Effectiveness of Novel Sympathetic Nerve Entrapment Point Injections for Chronic Migraine: A Pilot Study.

No studies to date have investigated the ability of sympathetic nerve entrapment point saline (SNEP) injections to achieve long-term pain relief in patients with migraine. Therefore, this study aimed to investigate the safety and long-term efficacy of repeat splenius capitis (SC) SNEP injections in patients with migraine (with/without tension-type headache). This retrospective, single-arm study included 12 patients with migraine. Isotonic saline was injected into their SC approximately six times for 3 months. Headache frequency, duration (hour/week), intensity (using the visual analog scale), and quality of life (using the Headache Impact Test-6) were assessed during the follow-up visits for up to 24 months after the first injection. Changes before and after treatment were assessed using repeated-measures analysis of variance. Significant reductions in headache frequency, duration, and intensity were observed at all assessment points after SNEP injections when compared with the baseline values (p < 0.05), while the patients' headache-related quality of life also improved. Treatment was continued for up to 3 months to maintain these improvements, and no worsening of status or adverse effects were observed in any of the patients over the following 24 months. Our results show that SNEP injections may offer persistent, substantial, and clinically relevant benefits in patients with migraine.

Correction to: Correlation between the presence of herniation pit and femoroacetabular impingement: a systematic review and meta-analysis.

Authors would like to correct the errors in figure 4 legend.

Correlation between the presence of herniation pit and femoroacetabular impingement: a systematic review and meta-analysis.

PURPOSE: The purpose of this systematic review and meta-analysis was to evaluate the correlation between the incidence of herniation pits (HPs) and femoroacetabular impingement (FAI)-related morphologies. METHODS: A systematic search of the MEDLINE, EMBASE, and Cochrane Library databases was performed for studies evaluating the relationship between the incidence of HPs and FAI-related morphologies published up to August 16, 2019. Subgroup analyses were also performed to determine the differences in the relationship between the presence/absence of hip symptoms and cam-/pincer-type FAI. RESULTS: Seven studies involving 7950 hips were included. The pooled odds ratio (OR) for the incidence of HPs in the presence of an FAI-related morphology was 1.64 (95% confidence interval [CI] = 1.09-2.46; P = 0.02). In the subgroup analyses, the ORs for the incidence of HPs in the symptomatic and asymptomatic hips were 1.00 (95% CI 0.40-2.51; P = 1.00) and 1.59 (95% CI 1.42-1.77; P < 0.0001), respectively; the ORs for the incidence of HPs in the cam- and pincer-type FAI were 1.61 (95% CI 1.43-1.81; P < 0.0001) and 1.42 (95% CI 0.77-2.61; P = n.s.), respectively. CONCLUSIONS: The incidence of HPs has a significant relationship with FAI-related morphology, especially in asymptomatic patients and those with cam-type FAI morphology. LEVEL OF EVIDENCE: III.

Leukocyte-Poor Platelet-Rich Plasma-Derived Growth Factors Enhance Human Fibroblast Proliferation In Vitro.

BACKGROUND: Leukocyte-poor platelet-rich plasma (LP-PRP) from peripheral blood is currently used as a concentrated source of growth factors to stimulate repair at sites of soft tissue injury. Fibroblasts are primary mediators of wound healing. Thus, we aimed to assess the positive effect of LP-PRP on human fibroblast proliferation in vitro. METHODS: LP-PRP was prepared from 49 donors. The fibroblasts were seeded, and at 24 hours after seeding, 1 × 107/10 µL LP-PRP was added once to each well. The cells were harvested 10 times during study period at our planned points, and we examined cell proliferation using the water-soluble tetrazolium salt-1 assay. We collected the supernatants and measured the amount of growth factors such as platelet-derived growth factor (PDGF)-AB/BB, insulin-like growth factor-1 (IGF-1), transforming growth factor-ß1 (TGF-ß1), and vascular endothelial growth factor (VEGF), which are known to be involved in wound healing processes, by multiplex assay. RESULTS: Human fibroblasts treated with LP-PRP showed a significant increase in proliferation when compared to untreated controls (p < 0.001 at days 4, 6, and 8). Multiplex cytokine assays revealed various secretion patterns. PDGF-AB/BB appeared at early time points and peaked before fibroblast proliferation. IGF-1 and TGF-ß1 secretion gradually increased and peaked on days 4 and 6 post-treatment. The early VEGF concentration was lower than the concentration of other growth factors but increased along with cell proliferation. CONCLUSIONS: Platelets in LP-PRP release growth factors such as PDGF, IGF-1, TGF-ß1 and VEGF, and these growth factors have a promoting effect for human fibroblast proliferation, one of the important mediators of wound healing. These results suggest that growth factors derived from LP-PRP enhance the proliferation of human fibroblast.

