Accuracy of femoral tunnel positioning in medial patellofemoral ligament reconstruction: anatomic insertion leads to better clinical outcome.

PURPOSE: The medial patello-femoral ligament (MPFL) is considered the primary restraint against patellar dislocation and its reconstruction is indicated in recurrent patellar instability. An anatomical positioning of MPFL femoral insertion is recommended to achieve satisfactory clinical outcomes and prevent osteoarthritis (OA) due to an altered kinematics. The purpose of the study was first to assess the relationship between correct femoral tunnel position and better clinical outcomes and lower patellofemoral osteoarthritis rate. Second, correlation of outcomes with factors potentially affecting the results, such as the type of graft, patellar height and trochlear dysplasia. METHODS: Fifty-three patients (58 knees) who underwent MPFL reconstruction between 2009 and 2018 by a senior knee surgeon were retrospectively evaluated. Knee radiographs were performed before surgery, 12 months later and at last follow-up to assess trochlear dysplasia, patellar height and patellofemoral OA. The tibial tuberosity-trochlear groove (TT-TG) value was measured on a CT scan. The accuracy of graft positioning was evaluated on sagittal radiographs according to Schöttle et al. Subjective outcomes were collected before surgery, at 12 months and at last follow-up using several validated scores. RESULTS: Forty-six patients (51 knees) with a mean age of 24.1 ± 7.4 years were included in the study. Mean follow-up was 8.9 ± 2.1 years. A significant improvement in all clinical scores was observed at 12 months and final follow-up. Anatomic Insertion (AI) of reconstructed MPFL was considered optimal in 33 (64.7%) and sub-optimal in 18 (35.3%) patients. Sub-optimal AI resulted in lower Kujala, IKCD and higher VAS score (p < 0.01); moreover, for every 1 mm distance in any direction from the ideal insertion, a decrease of 0.8 [95% CI (-1.4; -0.2)] in Kujala score and 0.8 [95% CI (-1.3; -0.3)] in IKDC was observed. At final follow-up, 8 patients presented patellofemoral OA Iwano grade 3 (15.7%): although that incidence did not correlate to graft positioning, the use the artificial ligament in all these cases appeared to be significant. CONCLUSION: The present study confirms the importance of an optimal anatomic femoral insertion in MPFL reconstruction, reporting a significant positive correlation between graft positioning and clinical outcome. No significant correlations were found between anatomic insertion and patello-femoral OA development. LEVEL OF EVIDENCE: IV.

A fast, easy and reliable method for hamstrings graft size prediction in anterior cruciate ligament reconstruction.

PURPOSE: The aim of this study is to describe and validate a simple and reliable method to pre-operatively predict the size of the ACL graft in the double strand technique with autologous semitendinosus-gracilis tendons on the same MRI used for ACL rupture diagnosis. METHODS: The study included 92 patients, with a median age of 31 years (IQR 26-41 years), 73/92 (79%) of whom were males. All patients that underwent an ACL reconstruction with doubled ST + GT between 2017 and 2022 were counted in the study. RESULTS: Overall, the median predicted graft diameter from MR imaging was similar to the actual graft diameter with no significant differences (n.s.). Regarding the comparison between predicted and actual graft size, concordance was 78/92 (85%, 95% CI 76-91%), with κ = 0.797 which corresponds to a level of agreement defined as "Strong". Tendon sizes calculated on pre-operative MRI were evaluated both with intra-observer and inter-observer reliability demonstrating a statistically reproducible method. The predicted graft was then compared to the reported one with a statistically significant reliability found. CONCLUSION: This study can help the surgeons to perform a fast pre-operative planning of an ACL reconstruction for graft selection. If the planned graft with ST and GT is smaller than 8 mm, the clinician can decide to switch to a different type of graft or plan a different graft preparing technique and, therefore, reduce the risk of post-operative ligament re-rupture. The method proposed is reliable and reproducible. The major strength of the planning technique proposed is that it relies on data that are already available for the clinician before surgery, without the need of further analysis. LEVEL OF EVIDENCE: IV.

Good clinical results using a modified kinematic alignment technique with a cruciate sacrificing medially stabilised total knee arthroplasty.

