Adam Kwapisz

[Osteoarthritis: etiology, risk factors, molecular mechanisms].

Osteoarthritis is an incurable joint disease manifesting itself with gradually progressing degenerative changes, leading to premature motor disability. These changes mainly occur owing to an imbalance between the processes of degeneration and regeneration of articular cartilage structures. Until now many risk factors favoring the development of degenerative joint disease have been identified. These include age, weight, previously sustained traumas to joints, sports, sex and genetic predisposition. The latest scientific reports confirm that the pathogenesis of changes in osteoarthritic joints is complex and occurs on many levels. Enzymes belonging to the metalloproteinases family are mainly responsible for the degeneration of articular cartilage. Their activity is regulated by numerous pro-inflammatory cytokines, transcription factors and miRNA. A thorough analysis of all processes occurring in the afflicted joints needs to be carried out before effective therapeutic strategies can be developed.

Clinical evaluation of the shape of the suprascapular notch—an ultrasonographic and computed tomography comparative study: Application to shoulder pain syndromes

The most common site of suprascapular nerve compression and injury is the suprascapular notch. The aim of this study was to assess the sensitivity and specificity of sonography in determining the type of suprascapular notch (SSN). Thirty randomized patients (60 upper extremities) underwent USG examination of the shoulder area. The results were further compared with three‐dimensional reconstructions of the scapulae obtained through CT examination to place the SSNs within a fivefold classification. For identification of type I, the sensitivity was 73.3% and the specificity 97.8%. For identification of type III, the values was 96.9% and 85.7%, respectively. Type II was not found in USG examination. Discrimination between type IV and V was not possible. The mean distance between the line connecting the edges of the SSN and the skin was 38 mm in right‐handed patients and 34 mm in ambidextrous subjects. Ultrasonographic examination of the SSN is characterized by high specificity for type I, and high sensitivity for type III SSN. Discrimination between type IV and V of the SSN is not recommended based on sonographic evaluation. Clin. Anat. 28:774–779, 2015.

Nonoperative management versus reverse shoulder arthroplasty for treatment of 3- and 4-part proximal humeral fractures in older adults

BACKGROUND The treatment of 3- and 4-part proximal humeral fractures in the older adult is controversial. No study has directly compared reverse shoulder arthroplasty (RSA) with nonoperative treatment for these fractures. The purpose of this study was to compare clinical and patient-reported outcomes between RSA and nonoperative treatment groups. METHODS A retrospective review was performed on all 3- and 4-part proximal humeral fractures treated with either RSA or nonoperative treatment with minimum 1-year follow-up. All patients in the nonoperative cohort were offered RSA but declined. Objective patient data were obtained from medical records. Patient-reported outcomes including visual analog scale score, Single Assessment Numeric Evaluation score, Penn Shoulder Score, American Shoulder and Elbow Surgeons score, resiliency score, and Veterans Rand-12 scores were obtained at follow-up. Statistical analysis was performed by use of the Student t test for continuous variables and χ2 analysis for nonparametric data. RESULTS We analyzed 19 nonoperative and 20 RSA patients with a mean follow-up period greater than 2 years (29 months in nonoperative group and 53 months in RSA group). There were no differences in range of motion between groups (forward elevation, 120° vs 119° [P = .87]; external rotation, 23° vs 31° [P = .06]). No differences between the nonoperative and RSA groups were noted for any patient-reported outcomes. Among patients receiving RSA, there was no difference in outcomes in those undergoing surgery less than 30 days after injury versus those receiving delayed RSA. CONCLUSIONS This study suggests that there are minimal benefits of RSA over nonoperative treatment for 3- and 4-part proximal humeral fractures in older adults.

Clinical outcomes of suprascapular nerve decompression: a systematic review

BACKGROUND Suprascapular neuropathy is an uncommon clinical diagnosis. Although there have been a number of case series reporting on this pathologic process, to date there has been no systematic review of these studies. This study aimed to synthesize the literature on suprascapular neuropathy with regard to clinical outcomes. The secondary objective was to detail the diagnosis and treatment of suprascapular neuropathy and any associated complications. METHODS A systematic review was performed to identify studies that reported the results or clinical outcomes of suprascapular nerve decompression. The searches were performed using MEDLINE through PubMed and Cochrane Database of Systematic Reviews. RESULTS Twenty-one studies comprising 275 patients and 276 shoulders met inclusion criteria. The mean age was 41.9 years, and mean follow-up was 32.5 months. The most common symptom was deep, posterior shoulder pain (97.8%), with a mean duration of symptoms before decompression of 19.0 months; 94% of patients underwent electrodiagnostic testing before decompression, and 85% of patients had results consistent with suprascapular neuropathy. The most common outcome reported was the visual analog scale score, followed by the Constant-Murley score. The mean postoperative Constant-Murley score obtained was 89% of ideal maximum. Ninety-two percent of athletes were able to return to sport. Only 2 (0.74%) complications were reported in the included studies. CONCLUSIONS Surgical decompression in the setting of suprascapular neuropathy leads to satisfactory outcomes as evidenced by the patient-reported outcomes and return to sport rate. Furthermore, the rate of complications appears to be low.

