Biophysical stimulation of bone and cartilage: state of the art and future perspectives.

INTRODUCTION: Biophysical stimulation is a non-invasive therapy used in orthopaedic practice to increase and enhance reparative and anabolic activities of tissue. METHODS: A sistematic web-based search for papers was conducted using the following titles: (1) pulsed electromagnetic field (PEMF), capacitively coupled electrical field (CCEF), low intensity pulsed ultrasound system (LIPUS) and biophysical stimulation; (2) bone cells, bone tissue, fracture, non-union, prosthesis and vertebral fracture; and (3) chondrocyte, synoviocytes, joint chondroprotection, arthroscopy and knee arthroplasty. RESULTS: Pre-clinical studies have shown that the site of interaction of biophysical stimuli is the cell membrane. Its effect on bone tissue is to increase proliferation, synthesis and release of growth factors. On articular cells, it creates a strong A2A and A3 adenosine-agonist effect inducing an anti-inflammatory and chondroprotective result. In treated animals, it has been shown that the mineralisation rate of newly formed bone is almost doubled, the progression of the osteoarthritic cartilage degeneration is inhibited and quality of cartilage is preserved. Biophysical stimulation has been used in the clinical setting to promote the healing of fractures and non-unions. It has been successfully used on joint pathologies for its beneficial effect on improving function in early OA and after knee surgery to limit the inflammation of periarticular tissues. DISCUSSION: The pooled result of the studies in this review revealed the efficacy of biophysical stimulation for bone healing and joint chondroprotection based on proven methodological quality. CONCLUSION: The orthopaedic community has played a central role in the development and understanding of the importance of the physical stimuli. Biophysical stimulation requires care and precision in use if it is to ensure the success expected of it by physicians and patients.

Arthroscopic-assisted latissimus dorsi transfer for massive rotator cuff tear: a systematic review.

Introduction: This systematic review provides a comprehensive description of different surgical techniques for massive rotator cuff tears (MRCTs) using arthroscopic-assisted latissimus dorsi transfer (A-LDT), reporting clinical outcomes and complications. Sources of data: We searched the literature on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'latissimus dorsi', 'tendon', 'transfer', 'rotator cuff tears', 'shoulder' and 'arthroscopy' to identify articles published in English, Spanish, French and Italian. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed for the manuscript selection. Areas of agreement: Ten studies (five retrospective and five prospective investigations), all published between 2014 and 2018, fulfilled our inclusion criteria, dealing with 348 (55.7% male) patients, with a mean age of 61.6 years (range 31-83). Areas of controversy: A-LDT is a technical demanding procedure. When compared with the open technique, it does not seem to provide significant subjective and objective clinical outcome improvements. Growing points: A-LDT seems to yield lesser surgical complications and post-operative stiffness. Sparing the deltoid muscle belly could result in a more effective shoulder post-surgery function. Areas timely for developing research: Further comparative randomized controlled trials with longer follow-up are needed to clarify the potentially promising superiority of A-LDT.

Transtendon repair in partial articular supraspinatus tendon tear.

Introduction: Partial thickness rotator cuff tears (PTRCTs) are common, with an incidence between 17% and 37%, and a high prevalence in throwing athletes. Different surgical procedures are suggested when partial tears involve the articular portion of the rotator cuff, including arthroscopic debridement of the tear, debridement with acromioplasty, tear completion and repair, and lately transtendon repair. This systematic review describes the transtendon repair and examines indications, contraindications, complications and clinical outcome. Source of data: We identified clinical studies listed in the Pubmed Google Scholar, CINAHL, Cochrane Central and Embase Biomedical databases in English and Italian concerning the clinical outcomes following treatment of partial articular supraspinatus tendon tear using transtendon surgical repair. Areas of agreement: Eighteen studies fulfilled our inclusion criteria. All were published between 2005 and 2016, three were retrospective, and 15 prospective. The total number of patients was 507 with a mean age of 50.8 years. Areas of controversy: Tear completion and repair and transtendon repair alone produce similar results. Growing points: Transtendon surgical repair allows to obtain good-excellent results in the treatment of partial articular supraspinatus tendon tears. Areas timely for developing research: Further studies are needed to produce clear guidelines in the treatment of partial articular supraspinatus tendon tears. Level of evidence: IV.

Apoptosis and rotator cuff tears: scientific evidence from basic science to clinical findings.

Introduction: Excessive apoptosis has been hypothesized as possible cause of tendinopathy and tear in the tendons of the rotator cuff (RC). Different mechanisms and molecules play a key role in cell regulation. Biological interventions can affect the process of apoptosis to control the tendinopathy process, and may be useful to design new treatments. Source of data: We identified basic science, in vitro and in vivo preclinical and clinical studies listed in the Pubmed Google Scholar, CINAHL, Cochrane Central and Embase Biomedical databases in English, Spanish, Italian and French concerning the effects of apoptosis on RC tendons. Areas of agreement: The homeostasis between the apoptotic and inflammatory processes is dynamic and controlled by pro- and anti-apoptotic mechanisms and signals, with variable balance in different areas of the RC tendons in human specimens. Areas of controversy: Apoptosis can be identified along the whole tendon, not only in the area of the lesion. Therefore, it is not necessary to undertake wide debridement of the torn edges of the tendon when undertaking a repair. Growing points: The identification of the various factors that control apoptosis and its mechanisms can help to design new treatments and exert positive effects in the recovery from tendon tears. Areas timely for developing research: Further studies are needed to produce clear guidelines to determine how to balance the apoptosis process to reduce the failed healing response found in non-traumatic RC tears.