BACKGROUND: This study aims to evaluate the clinical and radiological outcomes of a modified technique of Kinematically Aligned Total Knee Arthroplasty (KA TKA) using a cruciate sacrificing (CS) medially stabilised prosthesis at a minimum 24-months follow-up. METHODS: 59 patients with a varus HKA angle who underwent a TKA from May, 2016 to April, 2017 were retrospectively enrolled. Radiological and clinical evaluations were assessed after 40 days, 6 months and at a minimum follow-up of 24 months. Long leg standing X-rays were performed pre-operatively and the Hip-Knee-Ankle (HKA) angle, the mechanical Lateral Distal Femoral Angle (mLDFA), the mechanical Medial Proximal Tibial Angle (mMPTA) and the Knee Joint Line Obliquity Angle (KJLOA) were analysed. At a minimum follow-up of 24 months, the patients were evaluated subjectively based on the Western Ontario and McMaster Universities Osteoarthritis Index Score (WOMAC) and the Oxford Knee Score (OKS). The post-operative range of motion (ROM) was measured. To reduce flexion instability, an original technique was used, with more posterior positioning of the femoral component, called the "virtuous mistake". Results were compared to the data reported in the literature in patients treated with standard kinematic alignment (KA) technique. RESULTS: No difference was found between the mean pre-operative and post-operative angles regarding mLDFA (p value = 0.410) and mMTPA (p value = 0.242). A difference of 0.8° in HKA angle between males and females was found, with more varus results in males. At a minimum follow-up of 24 months, the WOMAC was 87 (SD 4.3), the OKS was 41 (SD 2.4), and the flexion was 124°, which was similar to the data reported in literature with standard KA. There were not any cases of aseptic failures. CONCLUSIONS: The modified KA TKA surgical technique proposed in this study can achieve good clinical results at minimum 24 months of follow-up, reproducing accurately native mLDFA and mMPTA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Risk factors for post-operative shoulder stiffness: are there new candidates?

The aim of this study was to document the incidence of postoperative shoulder stiffness (SS) after arthroscopic rotator cuff repair and evaluate the role of risk factors for its development. Seventy-five consecutive patients that underwent arthroscopic rotator cuff repair were included. The incidence of postoperative SS was prospectively investigated and the presence of 20 potential risk factors was documented retrospectively. The incidence of post-operative SS was 10.4%. All patients were women, and sex was significantly associated to pathology development (p=0.0067). The presence of gastroesophageal diseases was found to be significantly associated with post-operative SS development (p=0.0046). A significant association between the occurrence of post-operative SS and the presence of gastroesophageal diseases was identified. This finding, not yet reported in literature, deserves further investigation. The incidence of postoperative SS fell among previously reported ranges, with females significantly more affected than men.

Open Latarjet versus arthroscopic Latarjet: clinical results and cost analysis.

PURPOSE: The aim of this study was to compare the clinical results between open and arthroscopic Latarjet and perform a cost analysis of the two techniques. MATERIALS AND METHODS: A systematic review of articles present in PubMed and MEDLINE was performed in accordance with PRISMA guidelines. Studies concerning post-operative outcomes following Latarjet procedures for chronic anterior shoulder instability were selected for analysis. The clinical and radiographic results as well as the costs of the open and arthroscopic techniques were evaluated. RESULTS: Twenty-three articles, describing a total of 1317 shoulders, met the inclusion criteria: 17 studies were related to open Latarjet, and 6 to the arthroscopic technique. Despite the heterogeneity of the evaluation scales, the clinical results seemed very satisfactory for both techniques. We detected a statistically significant difference in the percentage of bone graft healing in favour of the open technique (88.6 vs 77.6 %). Recurrent dislocation was more frequent following open surgery (3.3 % after open surgery vs 0.3 % after arthroscopy), but this finding was biased by the large difference in follow-up duration between the two techniques. The direct costs of the arthroscopic procedure were double in comparison to open surgery (€2335 vs €1040). A lack of data prevented evaluation of indirect costs and, therefore, a cost-effectiveness analysis. CONCLUSIONS: The open and arthroscopic Latarjet techniques showed excellent and comparable clinical results. However, the much higher direct costs of the arthroscopic procedure do not seem, at present, to be justified by a benefit to the patient. LEVEL OF EVIDENCE: III.

Why menisci show higher healing rate when repaired during ACL reconstruction? Growth factors release can be the explanation.

