Protective Effect of Knee Postoperative Fluid on Oxidative-Induced Damage in Human Knee Articular Chondrocytes.

The oxidative-stress-elicited deterioration of chondrocyte function is the initial stage of changes leading to the disruption of cartilage homeostasis. These changes entail a series of catabolic damages mediated by proinflammatory cytokines, MMPs, and aggrecanases, which increase ROS generation. Such uncontrolled ROS production, inadequately balanced by the cellular antioxidant capacity, eventually contributes to the development and progression of chondropathies. Several pieces of evidence show that different growth factors, single or combined, as well as anti-inflammatory cytokines and chemokines, can stimulate chondrogenesis and improve cartilage repair and regeneration. In this view, hypothesizing a potential growth-factor-associated action, we investigate the possible protective effect of post-operation knee fluid from patients undergoing prosthesis replacement surgery against ROS-induced damage on normal human knee articular chondrocytes (HKACs). To this end, HKACs were pre-treated with post-operation knee fluid and then exposed to H2O2 to mimic oxidative stress. Intracellular ROS levels were measured by using the molecular probe H2DCFDA; cytosolic and mitochondrial oxidative status were assessed by using HKACs infected with lentiviral particles harboring the redox-sensing green fluorescent protein (roGFP); and cell proliferation was determined by measuring the rate of DNA synthesis with BrdU incorporation. Moreover, superoxide dismutase (SOD), catalase, and glutathione levels from the cell lysates of treated cells were also measured. Postoperative peripheral blood sera from the same patients were used as controls. Our study shows that post-operation knee fluid can counteract H2O2-elicited oxidative stress by decreasing the intracellular ROS levels, preserving the cytosolic and mitochondrial redox status, maintaining the proliferation of oxidatively stressed HKACs, and upregulating chondrocyte antioxidant defense. Overall, our results support and propose an important effect of post-operation knee fluid substances in maintaining HKAC function by mediating cell antioxidative system upregulation and protecting cells from oxidative stress.

The reimbursement system can influence the treatment choice and favor joint replacement versus other less invasive solutions in patients affected by osteoarthritis.

PURPOSE: The aim of this study was to assess how physicians perceive the role of the reimbursement system and its potential influence in affecting their treatment choice in the management of patients affected by osteoarthritis (OA). METHODS: A survey was administered to 283 members of SIAGASCOT (Italian Society of Arthroscopy, Knee, Upper Limb, Sport, Cartilage and Orthopaedic Technologies), a National scientific orthopaedic society. The survey presented multiple choice questions on the access allowed by the current Diagnosis-Related Groups (DRG) system to all necessary options to treat patients affected by OA and on the influence toward prosthetic solutions versus other less invasive options. RESULTS: Almost 70% of the participants consider that the current DRG system does not allow access to all necessary options to best treat patients affected by OA. More than half of the participants thought that the current DRG system favors the choice of prosthetic solutions (55%) and that it can contribute to the increase in prosthetic implantation at the expense of less invasive solutions (54%). The sub-analyses based on different age groups, professional roles, and places of work allowed to evaluate the response in each specific category, confirming the findings for all investigated aspects. CONCLUSIONS: This survey documented that the majority of physicians consider that the reimbursement system can influence the treatment choice when managing OA patients. The current DRG system was perceived as unbalanced in favor of the choice of the prosthetic solution, which could contribute to the increase in prosthetic implantation at the expense of other less invasive options for OA management.

Atypical Presentation of Non-Ossifying Fibroma in a Professional Muay Thai Boxer: A Case Report and a Narrative Review of the Literature.

