Alterations in the Structure, Composition, and Organization of Galactosaminoglycan-Containing Proteoglycans and Collagen Correspond to the Progressive Stages of Dupuytren's Disease.

Dupuytren's disease (DD) is a prevalent fibroproliferative disorder of the hand, shaped by genetic, epigenetic, and environmental influences. The extracellular matrix (ECM) is a complex assembly of diverse macromolecules. Alterations in the ECM's content, structure and organization can impact both normal physiological functions and pathological conditions. This study explored the content and organization of glycosaminoglycans, proteoglycans, and collagen in the ECM of patients at various stages of DD, assessing their potential as prognostic indicators. This research reveals, for the first time, relevant changes in the complexity of chondroitin/dermatan sulfate structures, specifically an increase of disaccharides containing iduronic acid residues covalently linked to either N-acetylgalactosamine 6-O-sulfated or N-acetylgalactosamine 4-O-sulfated, correlating with the disease's severity. Additionally, we noted an increase in versican expression, a high molecular weight proteoglycan, across stages I to IV, while decorin, a small leucine-rich proteoglycan, significantly diminishes as DD progresses, both confirmed by mRNA analysis and protein detection via confocal microscopy. Coherent anti-Stokes Raman scattering (CARS) microscopy further demonstrated that collagen fibril architecture in DD varies importantly with disease stages. Moreover, the urinary excretion of both hyaluronic and sulfated glycosaminoglycans markedly decreased among DD patients.Our findings indicate that specific proteoglycans with galactosaminoglycan chains and collagen arrangements could serve as biomarkers for DD progression. The reduction in glycosaminoglycan excretion suggests a systemic manifestation of the disease.

Surgery for trigger finger.

BACKGROUND: Trigger finger is a common clinical disorder, characterised by pain and catching as the patient flexes and extends digits because of disproportion between the diameter of flexor tendons and the A1 pulley. The treatment approach may include non-surgical or surgical treatments. Currently there is no consensus about the best surgical treatment approach (open, percutaneous or endoscopic approaches). OBJECTIVES: To evaluate the effectiveness and safety of different methods of surgical treatment for trigger finger (open, percutaneous or endoscopic approaches) in adults at any stage of the disease. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and LILACS up to August 2017. SELECTION CRITERIA: We included randomised or quasi-randomised controlled trials that assessed adults with trigger finger and compared any type of surgical treatment with each other or with any other non-surgical intervention. The major outcomes were the resolution of trigger finger, pain, hand function, participant-reported treatment success or satisfaction, recurrence of triggering, adverse events and neurovascular injury. DATA COLLECTION AND ANALYSIS: Two review authors independently selected the trial reports, extracted the data and assessed the risk of bias. Measures of treatment effect for dichotomous outcomes calculated risk ratios (RRs), and mean differences (MDs) or standardised mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CIs). When possible, the data were pooled into meta-analysis using the random-effects model. GRADE was used to assess the quality of evidence for each outcome. MAIN RESULTS: Fourteen trials were included, totalling 1260 participants, with 1361 trigger fingers. The age of participants included in the studies ranged from 16 to 88 years; and the majority of participants were women (approximately 70%). The average duration of symptoms ranged from three to 15 months, and the follow-up after the procedure ranged from eight weeks to 23 months.The studies reported nine types of comparisons: open surgery versus steroid injections (two studies); percutaneous surgery versus steroid injection (five studies); open surgery versus steroid injection plus ultrasound-guided hyaluronic acid injection (one study); percutaneous surgery plus steroid injection versus steroid injection (one study); percutaneous surgery versus open surgery (five studies); endoscopic surgery versus open surgery (one study); and three comparisons of types of incision for open surgery (transverse incision of the skin in the distal palmar crease, transverse incision of the skin about 2-3 mm distally from distal palmar crease, and longitudinal incision of the skin) (one study).Most studies had significant methodological flaws and were considered at high or unclear risk of selection bias, performance bias, detection bias and reporting bias. The primary comparison was open surgery versus steroid injections, because open surgery is the oldest and the most widely used treatment method and considered as standard surgery, whereas steroid injection is the least invasive control treatment method as reported in the studies in this review and is often used as first-line treatment in clinical practice.Compared with steroid injection, there was low-quality evidence that open surgery provides benefits with respect to less triggering recurrence, although it has the disadvantage of being more painful. Evidence was downgraded due to study design flaws and imprecision.Based on two trials (270 participants) from six up to 12 months, 50/130 (or 385 per 1000) individuals had recurrence of trigger finger in the steroid injection group compared with 8/140 (or 65 per 1000; range 35 to 127) in the open surgery group, RR 0.17 (95% CI 0.09 to 0.33), for an absolute risk difference that 29% fewer people had recurrence of symptoms with open surgery (60% fewer to 3% more individuals); relative change translates to improvement of 83% in the open surgery group (67% to 91% better).At one week, 9/49 (184 per 1000) people had pain on the palm of the hand in the steroid injection group compared with 38/56 (or 678 per 1000; ranging from 366 to 1000) in the open surgery group, RR 3.69 (95% CI 1.99 to 6.85), for an absolute risk difference that 49% more had pain with open surgery (33% to 66% more); relative change translates to worsening of 269% (585% to 99% worse) (one trial, 105 participants).Because of very low quality evidence from two trials we are uncertain whether open surgery improve resolution of trigger finger in the follow-up at six to 12 months, when compared with steroid injection (131/140 observed in the open surgery group compared with 80/130 in the control group; RR 1.48, 95% CI 0.79 to 2.76); evidence was downgraded due to study design flaws, inconsistency and imprecision. Low-quality evidence from two trials and few event rates (270 participants) from six up to 12 months of follow-up, we are uncertain whether open surgery increased the risk of adverse events (incidence of infection, tendon injury, flare, cutaneous discomfort and fat necrosis) (18/140 observed in the open surgery group compared with 17/130 in the control group; RR 1.02, 95% CI 0.57 to 1.84) and neurovascular injury (9/140 observed in the open surgery group compared with 4/130 in the control group; RR 2.17, 95% CI 0.7 to 6.77). Twelve participants (8 versus 4) did not complete the follow-up, and it was considered that they did not have a positive outcome in the data analysis. We are uncertain whether open surgery was more effective than steroid injection in improving hand function or participant satisfaction as studies did not report these outcomes. AUTHORS' CONCLUSIONS: Low-quality evidence indicates that, compared with steroid injection, open surgical treatment in people with trigger finger, may result in a less recurrence rate from six up to 12 months following the treatment, although it increases the incidence of pain during the first follow-up week. We are uncertain about the effect of open surgery with regard to the resolution rate in follow-up at six to 12 months, compared with steroid injections, due high heterogeneity and few events occurred in the trials; we are uncertain too about the risk of adverse events and neurovascular injury because of a few events occurred in the studies. Hand function or participant satisfaction were not reported.