Preoperative Planning for ACL Revision Surgery.

The number of patients undergoing revision surgery following failure of anterior cruciate ligament (ACL) reconstruction has increased over the recent past, following the overall increased number of primary ACL reconstruction performed. Failure of primary ACL reconstruction can be attributed to technical errors, biological failures, or new traumatic injuries. Technical errors include femoral and/or tibial tunnels malposition, untreated associated ligaments insufficiencies, uncorrected lower limb malalignment, and graft fixation failures. Candidates for revision surgery should be carefully selected, and the success of ACL revision requires precise preoperative planning to obtain successful results. Preoperative planning begins with the analysis of the mechanisms of ACL reconstruction failure, and information regarding previous surgery, such as the type of graft implanted, and the position of existing hardware. Appropriate imaging is necessary to evaluate the position of the femoral and tibial tunnels, and abnormal tunnel widening. On the basis of clinical examination and imaging, surgeon can perform an ACL revision procedure in 1 or 2 stages.

Arthroscopic treatment of tibial eminence fracture: a systematic review of different fixation methods.

INTRODUCTION: Arthroscopy procedures are the gold standard for the management of tibial spine avulsion. This review evaluates and compares different arthroscopic treatment options for tibial spine fractures. SOURCE OF DATA: PubMed, Medline, Ovid, Google Scholar and Embase databases were systematically searched with no limit regarding the year of publication. AREAS OF AGREEMENT: An arthroscopic approach compared with arthrotomy reduces complications such as soft-tissue lesions, post-operative pain and length of hospitalization. AREAS OF CONTROVERSY: The use of suture techniques, compared to cannulated screw technique, avoids a second surgery for removal of the screws, but requires longer immobilization and partial weight bearing. GROWING POINTS: Clinical outcomes and radiographic results do not seem to differ in relation to the chosen method of fixation. AREAS TIMELY FOR DEVELOPING RESEARCH: Further studies are needed to produce clear guidelines to define the best choice in terms of clinical outcomes, function and complications.

Tri-length laser therapy associated to tecar therapy in the treatment of low-back pain in adults: a preliminary report of a prospective case series.

Low-back pain is very frequent, especially in active adult population. There are several different orthopaedic condition that can cause low-back pain, and the pain worsen the quality of life significantly. The treatments vary from drugs, physical therapies, kinesiology, local infiltrations, and so on. Laser therapy has an important role in the treatment of the inflammatory causes of pain, with several studies that demonstrate the efficacy of low and high energy laser therapy in the treatment of low-back pain. Sixty-six consecutive patients with low-back pain with or without leg pain were treated using a combination of Tri-length laser I-Triax® (Mectronic Medicale, Bergamo, Italy) and Pharon® tecar therapy (Mectronic Medicale, Bergamo, Italy). The patients were treated three times a week, every other day, for a total of 10 sessions. Clinical results were evaluated using visual analogic scale for individual pain (0 to 10) and the Oswestry disability scale (ODS). Tests started before the beginning of therapies and 8 weeks after the end of the therapies. Visual analogic scale (VAS) score significantly improved from an average value of 8.1 ± 1.58 pre-treatment to an average value 8-weeks post-treatment of 2.63 ± 2.74 (P < .01). ODS values start from a pre-treatment average value of 53.0 ± 13.0 to a post-treatment average value of 23.5 ± 19.8 (P < .01). A higher improvement both in VAS and in ODS was denoted in the group of patient with low-back pain and leg pain (respectively, VAS from 8.66 ± 1.58 to 2.86 ± 2.94 and ODS from 57.8 ± 15.5 to 23.7 ± 19.5). Low-back pain, associated or not with leg pain, is a very common clinical situation. The treatments of this condition are different, and an important role can be given to the laser therapy. The conclusion of this study is that the association between laser therapy iLux-Triax® and tecar therapy Pharon® in the treatment of low-back pain, with or without leg pain, can significantly reduce pain and improve the quality of life in patients with degenerative and inflammatory problems.

Clinical evidence in the treatment of rotator cuff tears with hyaluronic acid.

PURPOSE: the aim of this quantitative review is to document potential benefit and adverse effects of hyaluronic acid (HA) injection into the shoulder with rotator cuff tears. METHODS: a systematic literature search was performed in english PubMed, Medline, Ovid, Google Scholar and Embase databases using the combined key words "hyaluronic acid", "rotator cuff tear", "hyaluronate", "shoulder", "viscosupplementation", with no limit regarding the year of publication. Articles were included if they reported data on clinical and functional outcomes, complications in series of patients who had undergone HA injection for management of rotator cuff tears. Two Authors screened the selected articles for title, abstract and full text in accordance with predefined inclusion and exclusion criteria. The papers were accurately analyzed focusing on objective rating scores reported. RESULTS: a total of 11 studies, prospective, 7 were randomized were included by full text. A total of 1102 patients were evaluated clinically after different HA injection compare with corticosteroid injection, physically therapies, saline solution injection and control groups. The use of HA in patients with rotator cuff tears improve VAS and functional score in all trials that we have analyzed. CONCLUSION: intra-articular injection with HA is effective in reducing pain and improving function in shoulder with rotator cuff tears and without severe adverse reaction. LEVEL OF EVIDENCE: Level I.