Introduction: Sports injuries occur during sport athletic activities, or exercising. However, there are some lesions which are typically associated to sports, in such a demanding and physical sport like Muay Thai that no typical lesion has been detected yet. We performed a narrative review of the literature to highlight the typical lesions of this sport to analyze the differential diagnosis of those conditions. Case Report: A 28-year-old female, Muay Thai athlete since 16 years, presented with a 6 months history of a persistent pain in the metaphyseal lateral part of the right tibia. Differentiation between stress injuries, malignant bone tumors, and tumor-like lesions after repetitive microtrauma following sport activities can be difficult. The diagnostic approach involved conventional X-ray, echotomography, computed tomography scan, and magnetic resonance imaging scan with controversial findings. The biopsy confirmed the final diagnosis of non-ossifying fibroma. Conclusion: The purpose of this case report is to exhibit the challenges in the diagnosis of a professional Muay Thai athlete with tibial pain and to discuss the clinical presentation of this type of patients with a limited population in the literature. Our case illustrates that even modern imaging techniques cannot always distinguish between tumor and tumor-like lesions caused by sports; meanwhile remembered us that we should never be too focused on a particular characteristic forgetting even rare pathologies as adamantinoma.

Is there a relation between loss of shoulder external rotation and sternoclavicular joint disorders?

BACKGROUND AND AIM: Scapulothoracic movements are essential in shoulder kinematics and can partially compensate  stiffness and loss of motion of glenohumeral joint. The scapulothoracic movement is strictly dependent on the translation and rotation of the clavicle at the sternoclavicular joint (SCJ), this being the only true joint between the axial and the upper appendicular skeleton.  Aim of the study is to define a possible correlation between loss of shoulder external rotation following surgery for anterior shoulder instability and long-term sternoclavicular joint disorders. METHODS: A group of 20 patients and a group of 20 healthy volunteers were studied.  Results: In the statistical analysis of the patient group and of the two groups jointly, the association between the reduction of shoulder external rotation and the onset of disorder of SCJ appeared statistically significant. CONCLUSIONS: Our results provide support for an association between some disorders of the SCJ and the alterations of the shoulder kinematics associated with a reduction of  ROM in external rotation. Our sample is too small to allow definitive conclusions to be drawn. These results, if confirmed by larger studies, could help us further clarify the complex kinematics of the shoulder girdle.

Inverse shoulder tumor megaprosthesis after large bone resection in massive metastasis of the proximal humerus.

BACKGROUND AND AIM: Bone metastases are a significant prognostic factor in the history of cancer and often involve pain and a great impairment of the quality of life. The complete resection of tumor tissue is increasingly performed in patients with solitary bone metastases, to improve the survival of patients and their functional outcomes Methods: We report the case of a 65-year-old man with a painful, massive, highly perfused osteolytic lesion localized at the proximal third of the humerus, associated with extensive lesions of the rotator cuff tendons was diagnosed with keratoblastic squamous cell lung cancer metastasis. RESULTS: The patient underwent shoulder and proximal humerus reconstruction with inverse tumor megaprosthesis after embolization of the lesion. At 3 and 6 months FU, a nearly complete resolution of painful symptoms, a significant improvement in functional skills, and better execution of most of the activities of daily life have been reported. CONCLUSIONS: Accordingly with the literature the inverse shoulder megaprosthesis seems able to restore a satisfactory function and the silver-coated modular tumor system appears as a safe and viable treatment option in metastases tumor of proximal humerus.

Why malnutrition in orthopaedic elective patient is still an issue? A recent review of the literature.

BACKGROUND: Malnutrition is a known risk factor for complications and adverse outcomes after elective total joint arthroplasty (TJA). The progressive increase in the ageing of world population and in the numbers of TJA, widens the demand for a faster post-operative recovery and function. The aim of this study was to review the literature regarding: post-operative transfusion, infections, wound complications, length of hospital stay (LOS), rate of admission in intensive care unit (ICU), and total patient charges, in malnourished patient undergoing TJA. METHODS: The search reviewed all fields of the available peer-reviewed literature, published in the English language during the last seven years 2015-2022. We started from a total of 745 studies and finally we included in the review 16 articles. RESULTS: In 10 studies, an increased surgical site infection was shown, being by far the most common complication, in 8 studies, malnutrition was associate with the increase of the average length of stay (LOS), and in 5 studies, the major founding was the increase in costs. An increase of the morbidity was found in 3 studies, instead a larger number of transfusions was highlighted in 2 studies. Lastly, one study showed a major unplanned ICU admission rate. CONCLUSIONS: Although the literature trend indicates that the nutritional status of TJA candidate patients is a parameter that influences the surgical outcome, in particular surgical site infections, length of stay, and costs, there are, to the authors' knowledge, no studies aimed at identifying validated and recognized protocols for the correction of malnutrition.

