Capsulectomy vs capsulotomy in total hip arthroplasty. Clinical outcomes and proprioception evaluation: Study protocol for a randomized, controlled, double blinded trial.

BACKGROUND: Patients affected by coxarthrosis may be treated surgically with total hip arthroplasty (THA). During the surgical intervention, the hip joint capsule can be completely removed, performing a capsulectomy. Otherwise it's possible to perform a capsulotomy, which allows for capsular conservation. Since there is no scientific evidence demonstrating the superiority of one method over the other, the choice whether to remove or conserve the capsule is at the surgeon's discretion and both procedures are actually accepted.The purpose of our study is to evaluate the differences in functional activities and proprioception in patients who underwent THA and capsulotomy with capsular conservation versus patients who underwent THA with capsulectomy. METHODS: In order to compare the two surgical techniques of capsulotomy with capsular conservation and capsulectomy, we created a randomized, controlled, double-blind, single-centre, non-pharmacological, interventional, superiority, parallel-group trial. The primary outcome of our study is evaluated using the HOOS scale (Hip disability and Osteoarthritis Outcome Score). Secondary outcomes are: the proprioceptive sensitivity, the postoperative bleeding, the surgical time, the active range of motion, and the ability to walk, sit and stand. The proprioception study is carried out through active and passive repositioning tests. THA is performed through the minimally invasive direct anterior approach. The evaluation tests are carried out in the 15 days preceding the intervention (T0), at 50-day post-operative (T1), and finally at three months after surgery (T2). DISCUSSION: Considering that the hip joint capsule is innervated by proprioceptive nerve endings, while the psuedocapsule that replaces the native capsule following a THA with capsulectomy doesn't have any active neurophysiological role, we hypothesize that capsulotomy with capsular conservation at the time of primary THA may lead to better proprioception and therefore better functional recovery. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02749058. Date of registration: 04/21/2016.

The "FraMo" System: A New Mini-Invasive Technique in the Treatment of Proximal Humerus Fractures.

Fractures of the proximal humerus are relatively common injuries in adults accounting for 5% of fractures. Nowadays the most common technique used is open reduction internal fixation with LCP plates. The risks associated with open reduction internal fixation had led us to develop and apply a "hybrid" system, which is based on external fixation and closed surgery principles. This system is capable of stabilize up to 4 fragment fractures on different planes while conferring a strong enough fixation to maintain fracture reduction while allowing the patient to perform passive and active movement since the first day following the surgery. Our study group started on November 2009 until December 2015 and consisted of 118 patients with a mean age of 68.84±10.52 years for females (76) and 65.62±12.56 for males (44). Patients were classified according to the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma association) Classification. In a few patients we performed mini lateral accesses to allow reduction of the humeral head and greater tuberosity. Shoulder mobilization was initiated from the first day following surgery. The external fixator was removed at 5 weeks with successive check-ups at 3, 6, and 12 months. The majority of type B and type C1 fractures had almost a complete functional recovery. Patients also, especially in the elderly, reported a good quality of life without pain during any range of motion. Our group of patients, after removal of the apparatus at 5 weeks following the surgery, had a mean articular range of motion with active abduction of 90 degrees and about 100 degrees with passive abduction. Postoperative CS scores at 12 months follow-up was 75,47±8.02. In addition there was also significant (P<0.05) improvement between preoperative and postoperative visual analog scale measurements (in cm), 7.67±2.70 and 1.71±2.08, respectively. This technique has shown good functional results with reduced surgical risks and complications that are typical of open reduction surgical fixation of proximal humerus fractures, is quick in execution and minimally invasive. Given the very good results of the study of this new external fixation technique has shown to be a viable option for the treatment of proximal humerus fractures.

An early-senescence state in aged mesenchymal stromal cells contributes to hematopoietic stem and progenitor cell clonogenic impairment through the activation of a pro-inflammatory program.

