Hyaluronic Acid Alleviates Oxidative Stress and Apoptosis in Human Tenocytes via Caspase 3 and 7.

Rotator cuff tendinopathy (RCT) is the primary reason for shoulder surgery and its clinical management is still challenging. Hyaluronic acid (HA) has been shown to have anti-inflammatory effects in vitro and in vivo under RCT conditions, characterized by an exaggerated oxidative stress (OS). However, molecular mechanisms underlying HA-related effects are still partially disclosed. With these aims, a cell model of RCT was established by exposing primary human tenocytes to H2O2 for up to 72 h. Four different HAs by molecular weight were administered to measure nitric oxide (NO) and OS, apoptosis, and collagen 1 expression. In parallel, the well-known antioxidant ascorbic acid was administered for comparison. The present study highlights that HAs characterized by a low molecular weight are able to counteract the H2O2-induced OS by decreasing the percentage of apoptotic cells and reversing the activation of caspase 3 and 7. Likewise, NO intracellular levels are comparable to the ones of controls. In parallel, collagen 1 expression was ameliorated by HAs characterized by higher molecular weights compared to AA. These findings confirm that HA plays an antioxidant role comparable to AA depending on the molecular weight, and highlight the molecular mechanisms underlying the HA anti-apoptotic effects.

Subacromial spacer implantation: an alternative to arthroscopic superior capsular reconstruction. A systematic review.

INTRODUCTION: This systematic review evaluated and compared the use of a subacromial spacer implantation (SSI) with arthroscopic superior capsular repair (ASCR) in the management of massive irreparable rotator cuff tears (MIRCTs) with an assessment of clinical and imaging outcomes. SOURCES OF DATA: This systematic review was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched in PubMed, Medline and Embase database literature using the keywords 'subacromial spacer', 'subacromial balloon', 'subacromial device', 'arthroscopy', 'superior capsular reconstruction', 'irreparable rotator cuff tears', 'satisfaction' and 'quality of life'. AREAS OF AGREEMENT: We included a total of 29 articles (14 about SSI and 15 about ASCR) dealing with outcomes, satisfaction and patients' quality of life. AREAS OF CONTROVERSY: The use of a subacromial spacer showed similar results in terms of patients' satisfaction and quality of life when compared with ASCR. GROWING POINTS: SSI can be implanted quickly and has a low complication rate. It can therefore be considered a good alternative for the management of MIRCTs. AREAS TIMELY FOR DEVELOPING RESEARCH: The subacromial spacer is a biodegradable implant easily implanted at arthroscopy. It can lead good clinical and imaging outcomes in MIRCTs. Similarly, ASCR can be performed with either an autograft or synthetic allograft transplantation, with satisfactory results. Long-term prospective studies are needed to compare SSI and ASCR to verify their effectiveness.

Pulsed electromagnetic fields after intramedullary nailing of tibial fractures: a case control study.

PURPOSE: To compare clinical and functional outcomes of two groups of patients undergoing reduction and nailing fixation for diaphyseal fractures of the tibia with (PEMF group) and without (control group) post-operative pulsed electromagnetic field (PEMF) application. METHODS: This is a retrospective study on 50 patients (mean age 43.3 years, 28 males and 22 females) with diaphyseal tibial fractures managed between 2017 and 2019. Twenty-five patients underwent reduction, nailing fixation, and PEMF application post-operatively (PEMF group) and 25 patients underwent nailing fixation. Radiographic imaging assessment was performed every month until fracture healing had been evident. Use of analgesics, fracture healing time, post-operative lower limb alignment, and post-operative complications were recorded. Patients were asked about return to preinjury activity. All patients were assessed at 3 months and at an average follow-up of 13 months. The VAS scale and Johner-Wruhs criteria were used for pain assessment and functional recovery, respectively. RESULTS: Comparing groups, VAS values were significantly lower in the PEMF group at three months and comparable at one year. The patients in the PEMF group took an average of 4.1 months to resume their preinjury activities, and control patients took an average of 5.3 months (P < 0.0001). According to the Johner-Wruhs score, the effective rate was 100% (25/25) in the PEMF group and 92% (23/25) in the control group (P = 0.14). CONCLUSIONS: PEMF application after intramedullary nailing is safe and reduces post-operative pain, use of analgesics, and the time of healing fracture. At one year, there is no difference in outcome measures, regardless of PEMF application.