Joint replacement for avascular necrosis in people living with HIV.

Recently, the interest on multifocal avascular necrosis (AVN) among people living with HIV (PLWH) is rising. PLWH have an incidence of symptomatic AVN significantly higher than the general population. The chronic viral infection may induce a direct damage via necrotizing vasculitis, on the other hand the highly active antiretroviral therapy represents a probable risk factor as it can indirectly lead to multifocal necrosis. Regardless of etiopathology, the AVN management in PLWH is the same as in the general population. Depending on symptoms, stage, and location, the AVN can be treated conservatively or surgically, but in its final stages joint replacement is often the most appropriate therapeutic option. The safety and outcomes of such major orthopedic surgery in PLWH are debated topics. In agreement with the literature in our case series we observed, despite some complication, a significant pain relief and excellent recovery of function after hip replacements. Although increased complication rates, several other independent risk factors associated with HIV infection can act as confounding factors. These confounders must be taken into account both in clinical practice and in data analysis. This case-based review highlights the increasing incidence of AVN in PLWH, and emphasizes the safety and effectiveness of the prosthetic joint replacement in this population.

Surgical management of hip prosthetic failure in metallosis: A case series and literature review.

Local and remote complications can be observed in hip prosthesis failures associated with metallosis. Structural changes in the periprosthetic bone and soft tissues may not always be precisely assessed preoperatively due to metal artifacts. The unpredictability of the damage extension, potentially leading to complex and insidious surgeries, requires the availability of alternative surgical plan(s) for the reconstruction of the joint. The aim of the study is to present and analyze, with the literature data support, practical tips for the revision of the prosthetic components, the management of ARMD and of intraoperative complications in the unusual scenario of metallosis.

Medial closure supracondylar femoral osteotomy: an effective solution for long-term treatment of arthritic valgus knee?

PURPOSE: The aim of this work was to retrospectively analyze the clinical, subjective, and radiological results of medial closing-wedge distal femur osteotomy (MCW-DFO) for the treatment of osteoarthritis (OA) in valgus knee at medium- to long-term follow-up. MATERIALS AND METHODS: A total of 57 patients (62 knees) treated with MCW-DFO between 1984 and 2018 were included in the study. Patient age at the time of the surgery ranged between 28 and 61 years (average: 48 years). All patients with a minimum follow-up of 4 years were contacted to request for them to undergo clinical, subjective, and radiological evaluation. Preoperative hip-knee-ankle (HKA) angle (i.e., preoperative valgus malalignment) was 8.6° ± 2°. Patients were evaluated using the following scales: the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Knee Society Score (KSS), the International Knee Documentation Committee (IKDC), the Visual Analog Scale (VAS), and the Numeric Rating Scale 11 (NRS-11). RESULTS: Mean follow-up was 11.6 ± 4.9 years, and a total of 17 patients (20 knees) were available for the last examination. At maximum follow-up, 4 patients underwent conversion to a total knee replacement (20%); their survival rate was 100% at 10 years and 66.7% at 15 years, as estimated using the Kaplan-Meier curve. The subjective Knee Society Score improved on average from 37.7 ± 10 to 63.9 ± 15.4. The objective Knee Society Score improved on average from 42.2 ± 11.7 to 75 ± 22.5. The pain detected through the VAS and NRS-11 scales improved from 56.7 ± 12.9 to 42 ± 17.1 and from 5.8 ± 1.1 to 4.4 ± 1.7, respectively. Thirteen patients (70%) required hardware removal at an average time of 19 ± 4 months due to a local nuisance. CONCLUSIONS: MCW-DFO can improve symptoms in patients with osteoarthritis in a valgus knee at medium- to long-term follow-up, reducing the progression of osteoarthritis in properly selected patients.

