS score had significantly improved from 36 ± 11 preoperatively to a mean of 89 ± 18 (p 90) significantly more often with a shorter delay than after open neurectomy (p = .03). At the latest follow-up visit, metatarsalgia due to plantar hyperpressure or bursitis and requiring plantar orthotics was present in 11 of 26 patients (44%) after open neurectomy and in 1 of 26 patients (4%) after the percutaneous procedure (p = .002). Percutaneous treatment of Morton's disease is a reliable procedure providing results as good as those after open neurectomy, with significantly better outcomes in the longer term and a lower rate of late metatarsalgia.

Pharmacological interventions for the treatment of Achilles tendinopathy: a systematic review of randomized controlled trials

Abstract: Introduction: Several pharmacological interventions have been proposed for the management of Achilles tendinopathy, with no agreement on which is the overall best option available. This systematic review investigates the efficacy and safety of different local pharmacological treatments for Achilles tendinopathy. Sources of data: We included only randomized controlled studies (RCTs) focusing on clinical and functional outcomes of therapies consisting in injection of a substance or local application. Assessment of the methodological quality was performed using a modified version of the Coleman methodology score (CMS) to determine possible risks of bias. Areas of agreement: Thirteen RCTs were included with a total of 528 studied patients. Eleven studies reported the outcomes of injection therapies. Two studies examined the outcomes of patients who applied glyceryl trinitrate patch. The mean modified CMS was 70.6 out of 90. Areas of controversy: There was no significant evidence of remarkable benefits provided by any of the therapies studied.

The management of chronic rupture of the Achilles tendon: minimally invasive peroneus brevis tendon transfer

Abstract: We hypothesised that a minimally invasive peroneus brevis tendon transfer would be effective for the management of a chronic rupture of the Achilles tendon. In 17 patients (three women, 14 men) who underwent minimally invasive transfer and tenodesis of the peroneus brevis to the calcaneum, at a mean follow-up of 4.6 years (2 to 7) the modified Achilles tendon total rupture score (ATRS) was recorded and the maximum circumference of the calf of the operated and contralateral limbs was measured. The strength of isometric plantar flexion of the gastrocsoleus complex and of eversion of the ankle were measured bilaterally. Functional outcomes were classified according to the four-point Boyden scale. At the latest review, the mean maximum circumference of the calf of the operated limb was not significantly different from the pre-operative mean value, (41.4 cm, 32 to 50 vs 40.6 cm, 33 to 46; p = 0.45), and not significantly less than that of the contralateral limb (43.1 cm, 35 to 52; p = 0.16). The mean peak torque (244.6 N, 125 to 367) and the strength of eversion of the operated ankle (149.1 N, 65 to 240) were significantly lower (p < 0.01) than those of the contralateral limb (mean peak torque 289, 145 to 419; strength of eversion: 175.2, 71 to 280). The mean ATRS significantly improved from 58 pre-operatively (35 to 68) to 91 (75 to 97; 95% confidence interval 85.3 to 93.2) at the time of final review. Of 13 patients who practised sport at the time of injury, ten still undertook recreational activities. This procedure may be safely performed, is minimally invasive, and allows most patients to return to pre-injury sport and daily activities.

Volar locking plates versus K-wire/pin fixation for the treatment of distal radial fractures: a systematic review and quantitative synthesis

Abstract: Introduction: Volar locking plate and Kirschner wire/pin fixations are the most commonly used methods for surgical fixation of distal radius fractures. Sources of data: A literature search was performed using PubMed, CINAHL, Cochrane Central and Embase Biomedical databases, selecting studies comparing two or more different surgical treatments including Kirschner wire fixation and volar locking-plate fixation. This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Methodological quality of all selected articles was assessed. Areas of agreement: A total of 14 publications (1306 patients) were included in this review, 10 of which were prospectively designed (8 randomized controlled trial). A total of 659 (50.5%) patients underwent volar locking plating (VLP group), while 647 of 1306 (49.5%) were treated with Kirschner wire/pin fixation (KW group). No differences were recorded in terms of ROM, grip strength, radiographic variables and total rate of complications. There is no clear superiority of either fixation method for the surgical management of distal radius fractures. Areas of controversy: At a pooled analysis, VLP obtained statistically significant better DASH value compared to KW (18.1 ±7.8 vs. 12.8±6.4%, P=0.026). Costs and surgical times were significantly higher for plate fixation.