Arthroscopic superior capsular reconstruction versus latissimus dorsi transfer for irreparable rotator cuff lesions: a systematic review.

INTRODUCTION: The present systematic review compared arthroscopic superior capsular reconstruction (ASCR) and latissimus dorsi transfer (ALDT) for the management of massive irreparable rotator cuff lesions. SOURCES OF DATA: We performed a systematic review searching the literature on Medline, Cochrane and Scopus databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. AREAS OF AGREEMENT: We included a total of 20 articles, 10 on ASCR and 10 on ALDT (12 retrospective and 8 prospective studies), all published between 2013 and 2019. AREAS OF CONTROVERSY: ASCR and ALDT are technical demanding procedures. When compared to each other, they do not produce significantly different improvements in clinical outcome. GROWING POINTS: Both ASCR and ALDT are valid options for surgical management of MIRCLs. Although ALDT has shown a greater complication rate and a less improvement in acromion-humeral distance, its clinical outcomes overlap those obtained with ASCR. AREAS TIMELY FOR DEVELOPING RESEARCH: Further comparative prospective and retrospective studies with longer follow-up could confirm which surgical procedure can lead to better outcomes with a lower complication rate.

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.

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.

Hyaluronic acid increases tendon derived cell viability and collagen type I expression in vitro: Comparative study of four different Hyaluronic acid preparations by molecular weight.

BACKGROUND: Hyaluronic Acid (HA) has been already approved by Food and Drug Administration (FDA) for osteoarthritis (OA), while its use in the treatment of tendinopathy is still debated. The aim of this study was to evaluate in human rotator cuff tendon derived cells the effects of four different HA on cell viability, proliferation, apoptosis and the expression of collagen type I and collagen type III. METHODS: An in vitro model was developed on human tendon derived cells from rotator cuff tears to study the effects of four different HA preparations (Ps) (sodium hyaluronate MW: 500-730 KDa - Hyalgan®, 1000 kDa Artrosulfur HA®, 1600 KDa Hyalubrix® and 2200 KDa Synolis-VA®) at various concentrations. Tendon derived cells morphology were evaluated after 0, 7 and 14 d of culture. Viability, proliferation, apoptosis were evaluated after 0, 24 and 48 h of culture. The expression and deposition of collagen type I and collagen type III were evaluated after 1, 7 and 14 d of culture. RESULTS: All HAPs tested increased viability and proliferation, in dose dependent manner. HAPs already reduce apoptosis at 24 h compared to control cells (without HAPs). Furthermore, HAPs stimulated the synthesis of collagen type I in a dose dependent fashion over 14 d, without increase in collagen type III; moreover, in the presence of Synolis-VA® the expression and deposition of collagen type I was significantly higher as compare with the other HAPs. CONCLUSIONS: HAPs enhanced viability, proliferation and expression of collagen type I in tendon derived cells.

Application of pulsed electromagnetic fields after microfractures to the knee: a mid-term study.

PURPOSE: Pulsed electromagnetic fields (PEMFs) may improve clinical outcomes following microfractures and prevent their decline over time. METHODS: Sixty-eight patients who underwent partial medial meniscectomy and microfractures to the medial femoral condyle for management of grade III-IV cartilage lesions were randomly divided into two groups using a block randomization procedure. After surgery, 34 patients underwent PEMFs application in the I-ONE group; 34 patients underwent placebo treatment in the placebo group. All patients had the same postoperative rehabilitation protocol. Sixty patients (28 in the I-ONE group, 32 in the placebo group) were assessed at an intermediate follow-up of two years and a minimum follow-up of five years after surgery. RESULTS: The two groups were homogeneous. There was a significant improvement from baseline to the last minimum follow up of two years. At two years, IKDC and Lysholm and Constant scores were significantly improved compared to baseline in both groups with no significant inter-group differences. At the last follow up (minimum five years), clinical and functional outcomes were decreased in both the groups, with significant better outcomes in the I-ONE group. At five years, the percentage of patients still active at the same level they were pre-operatively was greater in the I-ONE group (82% vs 68%, P = 0.28). At radiographic assessment, at the latest evaluation, six patients (21.4%) in the I-ONE group and nine (28.1%) in the placebo group demonstrated grade I-II degenerative changes according to Fairbank grading system (Χ = 0.36, P = 0.55). CONCLUSIONS: PEMFs application can improve the effectiveness of microfracture in the long term.