Hematopoietic stem and progenitor cells (HSPC) reside in the bone marrow (BM) niche and serve as a reservoir for mature blood cells throughout life. Aging in the BM is characterized by low-grade chronic inflammation that could contribute to the reduced functionality of aged HSPC. Mesenchymal stromal cells (MSC) in the BM support HSPC self-renewal. However, changes in MSC function with age and the crosstalk between MSC and HSPC remain understudied. Here, we conducted an extensive characterization of senescence features in BM-derived MSC from young and aged healthy donors. Aged MSC displayed an enlarged senescent-like morphology, a delayed clonogenic potential and reduced proliferation ability when compared to younger counterparts. Of note, the observed proliferation delay was associated with increased levels of SA-ß-galactosidase (SA-ß-Gal) and lipofuscin in aged MSC at early passages and a modest but consistent accumulation of physical DNA damage and DNA damage response (DDR) activation. Consistent with the establishment of a senescence-like state in aged MSC, we detected an increase in pro-inflammatory senescence-associated secretory phenotype (SASP) factors, both at the transcript and protein levels. Conversely, the immunomodulatory properties of aged MSC were significantly reduced. Importantly, exposure of young HSPC to factors secreted by aged MSC induced pro-inflammatory genes in HSPC and impaired HSPC clonogenic potential in a SASP-dependent manner. Altogether, our results reveal that BM-derived MSC from aged healthy donors display features of senescence and that, during aging, MSC-associated secretomes contribute to activate an inflammatory transcriptional program in HSPC that may ultimately impair their functionality.

GH prevents adipogenic differentiation of mesenchymal stromal stem cells derived from human trabecular bone via canonical Wnt signaling.

The imbalance between osteogenesis and adipogenesis, which naturally accompanies bone marrow senescence, may contribute to the development of bone-associated diseases, like osteoporosis. In the present study, using primary human mesenchymal stromal cells (hMSCs) isolated from trabecular bone, we assessed the possible effect of GH on hMSC differentiation potential into adipocytes. GH (5 ng/ml) significantly inhibited the lipid accumulation in hMSCs cultured for 14 days in lipogenic medium. GH decreased the expression of the adipogenic genes, CCAAT/enhancer-binding protein alpha (C/EBPα) and adiponectin (ADN) as well as the expression of two lipogenesis-related enzymes, lipoprotein lipase (LPL) and acethylCoA carboxylase (ACACA). In parallel, GH induced an increase in the gene expression and protein levels of osterix (OSX) and osteoprotegerin (OPG). These effects were ascribed to enhanced Wnt signaling as GH significantly reduced Wnt inhibitors, Dickkopf 1 (DKK1) and the secreted frizzled protein 2 (SFRP2), and increased the expression of an activator of Wnt, Wnt3. Accordingly, the expression of ß-catenin and its nuclear levels were raised. Wnt involvement in GH anti-adipogenic effect was further confirmed by the silencing of ß-catenin. In silenced hMSC, both the inhibitory effect of GH on the expression of the adipogenic genes, ADN and C/EBPα and the lipogenesis enzymes LPL and ACACA, were prevented together with the stimulatory effect of GH on the osteogenic genes OSX and OPG. The present study supports the hypothesis that when GH secretion declines as in aging, the fat in the bone-marrow cavities increases and the osteogenic capacity of the MSC pool is reduced due to a decrease in Wnt signaling.

Bone Marrow Edema Syndrome of the Medial Femoral Condyle Treated With Extracorporeal Shock Wave Therapy: A Clinical and MRI Retrospective Comparative Study.