PURPOSE: Healing rate of meniscus repair is higher when the suture is associated with anterior cruciate ligament reconstruction. A possible explanation can be a different pattern of release of growth factors between anterior cruciate ligament reconstruction and isolated meniscus surgery. Hypothesis of this study is that the concentrations of bFGF, TGF-ß and platelet-derived growth factor (PDGF) in joint fluid, immediately after single-bundle anterior cruciate ligament reconstruction and arthroscopic partial meniscectomy, can be different. METHODS: Twenty consecutive patients underwent partial medial meniscectomy and twenty consecutive patients underwent single-bundle anterior cruciate ligament reconstruction with hamstring grafts were enrolled in the study. Thirty minutes after the end of the surgical procedure, a sample of joint fluid, as well of venous blood, was collected from all the patients. Concentrations of growth factors were determined by enzyme-linked immunosorbent assay. RESULTS: The peripheral blood concentration of TGF-ß, bFGF and PDGF was comparable between partial meniscectomy and anterior cruciate ligament reconstruction groups. No differences between the two surgical techniques were also found in term of TGF-ß and bFGF joint fluid concentration, whereas joint PDGF concentration of anterior cruciate ligament reconstruction patients was significantly higher than the one found in partial meniscectomy patients. CONCLUSIONS: A significant growth factors release was detected in the knee joint during arthroscopic surgery. PDGF concentration was significantly higher in anterior cruciate ligament reconstructed knee than in the meniscectomy group. PDGF can play an important role enhancing the healing response of meniscus suture and can be one of the biological reasons of the higher meniscal healing rate in anterior cruciate ligament reconstructed knee.

Regional migratory osteoporosis of the knee: a literature overview.

The purpose of this article is to review the clinical syndrome of regional migratory osteoporosis (RMO) of the knee and to highlight all the important aspects of diagnosis and management that can be helpful to the physician. RMO is a rare, self-limiting disease characterized by migrating arthralgia, bone marrow edema and osteoporosis. The pathogenesis of RMO remains controversial and is not yet fully elucidated. A thorough presentation of the disease is conducted with presentation of the clinical features (progressive pain and local tenderness), differential diagnosis and appropriate diagnostic criteria. The role of MRI is underlined and strategies for the treatment of RMO are presented.

Risk factors for recurrence after Bankart repair a systematic review.

PURPOSE: Arthroscopic Bankart repair of anterior shoulder instability is a common practice in orthopedics. The aim of this study was to evaluate pre-operative risks factors associated with recurrent instability and to delineate possible indications for revision surgery. METHODS: A systematic review was performed including the following keywords: arthroscopy, Bankart repair, anterior shoulder instability, recurrence of instability, suture anchors and treatment outcome. Studies eligible for inclusion in the review were clinical trials published in the last 10 years investigating patients with anterior shoulder instability managed by an arthroscopic repair technique with suture anchors. The studies had to report data about recurrence of instability and investigational parameters (risk factors) that influenced the results referred to the rate of recurrence. Twenty-four articles were identified that met the inclusion criteria and underwent further review. Data from these studies were collected, and the risk of treatment failure was statistically recalculated. An estimate of the overall recurrence rate was obtained by pooling data about failure from the trials. RESULTS: The rate of recurrent instability at 10 years of follow-up ranged from 3.4 to 35 %. Epidemiological parameters significantly associated with the recurrence of instability were age below 22 years old, male gender, the number of preoperative dislocations and participation in competitive sports. Surgical parameters significantly associated with recurrence of instability were repair with fewer than three anchors and the use of knotless anchors. The patho-anatomical factors significantly associated with recurrences were substantial associated glenoid or humeral head bone loss and the presence of anterior labroligamentous periosteal sleeve avulsion. CONCLUSIONS: Knowledge of risk factors for post-operative outcomes allows surgeons to provide appropriate preoperative counselling to patients and support more realistic expectations. An accurate analysis of causes of failure should enable the correct revision strategy to be adopted. LEVEL OF EVIDENCE: II.

Current practice in shoulder pathology: results of a web-based survey among a community of 1,084 orthopedic surgeons.

