Non-surgical treatments for the management of early osteoarthritis.

Non-surgical treatments are usually the first choice for the management of knee degeneration, especially in the early osteoarthritis (OA) phase when no clear lesions or combined abnormalities need to be addressed surgically. Early OA may be addressed by a wide range of non-surgical approaches, from non-pharmacological modalities to dietary supplements and pharmacological therapies, as well as physical therapies and novel biological minimally invasive procedures involving injections of various substances to obtain a clinical improvement and possibly a disease-modifying effect. Numerous pharmaceutical agents are able to provide clinical benefit, but no one has shown all the characteristic of an ideal treatment, and side effects have been reported at both systemic and local level. Patients and physicians should have realistic outcome goals in pharmacological treatment, which should be considered together with other conservative measures. Among these, exercise is an effective conservative approach, while physical therapies lack literature support. Even though a combination of these therapeutic options might be the most suitable strategy, there is a paucity of studies focusing on combining treatments, which is the most common clinical scenario. Further studies are needed to increase the limited evidence on non-surgical treatments and their combination, to optimize indications, application modalities, and results with particular focus on early OA. In fact, most of the available evidence regards established OA. Increased knowledge about degeneration mechanisms will help to better target the available treatments and develop new biological options, where preliminary results are promising, especially concerning early disease phases. Specific treatments aimed at improving joint homoeostasis, or even counteracting tissue damage by inducing regenerative processes, might be successful in early OA, where tissue loss and anatomical changes are still at very initial stages.

Biological strategies to enhance rotator cuff healing.

Rotator cuff tear causes a high rate of morbidity. After surgical repair, the presence of a scar tissue reduces tendon biomechanical properties. Emerging strategies for enhancing tendon healing are growth factors, cytokines, gene therapy and tissue engineering. However their efficacy has to be proved. Growth factors help the process of tendon healing by aiding cells chemotaxis, differentiation and proliferation. Numerous growth factors, including the bone morphogenetic proteins and platelet-derived growth factor can be found during the early healing process of a rotator cuff repair. Growth factors are delivered to the repair site using tissue-engineered scaffolding, coated sutures, or dissolved in a fibrin sealant. Platelet-rich plasma is an autologous concentration of platelets and contains an high density of growth factors. There is some evidence that platelet-rich plasma may improve pain and recovery of function in a short time period, but it does not improve healing rates in rotator cuff. Thus the routine use of platelet-rich plasma in rotator cuff repair is not recommended. The addition of mesenchymal stem cells to scaffolds can lead to the production of a better quality healing tissue. Gene therapy is a gene transfer from a cell into another, in order to over-express the gene required. In this way, cultures of stem cells can over-express growth factors. Better understanding of the mechanisms of physiological tendon healing can promote the correct use of these new biological therapies for a better healing tissue.

Figure-of-four pivot shift test--a technical note.

The pivot shift test is a cornerstone in the clinical diagnosis of anterior cruciate ligament (ACL) deficiency. It can be difficult to perform in overweight patients or in those with long or bulky legs. We present an alternative method to perform the pivot shift test that recalls the judo technique of figure-of-four knee lock and eases the examination of the patient with anterior cruciate ligament deficiency. This modality of execution also makes the surgeon able to perform varus-valgus tests with small changes in hand positions. The surgeon, embracing with one arm the tibia of the affected limb, grasps with this hand the wrist of his free arm opposite to the affected limb. Then the surgeon hooks onto the posterior surface of the leg with his free hand. In this way, the surgeon can exert a moment on the limb of the patient, and can apply combined internal rotation, flexion, and valgus stress to perform the pivot shift test or simply varus or valgus force to perform the varus-valgus tests.

Novel approaches for the management of tendinopathy.

Tendinopathy is a failed healing response of the tendon. Despite an abundance of therapeutic options, very few randomized prospective, placebo-controlled trials have been carried out to assist physicians in choosing the best evidence-based management. Eccentric exercises have been proposed to promote collagen fiber cross-link formation within the tendon, thereby facilitating tendon remodeling. Overall results suggest a trend for a positive effect of eccentric exercises, with no reported adverse effects. Combining eccentric training and shock wave therapy produces higher success rates compared with eccentric loading alone or shock wave therapy alone. The use of injectable substances such as platelet-rich plasma, autologous blood, polidocanol, corticosteroids, and aprotinin in and around tendons is popular, but there is minimal clinical evidence to support their use. The aim of operative treatment is to excise fibrotic adhesions, remove areas of failed healing, and make multiple longitudinal incisions in the tendon to detect intratendinous lesions and to restore vascularity and possibly stimulate the remaining viable cells to initiate cell matrix response and healing. New operative procedures include endoscopy, electrocoagulation, and minimally invasive stripping. The aim of these techniques is to disrupt the abnormal neoinnervation to interfere with the pain sensation caused by tendinopathy. Randomized controlled trials are necessary to better clarify the best therapeutic options for the management of tendinopathy.