Complications involving the extensor mechanism after total knee arthroplasty

Abstract: To overview the complications involving extensor apparatus of the knee following total knee arthroplasty (TKA) and to summarize which are the lines of treatment available and their reported outcomes in literature A comprehensive search of several databases was performed using as basic keywords “complications after TKA”, “extensor mechanism disruption”, “periprosthetic patellar fracture”, “quadriceps tendon rupture”, “quadriceps tendon rupture” isolated or combined with other terms by using Boolean operators The methodological quality of each article was also evaluated using the Coleman methodology score (CMS) Twenty-nine studies were evaluated The mean CMS of the studies selected was 331/100 Patellar fractures, requiring surgical treatment when there is rupture of the extensor mechanism or loosening of the patellar component, were treated surgically in 281 % of patients The patellar and quadriceps tendon ruptures were surgically treated with reconstruction or augmented repair, respectively, in 986 and 765 % Complications involving the extensor apparatus of the knee following a TKA need early and appropriate management to avoid their devastating influence on joint functionality Management has to be evaluated very carefully based on the site of the lesion, integrity of the prosthetic components and surrounding tissue to restore, and the patients’ individual characteristics The surgical approach for comminuted periprosthetic fractures and reconstruction of torn tendons of the extensor apparatus are needed to restore function and decrease pain, but, given the poor methodological quality of the studies published so far, it is not clear which surgical technique or graft leads to better outcomes Therefore, there is an absolute need for better designed comparative trials producing clearer and stronger evidence on this critical matter IV

The safe zone for avoiding suprascapular nerve injury in bone block procedures for shoulder instability. A cadaveric study

Abstract: The purpose of the study is to identify the safe zone in which the surgeon can place the screws for fixation of the coracoid graft during the Latarjet procedure to avoid injuries of the suprascapular nerve with the shoulder in internal and external rotation. The dissection on twelve fresh-frozen shoulders was performed according to a standard posterior approach to the gleno-humeral joint. The suprascapular nerve and its branches for the infraspinatus muscle were identified at the spinoglenoid notch region. Then, the distance between the glenoid and the suprascapular nerve at the spinoglenoid notch region was measured by using a ruler with the shoulder at 90° internal rotation and at 90° of external rotation. The median distance between the glenoid and the suprascapular nerve was 12 mm (range 6–15 mm) with the shoulder at 90° of internal rotation and 19 mm (range 11–23 mm) with the shoulder at 90° of external rotation. The distance between the glenoid and the suprascapular nerve was statistically significantly greater with the shoulder at 90° of external rotation than 90° of internal rotation (P = 0.002). The suprascapular nerve is furthest away from the glenoid with the shoulder at 90° of external rotation. Therefore, the placement of screws in external rotation of the humerus during glenoid bone block procedures likely reduces the risk of iatrogenic injuries of the suprascapular nerve.

Pulsed electromagnetic fields after rotator cuff repair: a randomized, controlled study.

Abstract: The current study tested the hypothesis that the use of pulsed electromagnetic fields after rotator cuff repair is effective in the short term as an adjuvant treatment to reduce local inflammation, postoperative joint swelling, and recovery time, as well as to induce pain relief. Sixty-six patients who underwent shoulder arthroscopy for repair of small to medium rotator cuff tears were randomly divided into 2 groups with a block randomization procedure. Thirty-two patients underwent arthroscopic rotator cuff repair and application of pulsed electromagnetic fields postoperatively; 34 patients underwent rotator cuff repair and placebo treatment (placebo group). All patients had the same postoperative rehabilitation protocol. At 3 months from the index procedure, visual analog scale, range of motion, and University of California at Los Angeles and Constant scores were significantly better in the pulsed electromagnetic fields group than in the placebo group (P<.05). Three patients in the pulsed electromagnetic fields group and 7 patients in the placebo group had mild to moderate capsulitis (P=.2). Severe capsulitis occurred in 1 patient in the pulsed electromagnetic fields group and 2 patients in the placebo group (P=.6). At the last follow-up (minimum, 2 years), clinical and functional outcomes were further improved in both groups, with no significant intergroup differences. Application of pulsed electromagnetic fields after rotator cuff repair is safe and reduces postoperative pain, analgesic use, and stiffness in the short term. At 2 years, no difference was seen in outcomes in patients who did or did not undergo treatment with pulsed electromagnetic fields.