OBJECTIVE: To determine the validity of extracorporeal shock wave therapy (ESWT) in the treatment of bone marrow edema (BME) of the medial condyle of the knee. DESIGN: Retrospective. SETTING: Orthopedic Surgery outpatient clinic. PARTICIPANTS: Symptomatic patients (N=56) affected by BME of the medial condyle of the knee. Patients were equally divided into an ESWT-treated group and a control group, which was managed conservatively. INTERVENTIONS: ESWT delivery to the medial condyle of the affected knee. MAIN OUTCOME MEASURES: Clinical and functional assessment of the knee was performed with the use of the clinical and functional scores of the Knee Society Score (KSS). Pain was measured with the visual analog scale (VAS). BME area was measured with magnetic resonance imaging (MRI) before treatment and at 4 months' follow-up. RESULTS: Clinical evaluation of patients at final follow-up of 4 months posttreatment showed a significant improvement (P<.0001) of symptoms and knee functionality, both for range of motion and strength in both groups. VAS values were significantly improved (P<.0001) in both groups, with 3 patients in the ESWT group being pain-free (VAS=0) at 4 months' follow-up. At 4 months, MRI assessments on both sagittal and coronal views showed a significant reduction in BME in the ESWT group compared with the control group. CONCLUSIONS: Our findings show that ESWT is a valid nonpharmacologic and noninvasive therapy for spontaneous BME of the medial condyle that improves the affected vascular and metabolic state present in this pathologic disorder through its metabolic mechanisms of action.

Thoracic Outlet Syndrome in the Overhead Athlete: A Report of 2 Cases of Subclavius Posticus Muscle.

Subclavius posticus muscle is a supernumerary anatomical variation of the subclavius muscle. The aim of this study was to show the possible contribution of the posticus muscle in the development of unilateral thoracic outlet syndrome (TOS) in overhead athletes, presenting hypertrophy of the dominant arm due to their sport activity. Reported here are 2 young overhead athletes complaining pain, paresthesia, weakness in the dominant upper limb, although presenting none of the main shoulder and neurological disorders. After developing subclavian vein thrombosis, TOS was suspected and finally diagnosed by dynamic magnetic resonance angiography, which also showed bilateral subclavius posticus muscle in both patients. Despite bilateral subclavius posticus, TOS was only evident in the dominant limb in which the association of hypertrophy of lateral cervical muscles, resulting from the overhead sport activity, to the subclavius posticus likely led to a significant reduction of the upper thoracic outlet space.

Dupuytren's Disease: Predicting Factors and Associated Conditions. A Single Center Questionnaire-Based Case-Control Study.

BACKGROUND: Conflicting studies link several conditions and risk factors to Dupuytren's disease (DD). A questionnaire-based case-control study was set to investigate associated conditions and clinical features of DD in a sample of Italian patients. The main purpose was the identification of predicting factors for: DD development; involvement of multiple rays; involvement of both hands; development of radial DD; development of recurrences and extensions. METHODS: A self-administered questionnaire was used to investigate medical and drug histories, working and life habits, DD clinical features, familial history, recurrences and extensions. Binary logistic regression, Mann Whitney U-test and Fisher's exact test were used for the statistical analysis. RESULTS: A role in DD development was found for male sex, cigarette smoking, diabetes and heavy manual work. The development of aggressive DD has been linked to age, male sex, high alcohol intake, dyslipidemias and positive familial history. CONCLUSION: Further studies might explain the dual relationship between ischemic heart disease and DD. According to our results, the questionnaire used for this study revealed to be an easy-handling instrument to analyze the conditions associated to DD. Nevertheless, its use in further and larger studies is needed to confirm our results as well as the role of the questionnaire itself as investigation tool for clinical studies.

Evidence for Altered Canonical Wnt Signaling in the Trabecular Bone of Elderly Postmenopausal Women with Fragility Femoral Fracture.