Can a Single Sagittal Magnetic Resonance Imaging Slice Represent Whole Fatty Infiltration in Chronic Rotator Cuff Tears at the Supraspinatus?

BACKGROUND: This study aimed to investigate whether fatty infiltration (FI) measured on a single sagittal magnetic resonance imaging (MRI) slice can represent FI of the whole supraspinatus muscle. METHODS: This study retrospectively reviewed the MRIs of 106 patients (age 50-79 years) divided into three rotator cuff tear-size groups: medium, large, and massive. Fat mass and muscle mass on all T1-weighted sagittal MRI scans (FA and MA) were measured. Of the total MRI scans, the Y-view was defined as the most lateral image of the junction of the scapular spine with the scapular body on the oblique sagittal T1-weighted image. Fat mass and muscle mass seen on this Y-view single slice were recorded as F1 and M1, respectively. Fat mass and muscle mass were also assessed on MRI scans lateral and medial to the Y-view. The means of fat mass and muscle mass on these three slices were recorded as F3 and M3, respectively. Average FI ratios (fat mass/muscle mass) of the three assessment methods (F1/M1, FA/MA, and F3/M3) were compared. Intraclass correlation coefficients (ICCs) were calculated for inter- and intraobserver reliability. RESULTS: ICCs showed higher reliability (> 0.8) for all measurements. F1/M1 values were not statistically different from FA/MA and F3/M3 values (p > 0.05), except in males with medium and large tears. F3/M3 and FA/MA were not statistically different. The difference between F1/M1 and FA/MA did not exceed 2%. CONCLUSIONS: A single sagittal MRI slice can represent the whole FI in chronic rotator cuff tears, except in some patient groups. We recommend measurement of FI using a single sagittal MRI slice, given the effort required for repeated measurements.

Enhanced Tendon-to-Bone Healing of Chronic Rotator Cuff Tears by Bone Marrow Aspirate Concentrate in a Rabbit Model.

BACKGROUND: To evaluate the influence of bone marrow aspirate concentrate (BMAC) on tendon-to-bone healing in a rabbit rotator cuff model and to characterize the composition of growth factors in BMAC. METHODS: In this in vivo study, 40 rabbits were allocated into five groups: control (C), repair + saline (RS), repair + platelet-rich plasma (PRP; RP), repair + BMAC (RB) and repair + PRP + BMAC (RPB). A tear model was created by supraspinatus tendon transection at the footprint. Six weeks after transection, the torn tendon was repaired along with BMAC or PRP administration. Six weeks after repair, shoulder samples were harvested for biomechanical and histological testing. Ten rabbits were used for processing PRP and BMAC, followed by analysis of blood cell composition and the levels of growth factors in vitro. RESULTS: The ultimate load-to-failure was significantly higher in RPB group compared to RS group (p = 0.025). BMAC-treated groups showed higher values of biomechanical properties than RS group. The histology of BMAC-treated samples showed better collagen fiber continuity and orientation than RS group. BMAC contained significantly higher levels of the several growth factors than PRP. CONCLUSIONS: Locally administered BMAC enhanced tendon-to-bone healing and has potential for clinical applications.

Functional and Radiographic Outcomes After Arthroscopic Transosseous Suture Repair of Medium Sized Rotator Cuff Tears.