Microfractures at the rotator cuff footprint: a randomised controlled study.

PURPOSE: Microfractures at the footprint may be a potential additional source of growth factor and enhance the tendon healing at the bone-tendon junction when repairing rotator cuff tears. METHODS: Fifty-seven patients who underwent shoulder arthroscopy for repair of complete rotator cuff tears were randomly divided into two groups, using a block randomisation procedure. Patients underwent microfracture at the footprint in the treatment group. The patients in the control group (n = 29) did not receive that treatment. All patients had the same post-operative rehabilitation protocol. RESULTS: The two groups were homogeneous. There was a significant improvement from baseline to the last minimum follow-up of two years. At three months from the index procedure, visual analogue scale (VAS), range of motion (ROM) and University of California at Los Angeles (UCLA) and Constant scores were significantly better in group 1 than in group 2 (P < .05). At the last follow-up (minimum two years), clinical and functional outcomes were further improved in both the groups but inter-group differences were not significant. No technique-related complications were recorded. CONCLUSIONS: Microfractures at the footprint are simple, safe, inexpensive and effective at producing less pain in the short term in patients who undergo rotator cuff repair, but at two years they do not result in significantly different outcomes, either clinically or at imaging, compared to traditional rotator cuff repair.

Meniscectomy as a risk factor for knee osteoarthritis: a systematic review.

INTRODUCTION: This review defines the recognized risk factors responsible for the development of knee osteoarthritis after surgical management of meniscal tears. SOURCES OF DATA: We performed a literature search using Medline, Ovid, Cochrane and Google Scholar using the keywords: 'Meniscal tears', 'meniscectomy', 'osteoarthritis', 'complications' and 'risk factors'. Thirty-two published studies were identified. AREAS OF AGREEMENT: In the long term, osteoarthritis develops in the knee of patients undergoing surgery for meniscal tears. The Coleman methodology score showed great heterogeneity in terms of patient characteristics and outcome assessment. Amount of meniscus removed, duration of pre-operative symptoms and lateral meniscectomy show strong statistical association to onset of knee osteoarthritis. AREAS OF CONTROVERSY: We did not find univocal findings defining the risk factors responsible for the development of post-operative knee osteoarthritis. GROWING POINTS: There is a need for standardized clinical and imaging validated scale to improve definition of post-operative knee osteoarthritis to allow easier and more reliable comparison of outcomes in different studies. AREAS TIMELY FOR DEVELOPING RESEARCH: Appropriately powered randomized controlled trials reporting clinical and imaging-related outcomes in patients undergoing arthroscopic minimally invasive procedures and meniscal suturing should be performed. Comparing imaging findings of patients undergoing arthroscopic partial and open meniscectomy, a lower incidence of knee osteoarthritic evolution was detected after arthroscopy. The amount of removed meniscus is the most important predictor factor for the development of osteoarthritis. Minimally invasive procedures seem to reduce the incidence of long-term osteoarthritic changes of the knee compared with more invasive open and or arthroscopic procedures.

Surgery for ACL deficiency in patients over 50.

PURPOSE: To compare the outcomes of arthroscopic ACL reconstruction procedure in 20 middle-aged patients (12 men and 8 women) and 20 subjects younger than 30 years (control group) at a minimum post-operative follow-up of 24 months. METHODS: Pre- and post-operative anterior-posterior laxity was assessed by Lachman test, pivot shift test and KT1000 arthrometer at manual maximum stress. Clinical functional evaluation was assessed according to IKDC Committee (IKDC) subjective knee form, IKDC ligament standard evaluation and Lysholm score. RESULTS: At 2 years, all variables significantly improved in both groups compared to pre-operative values (P < 0.05), with non-significant intergroup difference. CONCLUSIONS: When faced with ACL deficiency, physiological age, condition of the knee at the time of examination, life expectancy and activity level are probably more important than chronologic age. In the present study, arthroscopic surgery for the management of ACL tear and secondary lesions provides comparable clinical outcomes in middle-aged patients and in patients aged below 30.

Creatinine and nonprotein nitrogen plasma levels: possible etiopathogenetic factors in rotator cuff tears.