Nerve regeneration: is there an alternative to nervous graft?

BACKGROUND: In nerve injury with nervous gap, no restitution method was found better than the autograft, however, it has the disadvantage of damaging a normal nerve to be used as a graft. Platelet-rich plasma (PRP) is a possible filler material for vein grafts used as conduits for nerve regeneration, preventing its collapse, and providing growth factors and osteoconductive proteins. METHODS: Isogenic rats were randomly divided into three groups. They received nerve autografts (GRF), PRP-containing vein grafts or a sham operation. Outcomes were evaluated by the sciatic functional index (SFI), morphometric, and morphologic analyses of the nerve distal to the lesion, and the number of spinal cord motoneurons positive for retrograde Fluoro-Gold (Santa Cruz Biotechnology, Inc., Dallas, TX) tracer. RESULTS: The PRP and GRF groups had lower SFI values than the control animals throughout the postoperative period. The SFI was significantly higher in the PRP group than the GRF group at 90 days postoperatively (p = 0.011). Fiber diameter and number of motoneurons were significantly decreased in both the PRP and GRF groups, as compared with the control. CONCLUSION: PRP within a vein conduit may be an effective alternative or adjuvant to GRF, the current preferred treatment for nerve injury with a nerve gap, and further investigations are required to fully define the role of PRP in nerve regeneration.

Surgical versus conservative interventions for treating acromioclavicular dislocation of the shoulder in adults.

BACKGROUND: Dislocation of the acromioclavicular joint is one of the most common shoulder problems in general orthopaedic practice. The question of whether surgery should be used remains controversial. OBJECTIVES: To assess the relative effects of surgical versus conservative (non-surgical) interventions for treating acromioclavicular dislocations in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to February 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 1), MEDLINE (1966 to February 2009), EMBASE (1988 to February 2009), and LILACS (1982 to February 2009), trial registries and reference lists of articles. There were no restrictions based on language or publication status. SELECTION CRITERIA: All randomised and quasi-randomised trials that compared surgical with conservative treatment of acromioclavicular dislocation in adults were included. DATA COLLECTION AND ANALYSIS: All review authors independently performed study selection. Two authors independently assessed the included trials and performed data extraction. MAIN RESULTS: Three trials were included in this review. These involved a total of 174 mainly male participants. Two trials were randomised and one was quasi-randomised. None used validated measures for assessing functional outcome.Fixation of the acromioclavicular joint using coracoclavicular screws, acromioclavicular pins or, usually threaded, wires was compared with supporting the arm in a sling or similar device. There were no significant differences between the two groups in unsatisfactory longer-term (one year) shoulder function based on a composite measure including pain, movement and strength or function (risk ratio 1.49, 95% confidence interval 0.75 to 2.95), nor in treatment failure that generally required an operation (risk ratio 1.72, 95% confidence interval 0.72 to 4.12). However, there were fixation failures in all three trials. Particularly, the trial using wires reported a high incidence of wire breakage (16/39 (41%)). Two trials reported that surgery significantly delayed the return to work. The methods used in the three trials also meant a routine second operation for implant removal was necessary. AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised controlled trials to determine when surgical treatment is indicated for acromioclavicular dislocation in adults in current practice. Sufficiently powered, good quality, well-reported randomised trials of currently-used surgical interventions versus conservative treatment for well-defined injuries are required.