PURPOSE: The aim of this study was to report orthopedic surgeons' management of choice for difficult clinical scenarios of shoulder pathologies. METHODS: A web questionnaire was developed including four clinical scenarios of shoulder pathologies. Subsequently, opinions were solicited from more than 1,000 members of an international association of surgeons specialized in sports traumatology and knee surgery (ESSKA). RESULTS: The response rate was 40% (412 questionnaires). For scenario 1, first anterior dislocation of the shoulder, the most indicated treatment for 71% of respondents was an arthroscopic Bankart repair (P < 0.001). For scenario 2, shoulder arthritis with concentric erosion and cuff tear, 38% chose a shoulder replacement, while 37% preferred a supraspinatus tendon repair in combination with long head of biceps (LHB) tenodesis or tenotomy. For scenario 3, large tendon tears with 70% fatty infiltration of the infraspinatus tendon and lateral LHB instability, 70% of surgeons considered that, among conservative treatments, hyaluronic acid injection was not an appropriate management. Arthroscopic rotator cuff repair, arthroscopic acromioplasty, and LHB tenotomy gained larger consensus (81, 80, and 79% of respondents, respectively). A double-row technique for rotator cuff repair was preferred to a single-row technique (P = 0.02). Scenario 4, adhesive capsulitis, split the respondents equally, with 51% in favor of a surgical approach and 49% in favor of a conservative approach (N.S.). CONCLUSIONS: On-line questionnaires have the potential to improve knowledge about current trends in clinical practice and can help orthopedic surgeons to develop guidelines. LEVEL OF EVIDENCE: Cross-sectional; Level V (expert opinion).

High articular levels of the angiogenetic factors VEGF and VEGF-receptor 2 as tissue healing biomarkers after single bundle anterior cruciate ligament reconstruction.

Various factors may account for the positive association between meniscal repair and anterior cruciate ligament reconstruction, one being the modulation of healing response of meniscal fibrochondrocytes by growth factors released with intra-articular bleeding and fibrin clot formation. Analysis of vascular endothelial growth factor (VEGF) and its receptors, VEGFR1 and VEGFR2, may be useful in the clinical assessment of bone and soft-tissue remodeling. We measured systemic and local levels of VEGF (VEGF165), VEGFR1 and VEGFR2 after either arthroscopic partial meniscectomy (APM) or single-bundle anterior cruciate ligament reconstruction (ACLR) in order to determine the local effect of bone tunnelling and notchplasty on the release of these growth factors. The study population included 40 patients: 20 consecutive patients had undergone ACLR with hamstring grafts and 20 had undergone APM. Thirty minutes after the end of the operation, knee joint fluid samples were collected via the drainage tube and at the same time venous blood samples were drawn. In both sets of samples, VEGF, VEGFR1 and VEGFR2 concentrations were determined by enzyme-linked immunosorbent assay (ELISA). No significant differences in VEGF, VEGFR1 or VEGFR2 concentrations in the venous blood were observed between the two treatment groups. In contrast, VEGF and VEGFR2 levels were significantly higher in the knee joint fluid of the ACLR group; furthermore, VEGF and VEGFR1 were significantly higher in the knee joint fluid than in the venous blood, whereas VEGFR2 was lower in the knee joint fluid than in the venous blood. Local release of VEGF and its angiogenetic receptor VEGFR2, but not the negative regulator VEGFR1, was significantly higher after ACLR than after APM, indicating a better vasculogenic potential for enhanced bone-graft and meniscus healing. These results could suggest that VEGF and VEGFRs could be considered as good biomarkers of tissue healing after knee joint surgery.

Autologous chondrocyte transplantation in the treatment of thumb CMC joint osteoarthritis.