OBJECTIVE: To determine the plasma levels of nonprotein nitrogen (NPN) and creatinine in healthy patients with rotator cuff tears. METHODS: The study included 400 subjects. The study group included 200 patients (93 men and 107 women; mean age, 56.8 years; range, 23-81 years) who underwent arthroscopic repair of a rotator cuff tear from 2004 to 2007. The control group included 200 patients (93 men and 107 women; mean age, 53.9 years; range, 20-81 years) who underwent arthroscopy for management of a meniscal tear, with or without articular cartilage damage, in the same period. The 2 groups were frequency-matched by age and sex. Measurement of plasma levels of NPN and creatinine were performed in all patients. RESULTS: Patients with rotator cuff tears showed higher plasma NPN levels within the normal range (P = 0.035) than patients with knee disorders (control group). Creatinine levels were comparable (P = 0.66) in both groups. CONCLUSION: There appears to be an association between plasma NPN levels and rotator cuff tears. On the basis of our findings, plasma NPN could be involved in the pathogenesis of rotator cuff tears, although we advocate further research to draw more definitive conclusions.

Management of combined ACL-MCL tears: a systematic review.

INTRODUCTION: The optimal management for combined anterior cruciate ligament-medial collateral ligament (ACL-MCL) injuries is controversial. SOURCES OF DATA: We performed a literature search using Medline, Cochrane and Google Scholar using the keywords: 'ACL' and 'MCL' in combination with 'surgery treatment', 'conservative treatment', 'surgery management', 'conservative management', 'surgical treatment' and 'surgical management'. We identified 23 published studies. AREAS OF AGREEMENT: Conservative and surgical management for combined ACL-MCL injuries resulted in different functional outcomes. The Coleman Methodology Score showed great heterogeneity in terms of study design, patient characteristics, management methods and outcome assessment and generally low methodological quality. AREAS OF CONTROVERSY: Given the heterogeneity in terms of treatment and results, we did not find a univocal trend over the years regarding MCL management (conservative or surgical). The use of several scoring systems did not allow us to compare outcomes in the different studies. GROWING POINTS: There is a need for a common validated scale for clinical measurements for ACL-MCL injuries, so as to allow easier and more reliable comparison of outcomes in different studies. To improve diagnostic certainty of combined ACL-MCL injuries, all patients should have imaging assessment (MR and stress-radiography) in addition to clinical examination. AREAS TIMELY FOR DEVELOPING RESEARCH: There is a need to perform appropriately powered randomized clinical trials of conservative and surgical treatment of combined ACL-MCL injuries, using standard diagnostic assessment, common and validated scoring system comparing reported outcomes and duration of follow-up more than 2 years.

Glenohumeral arthropathy following stabilization for recurrent instability.

Little attention has been focused on the most common risk factors for post-operative glenohumeral arthropathy in patients undergoing open and arthroscopic stabilization. We performed a literature search using Medline, Cochrane and Google Scholar using the keywords: 'Shoulder instability surgery' in combination with 'glenohumeral osteoarthrosis', 'recurrent shoulder dislocation' in combination with 'surgery' and 'complications'. We identified 33 published studies. There is evidence of long-term postoperative glenohumeral arthropathy in patients undergoing surgical management for shoulder instability. The Coleman methodology score showed great heterogeneity in terms of study design, patient characteristics, management methods and outcome assessment and generally low methodological quality. Follow-up length, age at first dislocation episode and limited external rotation have been shown to be strongly associated with shoulder arthropathy. There is no univocal outcome assessment available. To define the risk factors responsible for development of postoperative glenohumeral arthropathy, controversial findings have been detected. A common validated scale for clinical and imaging measurements for shoulder arthropathy is needed, so as to allow easier and more reliable comparison of outcomes in different studies. Patients should receive controlled imaging assessment (MR and radiographs) in addition to clinical examination. There is a need to perform appropriately powered randomized clinical trials comparing clinical and imaging related outcomes in patients undergoing open, arthroscopic and conservative management for shoulder instability. Standard diagnostic assessment, common and validated clinical and imaging scoring systems are needed.

RC-QOL score for rotator cuff pathology: adaptation to Italian.

