Efficacy and Tolerability of Progen, a Nutritional Supplement Based on Innovative Plasma Proteins, in ACL Reconstruction: A Multicenter Randomized Controlled Trial.

BACKGROUND: New biologic strategies are arising to enhance healing and improve the clinical outcome of anterior cruciate ligament (ACL) reconstruction. PURPOSE: To evaluate the efficacy of a new oral nutritional supplement (Progen) that contains hydrolyzed collagen peptides and plasma proteins, a hyaluronic acid-chondroitin sulfate complex, and vitamin C. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: The study included patients who underwent ACL reconstruction with hamstring autografts using the same fixation method. All patients received the same analgesia and physical therapy (PT) protocol and were randomized to receive either the nutritional supplement (supplemented group) or no additional therapy (control group). Patients were followed up at days 7, 30, 60, and 90. Pain was assessed by use of a visual analog scale (VAS) and by analgesic consumption. Clinical outcome was assessed via International Knee Documentation Committee (IKDC) score and the number of PT sessions. Perceived efficacy and tolerability were rated on a 5-point Likert scale. Graft maturation was assessed by a blinded musculoskeletal radiologist using magnetic resonance imaging. The number of adverse events (AEs) was recorded. RESULTS: The intention-to-treat analysis included 72 patients, 36 allocated to the supplemented group and 36 to the control group, with no significant differences regarding demographic and preoperative characteristics. Both groups showed significant improvement in pain and function (measured by VAS and IKDC scores) during the 90-day follow-up period (P < .001 for both), without significant differences between groups. The supplemented group had fewer patients that needed analgesics (8.5% vs 50.0%; P < .05) and attended fewer PT sessions (38.0 vs 48.4 sessions; P < .001) at 90 days and had a higher IKDC score at 60 days (62.5 vs 55.5; P = .029) compared with the control group. Patient- and physician-perceived efficacy was considered significantly higher in the supplemented group at 60 and 90 days (P < .05). Perceived tolerability of the overall intervention was better in the supplemented group at 30, 60, and 90 days (P < .05). Graft maturation showed more advanced degrees (grades 3 and 4) in the supplemented group at 90 days (61.8% vs 38.2%; P < .01). No intolerance or AEs associated with the nutritional supplement treatment were reported. CONCLUSION: The combination of the nutritional supplement and PT after ACL reconstruction improved pain, clinical outcome, and graft maturation. Nutritional supplementation showed higher efficacy during the second month of recovery, without causing AEs. REGISTRATION: NCT03355651 (ClinicalTrials.gov identifier).

Quadriceps tendon autograft and platelet rich plasma injection to treat chronic Achilles tears-a minimum two-year follow-up.

BACKGROUND: The possibility of using a bone-tendon quadriceps tendon graft and platelet rich plasma (PRP) injection to enhance healing capability, to solve the defect created by stump retraction in chronic Achilles tendon ruptures was studied in a series of 8 patients. METHODS: A series of 8 patients studied prospectively and followed for more than 24 months is presented. Results were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) score, and evaluating pain, level of activity, footwear restrictions, and satisfaction. Statistical analysis was done by the sign test for matched pairs and Wilcoxon signed-rank test. Alpha error was set at 0.05. RESULTS: Preoperatively, patients showed an average AOFAS score of 77.25 (range, 67-88). After surgery, AOFAS score showed a marked improvement in all the cases, with an average of 95.6 (range, 87-100). Improvement in AOFAS score results was statistically significant, both for sign test for matched pairs (P=0.008) and for Wilcoxon signed-rank test (P=0.012). All of the patients were satisfied with the results of the procedure, and would undergo it again. CONCLUSIONS: Autologous quadriceps tendon graft (in bone-tendon configuration) has proved as a simple technique that offers good results to patients with tissue defects in the Achilles tendon.

Quadriceps autograft to treat Achilles Chronic tears: a simple surgical technique.

BACKGROUND: Chronic Achilles tendon tears could hinder patients and represent a challenge to surgeons. Although many different surgical techniques have been proposed for reconstruction of a neglected Achilles tendon rupture, there is no clear evidence to support one technique over the others, but the use of a technique that could allow for an "anatomical" reconstructions seems desirable. METHODS: The present paper describes a new anatomic Achilles tendon reconstruction for chronic tears, using a quadriceps tendon autograft as graft source, with PRP injected into the graft and the neighbor tissue, and fixation in a bone trough with a simple small fragments screw. RESULTS: Autologous quadriceps tendon graft seems an excellent option, although -surprisingly- has received little attention until now. CONCLUSIONS: Autologous Quadriceps tendon graft (in bone-tendon configuration) is a simple technique that could allow surgeons to reconstruct tissue defects in the Achilles tendon with non-expensive hardware.

Initial evaluation of posterior cruciate ligament injuries: history, physical examination, imaging studies, surgical and nonsurgical indications.