Wnt signaling, a major regulator of bone formation and homeostasis, might be involved in the bone loss of osteoporotic patients and the consequent impaired response to fracture. Therefore we analyzed Wnt-related, osteogenic, and adipogenic genes in bone tissue of elderly postmenopausal women undergoing hip replacement for either femoral fracture or osteoarthritis. Bone specimens derived from the intertrochanteric region of the femurs of 25 women with fracture (F) and 29 with osteoarthritis without fracture (OA) were analyzed. Specific miRNAs were analyzed in bone and in matched blood samples. RUNX2, BGP, and OPG showed lower expression in F than in OA samples, while OSX, OPN, BSP, and RANKL were not different. Inhibitory genes of Wnt pathway were lower in F versus OA. ß-Catenin protein levels were higher in F versus OA, whereas its cotranscriptional regulator (Lef1) was lower in F group. miR-204, which targets RUNX2, and miR-130a, which inhibits PPARγ, were lower and higher, respectively, in F versus OA serum samples. The present study showed an inefficient Wnt signal transduction in F group despite higher ß-catenin protein levels, consistent with the expected overall postfracture systemic activation towards osteogenesis. This transcriptional inefficiency could contribute to the osteoporotic bone fragility.

Our Totally Intra-Articular "Needle-Anchor" Tenodesis Technique Applied in Isolated Long Head of the Biceps Tendinopathy: Clinical and Functional Results in 60 Patients.

BACKGROUND: The disorders of the long head of the biceps (LHB) are a common cause of shoulder pain. Among all surgical treatments used to resolve LHB tendon disorders, tenodesis is one of the most frequent.The literature describes many arthroscopic and open surgical techniques, but there is still no general consensus on the standard of care.The purpose of this paper is to describe the clinical and functional outcomes of our totally intra-articular "Needle-Anchor" arthroscopic tenodesis technique applied to isolated LHB tendinopathy. MATERIALS AND METHODS: We present a case study of 60 patients with an isolated LHB tendon disorder, treated with our totally intra-articular Needle-Anchor arthroscopic technique between 2011 and 2013.All patients were assessed preoperatively with University of California, Los Angeles (UCLA) and Constant-Murley (CS) shoulder scores and the visual analogue scale (VAS) for subjective pain assessment. Imaging studies were performed through magnetic resonance imaging. Patients were reevaluated with a follow-up at 3 and 12 months with VAS, UCLA, and CS scores.Statistical analysis was performed with the Mann-Whitney score where values of P<0.05 were considered as significant. RESULTS: CS showed a significant (P<0.05) improvement at 3 and 12 months follow-up, 81.54 ± 7.5 and 88.90 ± 5.2, respectively; when compared with preoperative values of 55.14 ± 9.8.Moreover, the UCLA score showed significant improvement (P<0.05) at the same follow-ups with values of 28.49 ± 2.1 and 30.88 ± 1.7, respectively, with preoperative scores of 14.03 ± 2.4.VAS values were significant at both follow-ups, 2.54 ± 0.2 and 0.58 ± 0.08, respectively, when compared with preoperative values of 5.34 ± 0.3. CONCLUSIONS: Biceps tenodesis performed with our Needle-Anchor technique applied to selected patients affected by isolated LHB pathology demonstrated to be effective both in terms of pain and functionality. Moreover, the described technique proved to be reliable, safe, time efficient, easily reproducible, and preserving cosmesis.

Vascular graft employment in the surgical treatment of acute and chronic acromio-clavicular dislocation.