Degenerative thumb carpometacarpal (CMC) joint osteoarthritis is a common disease in women starting at 40-50 years of age. Nevertheless, synovitis and initial cartilage damage start earlier, and then degenerative arthritis develops leading to joint narrowing with progressive exposure of subchondral bone, subluxation, osteophyte formation and joint deformity that can impact the surrounding joints. The aim of this study was to evaluate the outcome of patients treated with autologous chondrocyte transplantation at the thumb CMC joint at early stages. A prospective study on 10 cases of thumb CMC osteoarthritis in 8 patients was done. The thumbs were stage Eaton II (2 cases) and III (8 cases) and were treated by CMC arthroplasty with the implant of autologous chondrocytes by an open or arthroscopic technique. Two patients were treated bilaterally. Preoperatively all patients had persistent pain resistant to various kinds of nonoperative treatments for at least 1 year. Mean preoperative pinch strength was 3.7 Kg pain on VAS was 8, DASH was 55. All patients had limited abduction and flexion at the end range. Ethics committee approval was obtained for this study. Fragments of 3-4 mm of cartilage were harvested by arthroscopy or by an open technique from the wrist or elbow joint. Cartilage cells were sent to the laboratory to be grown on a collagenous biphasic matrix (MACI/Novocart®). After 3 weeks, the chondrocyte augmented scaffold was ready to be implanted in the thumb CMC joint, or frozen for a second operation later. All patients were females aged 42-67 years (mean 52 years). The dominant hand was treated in 6 cases. In 7 cases, the patients were operated with an open technique and in three cases by arthroscopy. Partial trapezium resection and dorsoradial ligament reconstruction was added to stabilize the CMC joint in most cases. Patients were seen in person at 1, 3, and 6, months, 1 year, 2 years, and 5 years after the initial surgery. Patients (nine thumbs) were then reviewed at a mean follow up 8 years (range 4.4-11 years); pain on VAS, Mayo, DASH and PRWE scores were evaluated at follow-up. One patient was lost to follow-up after 2 years. Of those nine hands, seven had an excellent result according to Mayo score, one had a good result. One thumb CMC joint was still painful and was reoperated and converted to arthroplasty after 4.4 years. All patients regained full range of motion. Mean pinch strength increased to 6.25 ± 1.3 Kg, mean DASH score was 7.3 ± 6.7; pain on VAS was 1.0 ± 1.5; these data were statistically significant compared to preoperative values (p < 0.01). Grip strength also increased in all cases, but this was not statistically significant. PRWE was 7.7 ± 6.4. No complications occurred postoperatively. The results obtained are encouraging since the implanted cartilage has lasted a mean of 8 years and up to 11 years. Biological tissue engineering techniques are being developed and could be a new solution to restore normal cartilage in young patients to postpone more aggressive surgical procedures until an older age. In cases of CMC joint instability, a ligament stabilization procedure was added to avoid subsequent damage to the implanted neocartilage. A longer follow-up and a greater number of cases are necessary to definitively establish the usefulness of this procedure, which has the advantage of being completely biological but the disadvantage of being costly.

Direct anterior approach and dual mobility cup: the "head-first" reduction technique: a technical note and early case series.

PURPOSE: Less invasive direct anterior approach (DAA) and dual mobility cup (DMC) are increasingly adopted in practice over the last decade. Their use aims to reduce, as much as possible, soft tissue dissection and dislocation rate. This study aims to present a novel surgical technique to reduce a DMC prosthesis during a DAA easily. METHODS: A mildly modified version of the direct anterior approach is proposed. When leg lengths, stability, impingement, and tension have been checked, the trial stem is disassembled in situ, dislocated, and removed, leaving the space to exchange the trial double mobility head with the definitive one. When the definitive stem is inserted, the surgeon guides and helps the assistant to match the trunnion in the double mobility head. As soon as the components are matched, the traction is released, and the unit is impacted by an alternation of axial traction and release. RESULTS: Of 164 patients who underwent primary total hip arthroplasty (December 2016-May 2017) by a single surgeon, a double mobility cup through DAA and the "head-first" technique was performed in 26 patients (15.8%). The mean operative time was 130 min (85-220 min; SD 34.28). No significant complications occurred during the mean follow-up of 23.6 months. CONCLUSIONS: Specific difficulties can be anticipated when pairing dual mobility cup and direct anterior approach. The "head-first" technique is a useful technique in reducing the possible difficulties related to the reduction of double mobility cup through a less invasive direct anterior approach.

Efficacy and safety of eperisone in patients with low back pain: a double blind randomized study.