We translated and adapted the English RC-QOL (rotator cuff quality of life) questionnaire into Italian and performed reliability and validity evaluations of the Italian RC-QOL version in patients with rotator cuff tears. The RC-QOL English version was translated into Italian by a bilingual orthopaedic surgeon. The back translation of the Italian version into English was performed by another bilingual orthopaedic surgeon. The original version was compared with the back translation. The RC-QOL questionnaire was then administered to 22 subjects (range 45-74 years) with a diagnosis of rotator cuff tears. For test-retest evaluation, the 22 patients were asked to complete the questionnaire at first examination, and 30 min following the end of this examination. The intraclass correlation coefficient for the 22 patients was 0.94 (95% CI = 0.85-0.98), indicating a high reliability. There were no significant differences between the scores immediately after the consultation and 30 min later. The Italian and the English versions of the RC-QOL questionnaire evaluate the same aspects of clinical severity in patients with rotator cuff tears.

Simultaneous surgical management of chronic grade-2 valgus instability of the knee and anterior cruciate ligament deficiency in athletes.

We report on 22 patients with chronic grade-2 valgus laxity of the knee combined with chronic anterior cruciate ligament (ACL) insufficiency, in whom the two lesions were addressed at the same surgical setting. At a minimum follow-up of 24 months, clinical and functional variables had improved significantly (P < 0.001), and 20 of the 22 patients (91%) had returned to sport at pre-injury level. There were no operative complications in this series. In selected athletes with chronic symptomatic valgus laxity of the knee combined with ACL insufficiency, surgical repair of the MCL in association with ACL reconstruction is a suitable and reliable option to restore knee stability and allow return to pre-injury activity level.

Comparison of arthroscopic rotator cuff repair in healthy patients over and under 65 years of age.

We compared the outcomes of arthroscopically repaired rotator cuff tears in 28 patients older than 65 years (the over 65 group: median age 70 years) with a control group of 28 patients younger than 65 years (the under 65 group: median age 57 years). The groups were similar in regard to sex distribution, surgical technique, and post-operative rehabilitation programmes, but different in age. After careful arthroscopic evaluation of the full-thickness rotator cuff tear, rotator cuff repair and biceps tenotomy were performed in all patients. Pre- and post-operatively, each patient was evaluated for range of motion, shoulder score (UCLA), and SF-36 self-administered questionnaire. Comparing pre- versus post-operative status at a minimum 24 months follow-up, forward elevation, internal and external rotation, modified UCLA rating system scores, and SF-36 scores improved significantly in both groups, with no significant difference between the groups. At the last follow-up, strength improved significantly in both groups, with non-significant intergroup difference. The Popeye sign was detected in 13/28 (46%) of the patients in the over 65 group and in 11/28 (39%) in the under 65 group (χ = 0.29) with non-significant difference between the two groups. In selected active patients older than 65, arthroscopic rotator cuff repair associated with biceps tenotomy (when necessary) can yield clinical and related quality of life outcomes similar to those of patients younger than 65 years.

Good results five years after surgical management of anterior cruciate ligament tears, and meniscal and cartilage injuries.

In athletes with anterior cruciate ligament (ACL) tears combined with meniscal and cartilage injuries, the goals are to restore knee laxity and relieve symptoms, while long-term goals are the return to pre-injury sport activity and to prevent onset of degenerative changes. We compared the post-operative (minimum 5 years) clinical and radiological outcomes of 50 patients, similar for ACL rupture and meniscal tears, but different for the grade of cartilage lesion. The patient population was divided into two groups similar for ACL reconstruction and surgical meniscal management. Group 1 included 25 patients undergoing microfracture management of grade III-IV cartilage lesions, while Group 2 included 25 patients with grade I-II cartilage lesions, managed by radiofrequency. Comparing pre- and post-operative status, Lachman test, pivot shift values and KT 1000 side to side difference measurements improved significantly (<.001) in both groups, with NS difference between the two groups (>0.05) at the intermediate and latest assessments. At both post-operative appointments, in both groups, the average Lysholm score and IKDC ranking rates improved significantly (<0.001) compared to pre-operative values, but slight worsening was observed in Group 1 patients at the latest review. At the latest assessment, 10 knees (40%) in Group 1 and 3 knees (15%) in Group 2 demonstrated degenerative changes according to Fairbank grading. Concerning the WOMAC index score and sport activity level rating, Group 1 patients had significantly lower scores than Group 2 patients (P < 0.05). In patients with symptomatic ACL instability combined to grade III-IV cartilage lesions, microfractures give excellent short-term clinical and functional improvement but do not prevent the evolution of degenerative changes.