Hamstring Tendon Regeneration After Harvest for Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Abstract: Purpose To assess whether the portions of the semitendinosus and gracilis tendons harvested for anterior cruciate ligament reconstruction have the potential to regenerate and, if so, to evaluate the histologic properties and actual function of this newly formed tissue. Methods We performed a comprehensive search of CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, Medline, the Cochrane Central Registry of Controlled Trials, and SPORTDiscus from inception of the databases to July 2014, using various combinations of keywords. Studies focusing on hamstring tendon and muscle regeneration through imaging and histology, as well as on the related functional outcomes, were selected. We included studies assessing evidence of tissue regeneration with imaging (magnetic resonance imaging, 3-dimensional computed tomography, ultrasonography) or with histologic examination of biopsy samples (or a combination thereof). Results Nineteen articles were included in this review, with a total of 400 patients observed. The overall rate of tissue regeneration was 86.0%, with similar values shown in most studies regardless of the methodology of the assessment. Biopsy confirmed that the tissue found at the site in 74% of the cases showed typical histologic features of the tendon. The mean modified Coleman Methodology Score of the studies included was 52.7 points, showing a modest methodologic quality for the studies published to date. Conclusions In over 85% of the cases analyzed, regeneration signs of the harvested tendon were found through different imaging and histologic methodologies. A torque deficit in deep knee flexion is always present postoperatively, but the cause for this is still unclear. There is a need for better-designed trials featuring a higher level of evidence to further investigate this matter, and the effects of postoperative care and the surgical approach used on the regeneration process should be analyzed in the future. Level of Evidence Level IV, systematic review of Level II, III, and IV studies.

BMP2 repression and optimized culture conditions promote human bone marrow-derived mesenchymal stem cell isolation

Abstract: Aim: Human mesenchymal stem cells (hMSC) are multipotent progenitor cells. We propose the optimization of hMSC isolation and recovery using the application of a controlled hypoxic environment. Materials & Methods: We evaluated oxygen, glucose and serum in the recovery of hMSC from bone marrow (BMhMSC). Colony forming units-fibroblastic, cell numbers, tri-lineage differentiation, immunofluorescence and microarray were used to confirm and characterize BMhMSC. Results: In an optimized (2% O2, 4.5 g/l glucose and 5% serum) environment both colony forming units-fibroblastic (p = 0.01) and cell numbers (p = 0.0001) were enhanced over standard conditions. Transcriptional analysis identified differential expression of bone morphogenetic protein 2 (BMP2) and, putatively, chemokine (C-X-C motif) receptor 2 (CXCR2) signaling pathways. Conclusion: We have detailed a potential milestone in the process of refinement of the BMhMSC isolation process.

Anterior cruciate ligament reconstruction and return to sport activity: postural control as the key to success.

Abstract: The risk for re-tear following anterior cruciate ligament (ACL) reconstruction is influenced by several hormonal, neuromuscular, biomechanical and anatomic factors. One of the most important negative prognostic factors that markedly increase the risk for ACL re-tear is the presence of high knee-abduction moment (KAM), which can be measured immediately by landing on both feet after a vertical jump. We evaluated the effect in postoperative values for KAM according to the type of graft used for ACL reconstruction (hamstring vs patellar tendon) and a specific rehabilitation protocol focusing on recovery of muscular strength, proprioception and joint stabilisation. From November 2010 to September 2012, we enrolled 40 female recreational athletes with clinical and imaging evidence of ACL tear and randomised them in two groups. One group of patients underwent reconstruction with a hamstring-tendon graft and the second with a patellar-tendon graft. A custom rehabilitation programme focusing on proprioception was adopted. Clinical outcomes [International Knee Documentation Committee (IKDC) and Lysholm scores] and performance in functional test for stability (single-leg hop, timed hop, crossover triple hop, KAM test) were assessed preoperatively at three and six months postoperatively. All patients showed statistically significant clinical improvements postoperatively when compared with preoperative values (P < 0.0001). No significant intergroup difference was observed in all clinical scores and functional tests, with the exception of the value registered for the KAM test (P < 0.0001). ACL reconstruction using patellar-tendon graft followed by rehabilitation centred on strength, proprioception and stability restoration can produce satisfactory values for KAM within the physiological range. The surgical strategies should be adapted to the patient on the basis of a multidisciplinary approach.

Management of cervical fractures in ankylosing spondylitis: anterior, posterior or combined approach?