Deltoid ligament reconstruction with autologous gracilis tendon in chronic medial ankle instability after ankle fracture surgery: A case report.

INTRODUCTION: The repair of a deltoid ligament injury, following an ankle fracture with involvement of the syndesmosis, has no univocal consensus. Also the surgical strategies in case of a subsequent chronic instability are still under debate. In this work the result of a double bundle anatomic reconstruction of deltoid ligament with ipsilateral autologous gracilis muscle tendon is presented. CASE REPORT: A 50 year old active male patient came to our attention with a catastrophic medial ankle instability, a severe pronation of the hindfoot and disabling ankle pain. He reported a Weber type B fracture of the left ankle with a lesion of the syndesmosis treated with anatomic plate and screws and a transyndesmotic screw 8 months before. The imaging showed a complete deltoid ligament lesion. Due to the impossibility of a direct repair of the ligament, we performed the reconstruction of the medial ligamentous complex with an autologous gracilis tendon graft. 10 months after the medial ligamentous complex reconstruction, the patient showed an excellent recovery of walking ability, disappearance of pain under load and resumed an active lifestyle. DISCUSSION: The deltoid ligament has a key role in ankle joint stability and its integrity promotes the recovery after ankle fractures. However, its lesion is often left untreated in the acute setting. The result of a chronic untreated deltoid ligament injury could be extremely disabling and the ligament reconstruction, when an optimal native deltoid ligament repair is not achievable, is the choice to restore ankle function and stability. CONCLUSION: In the delayed treatment of a deltoid ligament rupture the described double bundle anatomic reconstruction with autologous tendon graft can be an effective and suitable option.

Functional and radiological outcomes in displaced heel fractures: Open reduction and internal fixation versus external fixation.

Management of intra-articular heel fractures is controversial. The main goals of surgical treatment are restoring subtalar articular congruence and width, height, form and alignment of the heel. The gold standard is considered Open Reduction and Internal Fixation (ORIF), a complex technique with a high rate of complications. External Fixation (EF) could be a good alternative. In this study were identified 37 fractures in 35 patients (24 patients underwent ORIF and EF was performed in 13 cases) and the outcomes of the two techniques were compared. The mean surgical time for ORIF was 107.8 minutes, while for EF was 88.61 minutes and the ORIF group presented a higher rate of complications, despite of similar results in the mean postoperative AOFAS Ankle and Hindfoot Scale scores (73.31/100 points in the ORIF group and 75.40/100 points in the EF group). Fast learning curve, short surgery time and low complications rate make EF an alternative to ORIF in treating intraarticular heel fractures.

Surgical treatment of talar osteo-chondral lesions with micro-fractures, mesenchymal cells grafting on membrane, or allograft: Mid-term clinical and magnetic resonance assessment.

Talar dome osteo-chondral lesions (OCL) are defects of the cartilaginous surface and subchondral bone often associated with sport practice. This retrospective observational work has the purpose of assessing: a) The clinical outcomes in the patients study group and in the three sub-groups; b) medium-term morphological and qualitative outcomes of the newly formed tissue by magnetic resonance imaging; c) if there is the correlation between new formed tissue clinical, morphological RM evaluation and qualitative clinical outcomes.

Resumption of physical activity and sport after knee replacement.