PURPOSE: To evaluate the functional and anatomical outcomes after arthroscopic transosseous suture (TOS) repair of 2 to 4 cm sized rotator cuff tears and to identify preoperative factors influencing repair failure. METHODS: From May 2013 to August 2014, patients with symptomatic 2 to 4 cm full-thickness tears underwent arthroscopic TOS repair, and those who could be followed up for a minimum of 2 years were included in this retrospective study. Functional and anatomical outcomes were analyzed up to 2 years postoperatively. Factors affecting cuff repair failure were evaluated, using both univariate and multivariate analyses. RESULTS: Twenty-seven patients were included. On preoperative magnetic resonance imaging data, the mean anteroposterior dimension tear size was 27.0 ± 3.3 mm and mean retraction was 30.7 ± 3.1 mm. Anatomic failure (Sugaya III, IV, and V) rate was 33% with arthroscopic TOS repair; however, significant improvements were found regardless of cuff healing. Mean American Shoulder and Elbow Surgeons score (range, 0-100) improved from 48.8 ± 16.6 preoperatively to 80.1 ± 11.1 postoperatively (P < .001), mean Constant score (range, 0-100) improved from 54.5 ± 11.8 to 73.7 ± 8.5 (P < .001), and mean pain visual analog scale score (range, 0-10) improved from 3.9 ± 1.7 to 2.0 ± 1.1 (P < .001). These changes reached each minimal clinically important difference previously reported. Greater tear size in anteroposterior dimension (P = .034), decreased acromiohumeral distance (P = .022), and higher fatty infiltration of supraspinatus (P = .011) were independent preoperative factors associated with repair failure. Twelve patients (44%) experienced intraoperative bone laceration. CONCLUSIONS: Arthroscopic TOS repair was a reliable technique for patients with 2 to 4 cm size rotator cuff tear. Preoperative factors associated with cuff repair failure were greater tear size in anteroposterior dimension, decreased acromiohumeral distance, and higher fatty infiltration of supraspinatus. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Involvement of synovial matrix degradation and angiogenesis in oxidative stress-exposed degenerative rotator cuff tears with osteoarthritis.

BACKGROUND: Shoulder osteoarthritis is a gradual wearing of the articular cartilage concomitant with degenerative rotator cuff tears (RCTs). This pathologic disorder is related to inflammation, oxidative stress, and angiogenesis. Degenerative alterations may prompt production of cytokines and angiogenesis-related proteins, evoking rotator cuff diseases. This study tested the hypothesis that oxidative stress-responsive mediators can influence joint inflammation of patients with RCT. METHODS: Twelve healthy RCT patients not suffering shoulder osteoarthritis were categorized as the control group, and 24 patients were allocated to 2 RCT groups (RCTP1 and RCTP2), according to severity of RCT and glenohumeral arthritis. Cytokines, growth factors, and angiogenic biomarkers in synovial fluids, blood, platelet-rich plasma (PRP), and tendon tissues were analyzed with enzyme-linked immunosorbent assay, immunoblotting, and collagen zymography. RESULTS: Induction of interleukin 8, tumor necrosis factor α, and interleukin 1ß was considerably elevated in synovial fluids of RCTP groups (P = .0398, P = .0428, P = .0828, respectively). The joint inflammation highly enhanced insulin-like growth factor 1 and transforming growth factor ß1 (TGF-ß1) in the synovial fluids and serum. Angiogenesis-related angiopoietin (Ang) 1 and 2, Tie-2, and hypoxia-inducible factor 1α were upregulated in reactive oxygen species-exposed RCTP synovium (P < .05). The production of matrix metalloproteinase 1 markedly increased in synovial fluids of the RCTP group (P = .043), whereas tissue collagen type I expression diminished with reduction of connective tissue growth factor expression (P = .032). Although the secretion of platelet-derived growth factor AB and vascular endothelial growth factor was marginal in the circulation (P = .714, P = .335), platelet-derived growth factor AB, TGF-ß1, Ang-1, and matrix metalloproteinase 1 were enriched in PRP of the RCTP group (P < .001, P = .002, P = .0389, respectively). CONCLUSIONS: Synovial matrix degradation and oxidative stress-triggered angiogenesis may be involved in inducing RCT with joint inflammation. TGF-ß1, Ang-1, and Ang-2 are the major components to repair RCT and to alleviate joint inflammation in PRP therapy.

Effects of a Single-Dose Interscalene Block on Pain and Stress Biomarkers in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial.