Abstract: Introduction: Ankylosing spondylitis (AS) can lead to an increased risk of cervical fractures. Sources of data: A systematic review was undertaken using the keywords ‘ankylosing spondylitis’, ‘spine fractures’, ‘cervical fractures’, ‘surgery’ and ‘postoperative outcomes’ on Medline, Pubmed, Google Scholar, Ovid and Embase, and the quality of the studies included was evaluated according to the Coleman Methodology Score. Areas of agreement: Surgery ameliorates neurological function in patients with unstable AS-related cervical fractures. The combined anterior/posterior and the posterior approaches are more effective than the anterior approach. Areas of controversy: The optimal approach, anterior, posterior or combined anterior/posterior, for the management of AS related cervical fractures has not been defined.

Current techniques for management of transverse displaced olecranon fractures.

Abstract: BACKGROUND: displaced transverse fractures of the olecranon are the most common fractures occurring in the elbow in adults that requires operative intervention. METHODS: a literature search was performed on PubMed, Web of Science, Science Direct/Scopus, Google Scholar and Google using the keywords 'olecranon', 'fracture', 'internal fixation' and 'tension band wiring', with no limit for time or restrictions to language. RESULTS: thirty-one clinical articles were selected: 20 retrospective studies, 9 prospective cohort studies, and 2 randomized control trials. The CMS ranged from 18 to 66 (mean 41.68): overall, the quality of the studies was poor, and no moderate or good quality studies were found. The mean follow-up was 46.7 months (range 1 to 350 months). Several complications occurred after surgery: prominent hardware, skin breakdown, wire migration and infections occurred frequently. Removal of the hardware was required in 472 patients, usually after complaints, but also removal was routinely undertaken. CONCLUSIONS: tension band wiring is still the most widely applied method to operatively manage olecranon fractures, with the transcortical method of using K-wires the most satisfactory. Plate fixation is a good alternative as complications are minimal. Other techniques using absorbable sutures are less investigated, but are promising, especially in children.

Hyaluronic acid injections protect patellar tendon from detraining-associated damage.

Abstract: Introduction: Having previously demonstrated that detraining affects patellar tendon (PT) proteoglycan content and collagen fiber organization, we undertook the present study with two aims: to improve knowledge on the adaptation of PT and its enthesis to detraining from a histological and histomorphometric point of view, and to investigate the hypothesis that repeated peri-patellar injections of hyaluronic acid (HA) on detrained PT may reduce and limit detrained associated-damage. Methods: Twenty-four male Sprague-Dawley rats were divided into 3 groups: Untrained (n=6), Trained (n=6) (10 wks-treadmill) and Detrained (n=12). In the detrained rats, the left tendon was untreated while the right tendon received repeated peri-patellar injections of either HA or saline (NaCl). Structure and morphology of PTs (modified Movin score, tear density, collagen type I and III) and enthesis (cell morphology, chondrocyte cluster formation, tidemark integrity, matrix staining and vascularization) were evaluated. Results: The left PT and enthesis of the Detrained groups showed altered structure and morphology with the highest Movin score values, the highest percentage of collagen III and the lowest of collagen I; the lowest score values were observed in the Trained and Detrained-HA groups. Detrained-NaCl PTs showed the highest collagen III and the lowest collagen I values with respect to Detrained-HA PTs. Conclusion: This study strengthens previously published data showing the alteration in tendon and enthesis morphology due to discontinuation of training, and provides new data showing that treatment with HA is effective in the maintenance of the structural properties of PT and enthesis in Detrained rats. Such beneficial effects could play a significant role in the management of conservative and rehabilitation strategies in athletes that change type, intensity and duration of training

Release of the medial head of the gastrocnemius for Achilles tendinopathy in sedentary patients: a retrospective study

Abstract: Our aim was to ascertain whether releasing the medial head of he gastrocnemius improves clinical and functional outcomes of sedentary patients with long-standing tendinopathy of the main body of the Achilles tendon and allows return to daily activities. Eighteen patients (seven men, 11 women) underwent release of the gastrocnemius medial head to manage chronic unilateral Achilles tendinopathy. Pre- and postoperatively, each patient completed the Victorian Institute of Sports Assessment–Achilles tendon (VISA-A) questionnaire. The maximum calf circumference and isometric plantar flexion strength of the gastrocsoleus complex were measured in both the affected and the contralateral leg. Function was scored using the 4-point Boyden scale at the last assessment. At the last appointment, at an average follow-up of 54 months, maximum calf circumference and strength of the operated leg were not significantly different than pre-operatively and were significantly lower than the contralateral leg. All patients could satisfactorily perform the same work and daily activities as before symptom onset. At the last follow-up, the average VISA-A score was improved from a preoperative average value of 52.3 to 75 (range 51–94) (p < .001). This approach to managing isolated Achiles tendinopathy is safe, effective, low cost and allows safe return to preinjury daily activities.