The prevalence of carpal tunnel syndrome in adapted Sports athletes based on clinical diagnostic.

BACKGROUND: Electrical studies are often used to diagnose carpal tunnel syndrome (CTS). We noticed differences in results when we considered the clinical tests. OBJECTIVES: What's the prevalence of CTS in adapted sports athletes based on clinical diagnostic? Is there any relationship between the presence of symptoms and the use of wheelchairs, the type of sport practiced, dominance and how long the sport had been practiced? HYPOTHESIS: The prevalence of CTS in adapted sports athletes is close to that of the general population. STUDY DESIGN: Cross-sectional study. METHODS: We evaluated adapted athletes. Data collection included the dominant side, type of sports, sports practice time, wheelchair or non-wheelchairs users. To evaluate intensity of pain in the hands, we used the numerical pain rating scale (NPRS). For the evaluation of nocturnal paresthesia, we asked athletes about this symptom's presence. We evaluated the presence of paresthesia through the Tinel signal and Phalen test. For this study's purpose, we characterized CTS by the presence of two or more signs or symptoms. RESULTS: We evaluated 72 athletes, 144 hands. No athlete reported pain in the hands or nocturnal paresthesia. Fifteen athletes had at least one sign or symptom in a total of 21 hands. The presence of two concomitant clinical symptoms occurred in 4 (6%) right hands and 3 (4%) left hands. The presence of more than two concomitant clinical symptoms did not occur in any hand. We did not find a relation between the presence of signs and/or symptoms with the type of adapted sport, wheelchair use, the dominant side and the time of sports practice. DISCUSSION: Reviewing the literature we observed that the most researchers used electrodiagnostic studies to determine the diagnosis of CTS on persons with disabilities, without considering physical examination. CONCLUSION: The prevalence of CTS in the disabled athletes was 6 in 72 (8%). LEVEL OF EVIDENCE: III.

Surgical interventions for treating acute fractures or non-union of the middle third of the clavicle.

BACKGROUND: This review covers two conditions. These are acute fractures and non-union resulting from failed fracture healing. Clavicle or collarbone fractures account for around 4% of all fractures. While treatment of these fractures is usually non-operative, some types of fractures, as well as non-union of the middle third of the clavicle, are often treated surgically. OBJECTIVES: To evaluate the effectiveness of different methods of surgical treatment for acute fracture or non-union of the middle third of the clavicle. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to December 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 4), MEDLINE (1966 to December 2008), EMBASE (1988 to December 2008), LILACS (1982 to December 2008), trial registries and reference lists of articles. No language or publication restrictions were applied. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials evaluating any surgical intervention for treating people with fractures or non-union of the middle third of the clavicle were considered. The primary outcomes were pain, treatment failure and health-related quality of life or shoulder function. DATA COLLECTION AND ANALYSIS: Two authors independently selected eligible trials and three authors assessed methodological quality and cross-checked data extraction. There was no pooling of data. MAIN RESULTS: Data from three small trials, each testing a different comparison, were included. Two trials had design features that carry a high risk of bias, limiting the strength of their findings. Low-contact dynamic compression plates appeared to be associated with significantly better upper-limb function throughout the year following surgery, earlier fracture union and return to work, and a reduced incidence of implant-associated symptoms when compared with a standard dynamic compression plate in 36 adults with symptomatic non-union of the middle third of the clavicle. One study (69 participants) compared the Knowles pin versus a plate for treating middle third clavicle fractures or non-union. Knowles pins appeared to be associated with lower pain levels and use of post-operative analgesics, reduced incidence of implant-associated symptoms, and shorter operation time and hospital stay. One study (133 participants) found that a three-dimensional technique for fixation with a reconstruction plate was associated with a significantly lower incidence of symptomatic delayed union than a standard superior position surgical approach. AUTHORS' CONCLUSIONS: There is limited evidence, from single trials only, regarding the effectiveness of different methods of surgical fixation of fractures and non-union of the middle third of the clavicle.

Conservative interventions for treating middle third clavicle fractures in adolescents and adults.