OBJECTIVES: To show the efficiency and safety of a surgical treatment in both acute and chronic acromio-clavicular junction (ACJ) dislocations. DESIGN: Retrospective. SETTING: Department of Orthopedics and Traumatology at IRCCS San Raffaele Hospital. PATIENTS/PARTICIPANTS: This study was performed on 37 subjects classified as Rockwood grade III-V or Tossy III ACJ dislocation. PROCEDURE: The surgical treatment was carried out by placing a vascular graft (GorePropaten(®)) between the tip of the coracoid process and the mid-lateral side of the clavicle with two temporary percutaneous K-wires positioned in a parallel manner in the AC ligament through the acromion and clavicle for 30 days to improve stability. MAIN OUTCOME MEASUREMENTS: Outcomes were assessed using the Constant Shoulder (CS) score, DASH score, subjective satisfaction, and stability of AC joint at 24 months. UCLA scores taken preoperatively and at 15-month follow-up were used to perform statistical analysis significance using a control group treated conservatively. Postoperative X-rays were examined to assess joint stability after 24 months. RESULTS: Preoperative CS score was 51 ± 12 in the acute group and 55 ± 15 in the chronic group. Follow-up mean CS score was 88 ± 11 in the acute group and 82 ± 20 in the chronic group at 24 months. Preoperative DASH score was 19 ± 3 in the acute group and 14 ± 5 in the chronic group. Mean DASH score was 3.60 ± 7 in the acute group and 6.42 ± 6 in the chronic group. Preoperative UCLA scores were 14.6 ± 2 and 15 ± 7 in the acute group and chronic group, respectively. At 15-month follow-up, UCLA scores of 28.1 ± 1.9 and 27.7 ± 1 in the acute and chronic group, respectively, showed a significant improvement (p < 0.05) compared with UCLA scores taken preoperatively and at 15 months in the control group treated conservatively of 15.8 ± 0.9 and 16.2 ± 0.9, respectively. Results were good to excellent in 10 patients from the acute group and 23 patients from the chronic group who presented clinical stability of the AC joint without pain. Postoperative radiography showed anatomical repositioning of the ACJ and joint stability in 35 cases, but only two patients showed a partial re-dislocation at the 24-month X-ray follow-up. No infections, either deep or superficial, or nerve palsies were reported. CONCLUSIONS: Given the results obtained during the study and the response of the patients in both acute and chronic groups, the authors found that the employment of a vascular graft combined with temporary percutaneous K-wires is able to improve the patient's clinical outcome following an acromio-clavicular joint dislocation.

Employment of synthetic patch with augmentation of the long head of the biceps tendon in irreparable lesions of the rotator cuff: our technique applied to 60 patients.

BACKGROUND: The aim of our study was to evaluate the effectiveness of both clinical and functional benefits after the surgical repair of the rotator cuff in irreparable lesions using a synthetic patch with augmentation of the long head of the biceps (LHB) tendon. METHODS: This is a retrospective study analysis of a randomized series of 60 patients (45 women and 15 men; average age 66 y) who underwent open repair of irreparable rotator cuff tear with synthetic patch using LHB tendon augmentation between 1999 and 2008.The inclusion criteria were: patients painful symptomatology, presenting a deficit in elevation, who are not responsive to physiotherapy, irreparable tear size, minimum follow-up of 36 months after surgery, and active and motivated patients. We used a control group of 60 patients treated without employment of the synthetic patch and LHB tendon augmentation.Patients were evaluated preoperatively and after 36 months with a Visual Analog Scale (VAS) and the University of California, Los Angeles (UCLA) shoulder rating scale and by measuring elevation of the scapular plane and strength with a dynamometer. All the patients were assessed preoperatively also with plain radiographs (anteroposterior and axillary views), ultrasound, and NMRI of the shoulder. The VAS and UCLA scores were also obtained 3 months postoperatively. Tendon integrity was assessed after 1 year by NMRI. Statistical analysis was conducted by 1-way analysis of variance between groups of treatment, with Dunnett post hoc correction for multiple comparisons. P-values ≤ 0.05 were considered as statistically significant. This surgical technique consisted in a short deltoid splitting, irreparable lesion evaluation, and, after tenodesis, the proximal segment of the LHB tendon was sutured to the remaining cuff tendons to fill the gap of the corresponding lesion. To shield the repaired rotator cuff we inserted a synthetic patch. RESULTS: Satisfactory results were achieved in 52 of the patients treated with this procedure; after 3 months the mean VAS was 6.85 ± 1.11 versus 4.9 ± 0.9, whereas the mean UCLA was 11.28 ± 1.43 versus 20.85 ± 1.27, respectively, for control and prolene group. After 36 months the mean VAS was 3.7 ± 1.01 versus 3.23 ± 1.07, whereas the mean UCLA was 14.73 ± 1.96 versus 24.6 ± 3.3, respectively, for control and prolene group. In addition, after 36 months elevation on the scapular plane was 140.75 ± 10.48 degrees versus 174.75 ± 8.1 degrees and abduction strength was 8.57 kg ± 0.63 versus 13.61 kg ± 0.84, respectively, for control and prolene group (P-value = 0.005). Re-tear rate after 12 months was 40% (24/60) in the control group and 15% (9/60) in the prolene group. No adverse side effects (infection, rejection, allergy) were reported during the study period. CONCLUSIONS: The results of our study suggest that employing this surgical technique in patients (appropriately selected) with an irreparable rotator cuff tear can lead to pain relief and improved clinical outcome.