Microfracture produces inferior outcomes to other cartilage repair techniques in chondral injuries in the paediatric knee.

Abstract: INTRODUCTION Chondral injuries are becoming increasingly common in the paediatric knee. First line surgical therapy is usually microfracture (MF), but the emergence of alternative techniques raises the question of what is the optimal treatment in paediatric patients. SOURCES OF DATA A comprehensive search of PubMed, OVID, Web of Science, SportDiscus and Cochrane databases was performed using the key words 'autologous chondrocyte implantation, MF, mosaicplasty, juvenile, paediatric'. AREAS OF AGREEMENT Each technique demonstrated a significant post-surgical improvement in clinical outcome scores. However, MF demonstrated poorer outcomes in larger lesions (>3 cm(2)) and shorter durability. AREA OF CONTROVERSY The quality of the available literature is poor, and there is a lack of comparative trials. GROWING POINTS The impact of defect characteristics, mechanism of injury and concomitant surgeries should be investigated. AREAS TIMELY FOR DEVELOPING RESEARCH Appropriately powered randomized controlled trials with suitably long follow up and condition-specific outcome measures should compare different techniques against each other and placebo.

Reviewer acknowledgement 2014

Abstract: The Editors of Journal of Orthopaedic Surgery and Research would like to thank all our reviewers who have contributed to the journal in Volume 8 (2014).

Surgical management of Achilles tendon re-ruptures: a prospective cohort study.

Abstract: Purpose The purpose of this study was to compare outcomes of different minimally invasive techniques for reconstruction of Achilles tendon re-ruptures. Methods We prospectively enrolled 21 patients undergoing minimally invasive reconstruction using a transfer of the ipsilateral peroneus brevis (PB) (five patients) or the free ipsilateral semitendinosus tendon (ST) graft with or without interference screw fixation (ten and six patients, respectively). We assessed the maximum calf circumference and isometric plantar flexion strength before surgery and at the last follow up. TheAchillestendontotalrupturescore(ATRS)andnumberof single-leg heel lifts on the affected leg were evaluated at the last follow up. The median follow up was 39 months. Results The outcome of surgery was excellent/good in 17 (81 %) of 21 patients. In the operated leg, the maximum calf circumference and isometric plantar flexion strength were significantly improved after surgery (P<0.0001). The average ATRS was 86 (range 79-92), and the average number of single-legged heel lifts was 33 (range 11–48). No further reruptures were recorded. Conclusions Minimally invasive ipsilateral PB transfer and free ipsilateral ST graft with or without interference screw fixation are safe and effective procedures to reconstruct the Achilles tendon after are-rupture,providinga significant improvement of the symptoms and function in the mid term.

Application of pulsed electromagnetic fields after microfractures to the knee: a mid-term study.

Abstract: Pulsed electromagnetic fields (PEMFs) may improve clinical outcomes following microfractures and prevent their decline over time. Sixty-eight patients who underwent partial medial meniscectomy and microfractures to the medial femoral condyle for management of grade III–IV cartilage lesions were randomly divided into two groups using a block randomization procedure. After surgery, 34 patients underwent PEMFs application in the I-ONE group; 34 patients underwent placebo treatment in the placebo group. All patients had the same postoperative rehabilitation protocol. Sixty patients (28 in the I-ONE group, 32 in the placebo group) were assessed at an intermediate follow-up of two years and a minimum follow-up of five years after surgery. The two groups were homogeneous. There was a significant improvement from baseline to the last minimum follow up of two years. At two years, IKDC and Lysholm and Constant scores were significantly improved compared to baseline in both groups with no significant inter-group differences. At the last follow up (minimum five years), clinical and functional outcomes were decreased in both the groups, with significant better outcomes in the I-ONE group. At five years, the percentage of patients still active at the same level they were pre-operatively was greater in the I-ONE group (82 % vs 68 %, P = 0.28). At radiographic assessment, at the latest evaluation, six patients (21.4 %) in the I-ONE group and nine (28.1 %) in the placebo group demonstrated grade I–II degenerative changes according to Fairbank grading system (Χ = 0.36, P = 0.55). PEMFs application can improve the effectiveness of microfracture in the long term.