PURPOSE: To compare the effects of a single-dose interscalene block and general anesthesia (SISB/GA) with the effects of GA only in the early postoperative period after arthroscopic rotator cuff repair by evaluating subjective pain visual analog scale scores and objective pain-related stress biomarkers. METHODS: Patients refractory to conservative treatment of the affected shoulder were enrolled in this prospective, randomized endpoint study. Patients diagnosed with a rotator cuff tear (1-4 cm) based on magnetic resonance imaging were included. Exclusion criteria were small (<1 cm) and massive (>4 cm) rotator cuff tears. Thirty-one patients each were randomized into the SISB/GA and GA treatment groups. Preoperative pain scores were measured at 6:00 AM on the day of surgery, measured again at 1 and 6 hours postoperatively, and then every 6 hours until 3 days postoperatively. Blood sampling was performed to evaluate the stress biomarkers insulin, dehydroepiandrosterone sulfate, and fibrinogen preoperatively at 6:00 AM on the day of surgery and postoperatively at 18, 42, and 66 hours (6:00 AM on postoperative days 1-3). RESULTS: Pain scores were significantly decreased in the SISB/GA group (2.50 ± 0.94) versus the GA group (3.82 ± 1.31) on the day of surgery (P < .001), and especially at 6 hours postoperatively (SISB/GA: 2.42 ± 1.43; GA: 4.23 ± 2.17; P < .001). Insulin was decreased significantly in the SISB/GA group (10.55 ± 7.92 µU/mL) versus the GA group (20.39 ± 25.60 µU/mL) at 42 hours postoperatively (P = .048). There was no significant change in dehydroepiandrosterone sulfate or fibrinogen over time (P > .05). CONCLUSIONS: After arthroscopic rotator cuff repair, an SISB effectively relieved pain on the day of surgery without any complications. In addition, insulin levels were significantly reduced at 42 hours postoperatively. LEVEL OF EVIDENCE: Level I, prospective randomized controlled trial.

A Comparison between Clinical Results of Selective Bundle and Double Bundle Anterior Cruciate Ligament Reconstruction.

PURPOSE: The purpose of this study was to compare the clinical outcomes of arthroscopic anatomical double bundle (DB) anterior cruciate ligament (ACL) reconstruction with either selective anteromedial (AM) or posterolateral (PL) bundle reconstruction while preserving a relatively healthy ACL bundle. MATERIALS AND METHODS: The authors evaluated 98 patients with a mean follow-up of 30.8±4.0 months who had undergone DB or selective bundle ACL reconstructions. Of these, 34 cases underwent DB ACL reconstruction (group A), 34 underwent selective AM bundle reconstruction (group B), and 30 underwent selective PL bundle reconstructions (group C). These groups were compared with respect to Lysholm and International Knee Documentation Committee (IKDC) score, side-to-side differences of anterior laxity measured by KT-2000 arthrometer at 30 lbs, and stress radiography and Lachman and pivot shift test results. Pre- and post-operative data were objectively evaluated using a statistical approach. RESULTS: The preoperative anterior instability measured by manual stress radiography at 90° of knee flexion in group A was significantly greater than that in groups B and C (all p<0.001). At last follow-up, mean side-to-side instrumented laxities measured by the KT-2000 and manual stress radiography were significantly improved from preoperative data in all groups (all p<0.001). There were no significant differences between the three groups in anterior instability measured by KT-2000 arthrometer, pivot shift, or functional scores. CONCLUSION: Selective bundle reconstruction in partial ACL tears offers comparable clinical results to DB reconstruction in complete ACL tears.

Which Is Better for Arthroscopic Tenodesis of the Long Head of the Biceps: Soft Tissue or Bony Interference Fixation?

PURPOSE: To compare the outcome between arthroscopic soft tissue tenodesis (STT) at the rotator interval and bony interference fixation tenodesis (BIFT) at the distal bicipital groove for the long head of the biceps (LHB). METHODS: Twenty-five shoulders that underwent arthroscopic STT of the LHB were compared with 28 shoulders that underwent arthroscopic BIFT using a 5.5-mm Bio-Tenodesis screw (Arthrex, Naples, FL). American Shoulder and Elbow Surgeons scores, Constant score, and elbow flexion strength index (EFSI) were checked preoperatively, postoperative 1 year and 2 years. Ultrasound imaging evaluation took place at 1 year and 2 years postoperatively as well. RESULTS: The overall functional outcomes improved after surgery in both groups. The BIFT group showed a significant increase in EFSI (preop: 0.54, postoperative 2 years: 0.94) compared with that of the STT group (preop: 0.52, postoperative 2 years: 0.74) at postoperative 2 years (P = .006). However, no significant difference was seen in the increase of American Shoulder and Elbow Surgeons scores and Constant scores between the two groups. At postoperative 2 years, ultrasound showed seven empty grooves in the STT group, but only two empty grooves in the BIFT group (P = .046). CONCLUSIONS: Arthroscopic BIFT for the LHB showed better improvement in EFSI than arthroscopic STT. In addition, the STT group showed a higher failure rate than the BIFT group. LEVEL OF EVIDENCE: Level III, retrospective comparative study.