Compared with anterior cruciate ligament injuries, posterior cruciate ligament injuries are a rare event. The mechanisms are predictable and a thorough physical examination is mandatory to rule out or define combined injury patterns. Stress radiography and magnetic resonance imaging studies are very helpful adjuncts. Acute and chronic injuries require slightly different approaches. As our understanding of normal and pathologic knee joint kinematics develops, nonoperative rehabilitation goals and operative techniques continue to evolve.

Does the upward migration index predict function and quality of life in arthroscopic rotator cuff repair?

BACKGROUND: Although upward humeral head migration is a well-recognized phenomenon in patients with tears of the cuff, it is unclear whether it relates to patient function after cuff repair. The upward migration index (UMI) assesses proximal migration of the humeral head while controlling for patients' bony morphologic features. QUESTIONS/PURPOSES: We asked whether functional and quality-of-life (QOL) improvement occurs longitudinally in patients with low, moderate, or high degrees of proximal humeral migration after arthroscopic cuff repair and whether differences occur between groups. PATIENTS AND METHODS: We retrospectively reviewed 118 patients with full-thickness tears treated by arthroscopic cuff repair. Patients were divided into three groups depending on the severity of preoperative proximal humeral migration seen on MRI. We determined function using two functional scores and the Western Ontario Rotator Cuff Index (a QOL index). Evaluations were performed preoperatively and 6 and 12 months postoperatively. A general linear model analysis controlled for patient characteristics, including the UMI, to determine their effects on functional and QOL scores. RESULTS: Function and QOL improved after surgery in all three groups. The UMI did not correlate with final functional or QOL scores. Six-month functional and QOL scores correlated with final scores. The best predictor of final strength was initial strength. CONCLUSIONS: Preoperative UMI did not correlate with functional or QOL improvements after surgery. The data suggest substantial proximal migration of the humeral head, as measured by the UMI, should not be considered a contraindication to arthroscopic rotator cuff repair.

The use of platelet-rich plasma in arthroscopy and sports medicine: optimizing the healing environment.

Platelet-rich plasma (PRP) is a new technology focused on enhancing the healing response after injury of different tissue types. PRP is prepared by withdrawal of patients' peripheral blood and centrifugation to obtain a highly concentrated sample of platelets, which undergo degranulation to release growth factors with healing properties. It also contains plasma, cytokines, thrombin, and other growth factors that are implicated in wound healing and have inherent biological and adhesive properties. The prepared concentrate is then injected back into the patient at the site of morbidity. This may be intralesional, intra-articular, or surrounding the involved tissue bed. PRP preparations have been used therapeutically in various medical fields from implantology to vascular ulcers, with a more recent evolution and promising results in the field of sports medicine and arthroscopy. Sports medicine patients desire a rapid return to their preinjury level of function, and PRP may have certain applications that will speed recovery in cases of tendon, ligament, muscle, and cartilage disorders. In particular, anterior cruciate ligament reconstruction has shown better autograft maturation, improved donor site morbidity, and pain control, in addition to improved allograft incorporation. By acceleration of the biological integration of the graft by use of PRP, patients may undergo faster, more intensive rehabilitation programs and return to sports more rapidly. Because of its autogenous origin, easy preparation, and excellent safety profile, the advent of PRP has opened another therapeutic door for sports medicine physicians and orthopaedic surgeons. Future directions of PRP include improving the results of arthroscopic and related surgery, in addition to delineating correct dosage, timing, and quantification, as well as ideal techniques of PRP application.

The future: optimizing the healing environment in anterior cruciate ligament reconstruction.

The therapeutic use of autologous platelet-rich plasma constitutes a breakthrough in the stimulation and acceleration of soft-tissue healing and bone regeneration. Platelet-rich technologies seek to facilitate anterior cruciate ligament replacement by mimicking the native tissue and improving the adequacy of tissue function with appropriate cues, ultimately leading to better patient care. There are different technical protocols for preparing platelet-rich plasma, and the resultant products are typically heterogeneous; moreover, protocols for administrating the products in patients vary extensively. Poor standardization in the field makes full evaluation of different plasma products and establishing standards for the most beneficial applications of this technology difficult. This article presents the current data on the use of platelet-rich plasma in the reconstruction of the anterior cruciate ligament. Although the findings are not conclusive, the use of autologous platelet-rich plasma is shown to be safe, reproducible, and effective in mimicking the natural processes of soft tissue and bone healing. Platelet-rich technologies offer new opportunities for research and the application of anterior cruciate ligament tissue engineering.

Biomechanical evaluation of 2 arthroscopic biceps tenodeses: double-anchor versus percutaneous intra-articular transtendon (PITT) techniques.