Eperisone hydrochloride (4'-ethyl-2-methyl-3-piperidinopropiophenone hydrochloride) is an antispastic agent used for treatment of diseases characterized by muscle stiffness and pain. The aim of this research was to investigate the efficacy of eperisone in patients with acute low back pain and spasticity of spinal muscles. The study design was a randomized, double-blind (double-dummy) study in 160 patients with low back pain and no Rx finding of major spinal diseases, randomly assigned to a treatment with oral eperisone 100 mg three times daily (t.i.d.) or thiocolchicoside 8 mg twice daily (b.i.d.) for 12 consecutive days. Analgesic activity was evaluated by scoring "spontaneous pain" (VAS) and pain on movement and pression (4-digit scale), while muscle relaxant activity of the medication was evaluated by means of the "hand-to-floor" distance and the Lasegue's manoeuvre. All the measures were done at the inclusion day and after 3, 7 and 12 days of treatment. The two medications had comparable analgesic and muscle relaxant efficacy. Sponta-neous pain and pain on movement/pressure were significantly reduced by both treatments. Moreover, both eperisone- and thiocolchicoside-treated patients showed a clinically evident muscle relaxation as proved by a progressive reduction in the "hand-to-floor" distance and increase in the articular excursion (Lasegue's manoeuvre). Only 5% of eperisone-treated patients showed minor gastrointestinal side effects, while the incidence of side effects in the thiocolchicoside group was 21.25%. Moreover, in the thiocolchicoside-treated patients also diarrhoea was present, which reached a moderate intensity in some cases. In conclusions, eperisone represents a valuable and safer alternative to other muscle relaxant agents for treatment of low back pain.

Reliability of anterior medial collateral ligament plication of the elbow.

PURPOSE: The aim of this study is to describe a new surgical procedure to plicate the anterior bundle medial collateral ligament (aMCL) into its humeral footprint using a suture anchor, and to present the results of a preliminary clinical series. METHODS: Eight patients with posttraumatic medial elbow pain and signs of medial elbow instability underwent aMCL plication with suture anchors and decompression of ulnar nerve. Arthroscopic evaluation permitted to define signs of minor medial elbow instability; 70°-scope was used to document from an intra-articular point of view of the aMCL status. The patients were then retrospectively evaluated with the Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPI) and single-assessment numeric evaluation (SANE) by an independent examiner. RESULTS: In all cases, the 70°-scope allowed direct visualization of the aMCL. Lateral subluxation of the coronoid process into the trochlea was observed in all patients. Postoperative median SANE was 50 [35-74.5] points; postoperative median OES was 17 [15.5-31.5] points; postoperative median MEPI was 65 [57.5-72.5] points. None of the patients reported further episodes of medial elbow instability or pain and all patients returned to normal daily activities. CONCLUSIONS: The 70°-scope arthroscopic evaluation of the joint allows a direct evaluation of the inner aMCL status. Lateral subluxation of the coronoid process into the trochlea was observed and can be considered a sign of minor medial elbow instability. Mini-open suture anchor aMCL plication is an original technique that enables an anatomic and minimally invasive ligament retension. CLINICAL RELEVANCE: The authors introduce a valid and safe treatment of posttraumatic medial elbow laxity.

It's time to change perspective! New diagnostic tools for lateral elbow pain.

PURPOSE: The presence of intra-articular findings that may complement the extra-articular pathology in lateral epicondilytis has been suggested, and a role for minor instability of the elbow as part of the causative process of this disease has been postulated. This study was designed to describe two new clinical tests, aimed at detecting intra-articular pathology in patients affected by recalcitrant lateral epicondylitis and investigate their diagnostic performance. METHODS: Ten patients suffering of atraumatic lateral elbow pain unresponsive to conservative treatment were considered in this study. Two clinical tests were developed and administrated prior to arthroscopy: Supination and Antero-Lateral pain Test (SALT); Posterior Elbow Pain by Palpation-Extension of the Radiocapitellar joint (PEPPER). Sensitivity, specificity, predictive values and accuracy of SALT and PEPPER as diagnostic tests for seven intra-articular findings were calculated. RESULTS: In 90% of the patients, at least one test was positive. All patients with signs of lateral ligamentous patholaxity or intra-articular abnormal findings had a positive response to at least one of the two tests. SALT proved to have a high sensitivity but a low specificity and is accurate in detecting the presence of intra-articular abnormal findings, especially synovitis. PEPPER test was sensible, specific and accurate in the detection of radial head chondropathy. CONCLUSIONS: Two new diagnostic tests (SALT and PEPPER) were specifically designed to evoke pain from intra-articular structures. These tests could be a valid support in the diagnostic algorithm of recalcitrant lateral elbow pain. Positive findings may be indicative of a minor instability of the lateral elbow condition. LEVEL OF EVIDENCE: Diagnostic study, development of diagnostic criteria on basis of consecutive patients, level II.