The benefit of synthetic versus biological patch augmentation in the repair of posterosuperior massive rotator cuff tears: a 3-year follow-up study.

BACKGROUND: Rotator cuff repair typically results in a satisfactory, although variable, clinical outcome. However, anatomic failure of the repaired tendon often occurs. HYPOTHESIS: Patch augmentation can improve the results of open rotator cuff repair by supporting the healing process, protecting the suture, and reducing friction in the subacromial space. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 152 patients with a posterosuperior massive rotator cuff tear were treated by open repair only (control group; n = 51; mean age, 67.06 ± 4.42 years), open repair together with collagen patch augmentation (collagen group; n = 49; mean age, 66.53 ± 5.17 years), or open repair together with polypropylene patch augmentation (polypropylene group; n = 52; mean age, 66.17 ± 5.44 years) and were retrospectively studied. Patients were evaluated preoperatively and after 36 months with a visual analog scale (VAS) and the University of California, Los Angeles (UCLA) shoulder rating scale and by measuring elevation of the scapular plane and strength with a dynamometer. The VAS and UCLA scores were also obtained 2 months postoperatively. Tendon integrity was assessed after 1 year by ultrasound. Patients were homogeneous as per the preoperative assessment. RESULTS: After 2 months, results (mean ± standard deviation) for the control, collagen, and polypropylene groups, respectively, were as follows: VAS scores were 6.96 ± 1.11, 6.46 ± 1.02, and 4.92 ± 0.90, while UCLA scores were 11.29 ± 1.46, 11.40 ± 1.51, and 19.15 ± 1.99. After 36 months, the mean scores for the respective groups were 3.66 ± 1.05, 4.06 ± 1.02, and 3.28 ± 1.10 for the VAS and 14.88 ± 1.98, 14.69 ± 1.99, and 24.61 ± 3.22 for the UCLA scale. In addition, after 36 months, elevation on the scapular plane was 140.68° ± 9.84°, 140.61° ± 12.48°, and 174.71° ± 8.18°, and abduction strength was 8.73 ± 0.54 kg, 9.03 ± 0.60 kg, and 13.79 ± 0.64 kg for the control, collagen, and polypropylene groups, respectively. The retear rate after 12 months was 41% (21/51) for the control group, 51% (25/49) for the collagen group, and 17% (9/52) for the polypropylene group. In particular, the reduced 12-month retear rate and the increased UCLA scores, abduction strength, and elevation at 3-year follow-up were statistically significant for patients treated with a polypropylene patch compared with those treated with repair only or with a collagen patch. CONCLUSION: Polypropylene patch augmentation of rotator cuff repair was demonstrated to significantly improve the 36-month outcome in terms of function, strength, and retear rate.

17ß-Estradiol positively modulates growth hormone signaling through the reduction of SOCS2 negative feedback in human osteoblasts.