PURPOSE: to assess the resumption of physical activity after knee replacement. METHODS: retrospective study. RESULTS: 118 patients were included in the final analysis. A resumption of >93% of the activities performed before surgery was observed. Logistic regression analysis did not show any significant associations between postoperatory activity and epidemiological and clinical variables except the function perceived by the patient. CONCLUSIONS: the resumption of physical activity and sport is a paramount expectation for active patients. A clearer definition of physical activity and sports realistically achievable after a knee prosthesis is necessary but not yet fully available.

Suspension arthroplasty in the treatment of thumb carpometacarpal osteoarthritis.

Literature presents several examples of surgical techniques for the treatment of carpometacarpal osteoarthritis. In our study we used a modified Ceruso's suspended arthroplasty technique. In this study, 53 patients from 2011 to 2017 underwent arthroplasty with trapezius excision and suture suspension between abductor pollicis longus and flexor carpi radialis. The average age at surgery was 69, the participants were 43 women and 10 men. The average total operation time was 59 minutes. The modified CMC suspension arthroplasty technique provides excellent results compared with those in the literature.

Second Generation Needling Techniques for the Treatment of Chondral Defects in Animal Model.

Purpose To compare the macroscopic, histological, and immunohistochemical characteristics of the repair tissue of chondral defects treated with microfracture and nanofracture in an ovine model. Methods Full-thickness chondral lesions were created in the medial femoral condyle of both knees in four adult sheep and were treated with microfracture on one side and with nanofracture on the contralateral side. Chondral repair was assessed after 12 months by macroscopic, histological, and immunohistochemical analyses. Results Histological cartilage repair significantly improved in the samples treated with nanofracture for cellular morphological characteristics and cartilage architecture. The immunohistochemical analysis showed a significantly higher immunoreactivity to type II collagen in the defects treated with nanofracture. Conclusion Nanofracture provided better repair tissue than microfracture, with a more satisfactory cartilage architecture renovation and tissue having greater type II collagen content. Clinical Relevance Mesenchymal stem cell stimulation is the most frequently used primary cartilage repair procedure. Nanofracture represents a novel technique to stimulate bone marrow that results into a successful repair of chondral defects.

The use of embryonic cells in the treatment of osteochondral defects of the knee: an ovine in vivo study.

PURPOSE: the aim of this study was to determine whether local delivery of embryonic stem-like (ESL) cells into osteochondral defects in the femoral condyles of sheep would enhance regeneration of hyaline articular cartilage. METHODS: male ESL cells embedded in fibrin glue were engrafted into osteochondral defects in the medial condyles (ESL-M) of the left femur in 22 ewes. An identical defect was created in the medial condyle of the contralateral stifle joint and left untreated as a control (empty defect, ED). The ewes were divided into 5 groups. Four sheep each were euthanized at 1, 2, 6, and 12 months from surgery, and 6 ewes were euthanized 24 months post-implantation. To study the effect of varying loads on the long-term regeneration process, an identical defect was also created and ESL cell engraftment performed in the lateral condyle (ESL-L) of the left stifle joint of the animals in the 12- and 24-month groups. The evaluation of regenerated tissue was performed by biomechanical, macroscopic, histological, immunohistochemical (collagen type II) and fluorescent in situ hybridization (FISH) assays. RESULTS: no significant differences were found between treated and control sites in the biomechanical assays at any time point. ESL cell grafts showed significantly greater macroscopic evidence of regeneration as compared to controls at 24 months after surgery; significantly better histological evidence of repair in ESL-M samples versus controls was found throughout the considered period. At 24 months from surgery there was significantly improved integration of graft edges with the host tissue in the ESL-M as compared to the ESL-L samples, demonstrating that load bearing positively affects the long-term regeneration process. CONCLUSIONS: ESL cells enhanced the regeneration of hyaline cartilage. FISH confirmed that the regenerative tissue originated from ESL cells. CLINICAL RELEVANCE: ESL cells are able to self-renew for prolonged periods without differentiation and, most importantly, to differentiate into a large variety of tissues.

Subchondral bone remodeling: comparing nanofracture with microfracture. An ovine in vivo study.