BACKGROUND: Recently, there is increasing interest in different arthroscopic biceps tenodesis techniques. However, little data have been published about the biomechanical properties of soft tissue tenodesis. PURPOSE: This study was undertaken to evaluate the biomechanical properties of 2 different arthroscopic biceps tenodeses: the percutaneous intra-articular transtendon (PITT) technique and the suture-anchor technique. STUDY DESIGN: Controlled laboratory study. METHODS: Fifteen fresh-frozen cadaveric specimens were randomly allocated to the 2 different biceps tenodesis techniques. The humerus with biceps tenodesis was mounted on a materials testing machine to perform a load to failure test. The structural properties including ultimate load (N) and stiffness (N/mm) were derived from the load-displacement curve. The mode of failure was also recorded. Ultimate load and stiffness were compared with the parametric Student t test. RESULTS: Both repairs showed typical load-displacement curves followed by a constant increase in load and displacement until failure occurred. Suture-anchor and PITT techniques had ultimate loads of 175.4 +/- 40.4 N and 142.7 +/- 30.9 N (P = .10) and stiffness of 15.9 +/- 8.4 N/mm and 13.3 +/- 3 N/mm (P = .36), respectively, with no significant differences between them. All of the surgical constructs failed in the tendon site by pulling out with the sutures through the substance of the tendon. CONCLUSION: The suture-anchor and PITT techniques exhibited satisfactory initial strength with no statistical difference between the 2 groups. These findings, along with the consistent pullout of the suture through the tendon during failure, suggest that the most important factor for initial strength is not the attachment site but the quality of the biceps tendon. CLINICAL RELEVANCE: The quality of the tendon should be taken into account when deciding the surgical technique and the rehabilitation program. The PITT technique has the benefit of avoiding hardware complications and cost.

Evolving concepts in tunnel placement.

Tunnel placement in anterior cruciate ligament reconstruction has continued to evolve over time. The aim of this article is to review this evolution and comment on the senior author's current preferred technique. Initially, tunnels were dependent on the technique available, and isometry was felt to be important. Now, trying to reproduce the anatomy is preferred. Surgical technique has evolved from open surgery, with large anterior approaches, to arthroscopic two-incision outside-in techniques. After that, the evolution has led to the transtibial technique with one incision, then back to two incisions using the anteromedial portal, and finally, no incisions with the "all-inside technique." Anatomic, biomechanical, and clinical studies have shown that using the footprint as the site for tunnels restores the native anterior cruciate ligament kinematics and controls not only anteroposterior translation, but also rotational motion. Surgeons should evolve their techniques, as science does, to improve results and give better care to their patients.

Experimental model in cadavera of arthroscopic resection of calcaneonavicular coalition and its first in-vivo application: preliminary communication.

Open surgical resection of calcaneonavicular coalition is indicated after the failure of conservative treatment. Our objectives are to develop the arthroscopic surgical technique and to check the feasibility of the arthroscopic resection of the calcaneonavicular coalition. We designed and performed endoscopic resection of the calcaneonavicular ligament and part of the anterior process of calcaneus as a simulation of the coalition resection on four cadaver specimens. After this procedure, we successfully performed the first resection in a 12-year-old girl, without any soft tissue interposition. American Orthopaedic Foot and Ankle Society Hindfoot Scale was 55 before surgery, 98 after 10 weeks, and 100 after 2 years without recurrence.

Genetics of pheochromocytoma and paraganglioma in Spanish patients.

CONTEXT: The presence of familial history in pheochromocytoma/paraganglioma patients, including syndromic antecedents, leads in the majority of cases to a positive genetic testing for mutations in one of the major susceptibility genes described so far. Furthermore, it has been reported that in the absence of familial antecedents, about 11-24% of patients also carry a mutation in one of these related genes. In these cases, other clinical aspects like bilaterality, multiplicity, location of the tumors, or age at onset can help to recognize the underlying genes involved. OBJECTIVE: The objective of the study was to discuss clinical criteria helpful in the genetic diagnosis, placing special emphasis on apparently sporadic cases. DESIGN: Two hundred thirty-seven nonrelated probands were analyzed for the major susceptibility genes: VHL, RET, SDHB, SDHC, and SDHD. Genetic characterization included both point mutation analysis and gross deletions in the SDH genes performed by multiplex PCR. RESULTS: As expected, all syndromic probands were genetically diagnosed with a mutation affecting either RET or VHL. A total of 79.1% (19 of 24) and 18.4% (31 of 168) of patients presenting with either nonsyndromic familial antecedents or apparently sporadic presentation were found to carry a mutation in one of the susceptibility genes. Finally, we found a Spanish founder effect for two mutations: SDHB c.166_170delCCTCA and SDHD c.129G>A. CONCLUSIONS: Germline mutations are rare in apparently sporadic probands diagnosed after age 40 yr (3.9% in our series) and mainly involve SDHB. Therefore, we recommend prioritizing SDHB genetic testing in patients developing isolated tumors at any age, especially those with extraadrenal location or malignant behavior.