Recent evidence demonstrated an interplay between estrogens and growth hormone (GH) at cellular level. To investigate the possible mechanism/s involved, we studied the effect of 17ß-estradiol (E2) on GH signaling pathways in primary culture of human osteoblasts (hOBs). Exposure of hOBs to E2 (10(-8) M) 60 min before GH (5 ng/ml) significantly increased phosphorylated STAT5 (P-STAT5) levels compared with GH alone. E2 per se had no effect on P-STAT5. E2-enhanced GH signaling was effective in increasing osteopontin, bone-sialoprotein, and IGF II mRNA expression to a greater extent than GH alone. We then studied the effect of E2 on the protein levels of the negative regulator of GH signaling, suppressor of cytokine signaling-2 (SOCS2). E2 (10(-11) M-10(-7) M) reduced dose-dependently SOCS2 protein levels without modifying its mRNA expression. The silencing of SOCS2 gene prevented E2 positive effect on GH induced P-STAT5 and on GH induced bone-sialoprotein and osteopontin mRNA expression. Treatment with the inhibitor of DNA-dependent RNA synthesis, actinomycin-D, did not prevent E2 induced decrease of SOCS2, thus suggesting a non-genomic effect. E2 promoted an increase in SOCS2 ubiquitination. To determine if increased ubiquitination of SOCS2 by E2 led to degradation by proteasome, hOBs were pretreated with the proteasome inhibitor MG132 (5 µM) which blocked E2 reduction of SOCS2. These findings demonstrate for the first time that E2 can amplify GH intracellular signaling in hOBs with an essential role played by the reduction of the SOCS2 mediated feedback loop.

Fibrin-based model for cartilage regeneration: tissue maturation from in vitro to in vivo.

One of the crucial points for a successful tissue-engineering approach for cartilage repair is represented by the level of in vitro maturation of the engineered tissue before implantation. The purpose of this work was to evaluate the effect of the level of in vitro maturation of engineered cartilaginous samples on the tissue quality after in vivo implantation. Samples were obtained from isolated swine articular chondrocytes embedded in fibrin glue. The cell-fibrin composites were either cultured in vitro or directly implanted in vivo for 1, 5, and 9 weeks. Other experimental samples were precultured for either 1 or 5 weeks in vitro and then implanted in vivo for 4 additional weeks. All the samples were analyzed by histology, immunohistochemistry, biochemistry, and gene expression. The results strongly suggest that the in vivo culture in this model promoted a better tissue maturation than that obtained in the in vitro condition, and that 1 week in vitro preculture resulted in the primary structuring of the engineered composites and their subsequent maturation in vivo, without affecting the cell viability and activity, while a prolonged in vitro preculture caused a cell and matrix degeneration that could not be rescued in vivo.

Surgical treatment of thoracic outlet syndrome in young adults: single centre experience with minimum three-year follow-up.

Thoracic outlet syndrome is an often misdiagnosed syndrome which consists of a neurovascular compression at the upper thoracic outlet. The clinical presentation can be variable, ranging from mild symptoms to venous thrombosis and muscle atrophy. Many aetiologies, both congenital and acquired, related either to bony or soft tissue anomalies, have been associated with this syndrome. As a consequence, the diagnosis is often challenging and sometimes it can be obtained only with surgical exploration. Additionally, no specific clinical test is considered diagnostic of thoracic outlet syndrome. However, the recent advances in imaging techniques together with a careful clinical evaluation give the surgeon the chance to recognize the constricting anatomy before surgery in many cases. No standard surgical procedure has been identified; however, in literature the largest series have been treated with transaxillary first rib resection. Here we report our experience in the surgical treatment of this syndrome with a minimum follow-up of three years. Our approach consists of performing a supraclavicular decompression without routine first rib resection. This allows for identifying and removing the constricting anatomy in most cases, with satisfactory results in 96.9% of patients and a low complication rate.

Pseudoaneurysm overlying an osteochondroma: a noteworthy complication.

Pseuodaneurysms are an extremely rare complication of osteochondromas. We describe a case of traumatic pseudoaneurysm of the brachial artery presenting as a soft tissue mass in a patient who was treated for an osteochondroma 3 years earlier. This case demonstrates that radiographic follow-up of large osteochondromas is mandatory and that, in patients with soft tissue masses and a history of osteochondroma, pseudoaneurysms should be included in the differential diagnosis.

Surgical treatment of chronic acromioclavicular dislocation: comparison between two surgical procedures for anatomic reconstruction.