BACKGROUND: Clavicle fractures account for around 4% of all fractures. Treatment of these fractures is usually non-operative. OBJECTIVES: To evaluate the effects of different methods for conservative (non-operative) treatment for acute (treated soon after diagnosis) middle third clavicle fractures in adolescents and adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 4), MEDLINE (from 1966), EMBASE (from 1980), LILACS (from 1982), trial registers and reference lists of articles. No language or publication restrictions were applied. The date of last search was in December 2008. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials testing conservative interventions for treating adolescents and adults with acute middle third clavicle fractures were considered. The primary outcomes were pain, shoulder function, health-related quality of life and time to return to previous activities. DATA COLLECTION AND ANALYSIS: Two authors independently selected eligible trials, assessed methodological quality and cross-checked data extraction. Risk ratios and 95% confidence intervals were calculated for dichotomous variables, and mean differences and 95% confidence intervals were calculated for continuous variables. There was no pooling of data. MAIN RESULTS: Three trials were included in this review. Two trials compared the figure-of-eight bandage with an arm sling in a total of 234 participants. Both trials were underpowered and compromised by poor methodology. One trial found slightly higher pain levels in the bandage group at 15 days (mean difference 0.80, 95% confidence interval 0.34 to 1.26; visual analogue scale: 0 (no pain) to 10 (worst pain)), and the other trial reported greater discomfort during bandage wear. There were no significant differences in functional or other outcomes reported for either trial. The third trial, which evaluated therapeutic ultrasound in 120 participants, was also underpowered but had a low risk of bias. The trial found no statistically significant difference between low-intensity pulsed ultrasound and placebo in the time to clinical fracture healing (mean difference -0.32 days, 95% CI -5.85 to 5.21 days) nor in any of the other reported outcomes. AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised controlled trials to determine which methods of conservative treatment are the most appropriate for acute middle third clavicle fractures in adolescents and adults. Further research is warranted.

Bone marrow-derived mesenchymal stem cells versus adipose-derived mesenchymal stem cells for peripheral nerve regeneration.

Studies have confirmed that bone marrow-derived mesenchymal stem cells (MSCs) can be used for treatment of several nervous system diseases. However, isolation of bone marrow-derived MSCs (BMSCs) is an invasive and painful process and the yield is very low. Therefore, there is a need to search for other alterative stem cell sources. Adipose-derived MSCs (ADSCs) have phenotypic and gene expression profiles similar to those of BMSCs. The production of ADSCs is greater than that of BMSCs, and ADSCs proliferate faster than BMSCs. To compare the effects of venous grafts containing BMSCs or ADSCs on sciatic nerve injury, in this study, rats were randomly divided into four groups: sham (only sciatic nerve exposed), Matrigel (MG; sciatic nerve injury + intravenous transplantation of MG vehicle), ADSCs (sciatic nerve injury + intravenous MG containing ADSCs), and BMSCs (sciatic nerve injury + intravenous MG containing BMSCs) groups. Sciatic functional index was calculated to evaluate the function of injured sciatic nerve. Morphologic characteristics of nerves distal to the lesion were observed by toluidine blue staining. Spinal motor neurons labeled with Fluoro-Gold were quantitatively assessed. Compared with sham-operated rats, sciatic functional index was lower, the density of small-diameter fibers was significantly increased, and the number of motor neurons significantly decreased in rats with sciatic nerve injury. Neither ADSCs nor BMSCs significantly improved the sciatic nerve function of rats with sciatic nerve injury, increased fiber density, fiber diameters, axonal diameters, myelin sheath thickness, and G ratios (axonal diameter/fiber diameter ratios) in the sciatic nerve distal to the lesion site. There was no significant difference in the number of spinal motor neurons among ADSCs, BMSCs and MG groups. These results suggest that neither BMSCs nor ADSCs provide satisfactory results for peripheral nerve repair when using MG as the conductor for engraftment.

Study of tibial nerve regeneration in Wistar rats in primary neurorrhaphy with and without gap, wrapped in vein segments.

OBJECTIVE: This study compared nerve regeneration in Wistar rats, using epineural neurorrhaphy with a gap of 1.0 mm and without a gap, both wrapped with jugular vein tubes. Motor neurons in the spinal cord between L3 and S1 were used for the count, marked by exposure of the tibial nerve to Fluoro-Gold (FG). METHOD: The tibial nerves on both sides were cut and sutured, with a gap on one side and no gap in the other. The sutures were wrapped with a jugular vein. Four months after surgery the tibial nerves were exposed to Fluoro-Gold and the motor neuron count performed in the spinal cord. RESULTS: The results were statistically analyzed by the paired Wilcoxon test. There was a statistical difference between the groups with and without gap in relation to the motor neuron count (p=0.013). CONCLUSION: The epineural neurorraphy without gap wrapped with jugular vein showed better results for nerve regeneration than the same procedure with gap. LEVEL OF EVIDENCE: Experimental Study .