PURPOSE: microfracture, providing direct stimulation of chondrogenic mesenchymal stem cells (MSCs) in the subchondral bone, remains the most frequently used primary cartilage repair technique. However, the newly formed type I collagen-rich fibrocartilaginous tissue has poor biomechanical properties and a tendency to degenerate. To overcome these limitations the nanofracture technique was introduced. Our purpose was to compare subchondral bone remodeling 6 months after microfracture versus nanofracture (subchondral needling) treatment in an ovine model. METHODS: full-thickness chondral lesions were created in the load-bearing area of the medial femoral condyles in four adult sheep. Each animal was then treated on one side with microfracture and on the contralateral side with nanofracture. Subchondral bone remodeling was assessed by micro-CT using a Bruker(®) SKYSCAN and CTVOX 2.7 software (Bruker Corp., Billerica, MA, USA) for image reconstruction; trabecular bone density measurements were performed through a color-representation structure thickness analysis. RESULTS: at the six-month endpoint, the microfracture-treated samples showed limited perforation depth and cone-shaped channels with large diameters at the joint surface. The channel walls displayed a high degree of regularity with significant trabecular bone compaction leading to a sealing effect with limited communication with the surrounding trabecular canals. Condyles treated with nanofracture showed channels characterized by greater depth and smaller diameters and natural irregularities of the channel walls, absence of trabecular compaction around the perforation, remarkable communication with trabecular canals, and neo-trabecular remodeling inside the channels. CONCLUSIONS: nanofracture is an effective and innovative repair technique allowing deeper perforation into subchondral bone with less trabecular fragmentation and compaction when compared to microfracture; it results in better restoration of the normal subchondral bone architecture at six months. CLINICAL RELEVANCE: our data support the use of smaller-diameter and deeper subchondral bone perforation for MSC stimulation; this technique may prove to be an attractive alternative to standard microfracture procedures.

Early joint degeneration and antagonism between growth factors and reactive oxygen species. Is non-surgical management possible?

PURPOSE: in pathological conditions such as osteo-arthritis (OA), overproduction of reactive oxygen species (ROS) may overwhelm the antioxidant defenses of chondrocytes, thus promoting oxidative stress and cell death. It can be hypothesized that increasing the antioxidant machinery of chondrocytes may prevent the age-associated progression of this disease. Growth factors (GFs) play an important role in promoting both the resolution of inflammatory processes and tissue repair. In view of these considerations, we set out to investigate the protective effect, against H2O2-induced oxidative cell death, potentially exerted by fluid drained from the joint postoperatively. METHODS: the present study was conducted in 20 patients diagnosed with bilateral knee osteoarthritis and treated, between January 2013 and June 2014, with prosthetic knee implantation on the side more affected by the arthritic process, together with intraoperative placement of a closed-circuit drainage aspiration system. As a result, 20 different serum samples were collected from the drained articular fluid, prepared using two different methodologies. In addition, forty blood serum samples were obtained and prepared: 20 from the surgically treated patients and 20 from healthy controls. The present work was undertaken to investigate the potential protective effect of sera obtained from articular fluid drainage against hydrogen peroxide-induced oxidative stress in cultured human chondrocytes. RESULTS: exposure of chondrocytes to hydrogen peroxide elicited a dose-dependent increase in oxidative stress and chondrocyte cell death, phenomena that were significantly counteracted by the pre-treatment of cell cultures with sera from articular fluid drainage. CONCLUSIONS: oxidatively stressed chondrocytes treated with sera obtained from articular fluid drainage lived longer than those treated with blood serum samples and longer than untreated ones. CLINICAL RELEVANCE: synovial fluids are usually discarded once the drainage reservoir is full; instead they could benefit the patients from whom they are collected, as they are rich in growth factors and they may act as antagonists of ROS effects. Accordingly, they could be used to treat chondropathies, early OA, and mild OA located in other sites.