INTRODUCTION: Surgical treatment of chronic complete acromioclavicular (AC) joint dislocation is still debated and no gold standard surgical procedure has been identified. MATERIALS AND METHODS: A retrospective series of 90 patients treated for AC dislocations is reported here. Patients were divided into three groups: group 1 receiving AC reconstruction with a Dacron vascular prosthesis; group 2 receiving AC reconstruction with LARS(®) artificial ligament; group 3 receiving conservative treatment. Follow-up was performed after 1, 6 and 15 months with plain radiographs, UCLA, SPADI and modified UCLA acromioclavicular rating scales. RESULTS: Patients treated surgically presented significant better functional outcome compared to patients treated conservatively with overall positive results in 93.3% of patients for group 2 and 53.3% of patients for group 1. However, reconstruction with Dacron vascular prosthesis presented an unacceptable high complications rate (43.3%). CONCLUSION: Our results show that anatomic AC reconstruction with LARS(®) artificial ligament resulted in both satisfactory functional outcome and low complication rate. Therefore, we recommend this procedure for the treatment of chronic complete AC dislocations.

Calcitonin gene-related peptide (CGRP) inhibits apoptosis in human osteoblasts by ß-catenin stabilization.

Transgenic mice over-expressing calcitonin gene-related peptide (CGRP) in osteoblasts have increased bone density due to increased bone formation, thus suggesting that CGRP plays a role in bone metabolism. In this study we determined the relationship between CGRP, the canonical Wnt signaling and apoptosis in human osteoblasts (hOBs) in consideration of the well-documented involvement of this pathway in bone cells. Primary cultures of hOBs were treated with CGRP 10(-8) M. Levels of ß-catenin, which is the cytoplasmic protein mediator of canonical Wnt signaling, and mRNA were determined. CGRP increases both the expression and the levels of cytoplasmic ß-catenin by binding to its receptor, as this effect is blocked by the antagonist CGRP(8-37). This facilitatory action on ß-catenin appears to be mediated by the inhibition of the enzyme GSK-3ß via protein kinase A (PKA) activation. GSK-3ß is a glycogen synthase kinase that, by phosphorylating ß-catenin, promotes its degradation by the proteosomal machinery. Moreover, the peptide is able to inhibit hOBs apoptosis stimulated by dexamethasone or by serum deprivation, possibly through the accumulation of ß-catenin, since the inhibitor of PKA activity H89 partially prevents the antiapoptotic effect of the peptide. In conclusion CGRP, released by nerve fibers, exerts its anabolic action on bone cells by stimulating canonical Wnt signaling and by inhibiting hOBs apoptosis, thus favoring local bone regeneration.

Effect of in vitro culture on a chondrocyte-fibrin glue hydrogel for cartilage repair.

Research in tissue engineering has been focused on articular cartilage repair for more than a decade. Some pioneristic studies involved the use of hydrogels such as alginate and fibrin glue which still possess valuable potential for cartilage regeneration. One of the main issues in cartilage tissue engineering is represented by the ideal maturation of the construct, before in vivo implantation, in order to optimize matrix quality and integration. The present study was focused on the effect of in vitro culture on a fibrin glue hydrogel embedding swine chondrocytes. We performed an evaluation of the immunohistochemical and biochemical composition and of the biomechanical properties of the construct after 1 and 5 weeks of culture. We noticed that chondrocytes survived in the fibrin glue gel and enhanced their synthetic activity. In fact, DNA content remained stable, while all indices of cartilage matrix production increased (GAGs content, immunohistochemistry for collagen II and safranin-o staining). On the other hand, the biomechanical properties remained steady, indicating a gradual substitution of the hydrogel scaffold by cartilaginous matrix. This demonstrates that an optimal preculture could provide the surgeon with a better engineered cartilage for implantation. However, whether this more mature tissue will result in a more efficient regeneration of the articular surface still has to be evaluated in future investigations.