Different culture conditions affect the growth of human tendon stem/progenitor cells (TSPCs) within a mixed tendon cells (TCs) population.

BACKGROUND: Tendon resident cells (TCs) are a mixed population made of terminally differentiated tenocytes and tendon stem/progenitor cells (TSPCs). Since the enrichment of progenitors proportion could enhance the effectiveness of treatments based on these cell populations, the interest on the effect of culture conditions on the TSPCs is growing. In this study the clonal selection and the culture in presence or absence of basic fibroblast growth factor (bFGF) were used to assess their influences on the stemness properties and phenotype specific features of tendon cells. METHODS: Cells cultured with the different methods were analyzed in terms of clonogenic and differentiation abilities, stem and tendon specific genes expression and immunophenotype at passage 2 and passage 4. RESULTS: The clonal selection allowed to isolate cells with a higher multi-differentiation potential, but at the same time a lower proliferation rate in comparison to the whole population. Moreover, the clones express a higher amounts of stemness marker OCT4 and tendon specific transcription factor Scleraxis (SCX) mRNA, but a lower level of decorin (DCN). On the other hand, the number of cells obtained by clonal selection was extremely low and most of the clones were unable to reach a high number of passages in cultures. The presence of bFGF influences TCs morphology, enhance their proliferation rate and reduce their clonogenic ability. Interestingly, the expression of CD54, a known mesenchymal stem cell marker, is reduced in presence of bFGF at early passages. Nevertheless, bFGF does not affect the chondrogenic and osteogenic potential of TCs and the expression of tendon specific markers, while it was able to downregulate the OCT4 expression. CONCLUSION: This study showed that clonal selection enhance progenitors content in TCs populations, but the extremely low number of cells produced with this method could represent an insurmountable obstacle to its application in clinical approaches. We observed that the addition of bFGF to the culture medium promotes the maintenance of a higher number of differentiated cells, reducing the proportion of progenitors within the whole population. Overall our findings demonstrated the importance of the use of specific culture protocols to obtain tendon cells for possible clinical applications.

Diagnosis, classification and treatment of partial-thickness rotator cuff tears.

Partial-thickness rotator cuff tears are a challenge for shoulder surgeons. There is still no standard treatment protocol. The recent introduction of new arthroscopic techniques and a better grasp of pathogenic mechanisms along with a greater functional demand from patients, have led to the need for a thorough analysis of the problem. This paper analyses the literature in order to simplify the approach to treating partial-thickness rotator cuff tears.

Clinical outcome of latissimus dorsi tendon transfer and partial cuff repair in irreparable postero-superior rotator cuff tear.

BACKGROUND AND PURPOSE: Irreparable rotator cuff tears are a common cause of pain in adult population, requiring in many cases a surgical treatment. Possible alternatives are debridement, partial repair, muscle transfers and joint replacement. We evaluated two groups of patients with irreparable rotator cuff tear treated surgically: one group received an arthroscopic-assisted latissimus dorsi tendon transfer (LDTT), and the other an arthroscopic rotator cuff partial repair. Aim of our study was to compare clinical results and quality of life in two groups of patients with massive irreparable rotator cuff tear: one receiving an arthroscopic LDTT and the other receiving an arthroscopic rotator cuff partial repair. METHODS: Forty patients were assigned to two groups: 20 patients to group TT treated with LDTT and 20 patients to group PR treated with a partial repair. The average follow-up duration was 2.8 years (1-5, SD 3). Pre- and postoperative modified UCLA shoulder score, ROM, measurement of the strength and the rotator cuff quality of life (RC-QOL) were used to asses the outcome. RESULTS: LDTT showed significative improvements when compared to partial repair in UCLA score results, strength and RC-QOL questionnaire. No differences were found between the groups in pain relief. CONCLUSION: Both techniques are effective in reducing patients' symptoms. We believe that in younger, high-demanding patients with no or mild osteoarthritis, the LDTT represents a valid treatment option with better modified UCLA score improvement and strength at our follow-up.