Outcomes for subscapularis management techniques in shoulder arthroplasty: a systematic review

BACKGROUND This systematic review aims to synthesize published data for the most common subscapularis takedown and repair to compare outcomes in the setting of shoulder arthroplasty. METHODS Searches of MEDLINE and Cochrane Library databases identified studies that reported clinical or radiologic outcomes for subscapularis management in the setting of shoulder arthroplasty. Comparisons included musculotendinous integrity, subscapularis testing and strength, shoulder range of motion, and functional outcome scores. RESULTS The 14 included studies reported considerable variability in techniques, outcomes, and musculotendinous integrity. Lesser tuberosity osteotomy (LTO) demonstrated better healing rates (93.1%) than subscapularis peel (SP; 84.1%) and midsubstance tenotomy (ST; 75.7%), although not significantly different. A statistically significant increase in fatty infiltration was found after surgery across techniques, and range of motion and strength were similar. Mean rates of normal results for belly-press and lift-off tests were uniformly better for LTO (79.1% and 80.7%) over ST (66.7% and 65.6%), although multiple studies showed poor correlation between subscapularis functional testing and musculotendinous integrity. Mean total Constant and Western Ontario Osteoarthritis of the Shoulder Index outcome scores were slightly better for LTO (77.6, 84.2) than for SP (71.8 and 82.7). Mean American Shoulder and Elbow Surgeons scores favored the ST group (80.8) over the SP (79.1) and LTO (73) groups. CONCLUSIONS The data suggest no significant differences exist for postoperative musculotendinous integrity or clinical outcomes among the subscapularis management techniques in shoulder arthroplasty. Subscapularis healing and integrity appear to favor the lesser tuberosity takedown method. Additional randomized controlled comparisons with long-term follow-up are needed to more effectively compare these surgical approaches.

Distal Clavicular Osteochondral Autograft Augmentation for Glenoid Bone Loss: A Comparison of Radius of Restoration Versus Latarjet Graft:

Background: Bone loss in shoulder instability is a well-recognized cause of failure after stabilization surgery. Many approaches have been described to address glenoid bone loss, including coracoid transfer. This transfer can be technically difficult and has been associated with high complication rates. An ideal alternative to coracoid transfer would be an autologous source of fresh osteochondral graft with enough surface area to replace significant glenoid bone loss. The distal clavicle potentially provides such a graft source that is readily available and low-cost. Purpose: To evaluate distal clavicular autograft reconstruction for instability-related glenoid bone loss, specifically comparing the width of the clavicular autograft with the width of an ipsilateral coracoid graft as prepared for a Latarjet procedure. Further, we sought to compare the articular cartilage thickness of the distal clavicle graft with that of the native glenoid. Study Design: Controlled laboratory study. Methods: Twenty-seven fresh-frozen cadaver specimens were dissected, and an open distal clavicle excision was performed. The coracoid process in each specimen was prepared as has been described for a classic Latarjet coracoid transfer. In each specimen, the distal clavicle graft was compared with the coracoid graft for size and potential of glenoid articular radius of restoration. The distal clavicle graft was also compared with the native glenoid for cartilage thickness. Results: In all specimens, the distal clavicle grafts provided a greater radius of glenoid restoration than the coracoid grafts (P < .0001). On average, the clavicular graft was able to reconstruct 44% of the glenoid diameter, compared with 33% for the coracoid graft (P < .0001). The articular cartilage of the glenoid was significantly thicker (1.4 mm thicker, P < .0001) than that of the distal clavicular autograft (average ± SD, 3.5 ± 0.6 mm vs 2.1 ± 0.8 mm, respectively). When specimens with osteoarthritis were excluded, this difference decreased to 0.97 mm when compared with the clavicular cartilage (P = .0026). Conclusion: The distal clavicle autograft can restore a significantly greater glenoid bone deficit than the Latarjet procedure and has the additional benefit of restoring articular cartilage to the glenoid. The articular cartilage thickness of the distal clavicle is within 1.4 mm of that of the native glenoid. Clinical Relevance: The distal clavicular autograft may be a suitable option for reconstruction of instability-related glenoid bone loss. This graft provides a structural osteochondral autograft with a broader radius of reconstruction than that of a coracoid graft, is locally available, has minimal donor site morbidity, is anatomic, and provides articular cartilage.

Anterior Capsule Reconstruction for Irreparable Subscapularis Tears

A subscapularis complete tear presents its own challenges in management. The glenohumeral biomechanics and force couple are reliant on a competent and functioning subscapularis muscle. An irreparable subscapularis makes those same challenges even more difficult to address. Traditionally, this problem has been addressed with tendon transfers, including pectoralis major or latissimus dorsi. These techniques can alter the ideal biomechanics of the shoulder and have high rates or failure. Iliotibial autograft or tibialis anterior have also been wrought with high failure rates. Recently, the superior capsular reconstruction has been described for irreparable tears of the supraspinatus and infraspinatus. Theoretically, this procedure can act as a check rein against subluxation, and may serve to reconnect the force couples of the rotator cuff. Anterior escape may represent a similar challenge when the irreparable rotator cuff tendon is the subscapularis. To address this, we describe an open anterior capsule reconstruction technique with an acellular dermal graft. We theorize that this procedure may serve in a similar capacity to its superior capsular counterpart.

Correlations between BMP-4 gene expression, heterotopic ossification and function after uncemented total hip replacement.

BACKGROUND Heterotopic ossification (HO) is the abnormal, non-neoplastic presence of lamellar bone in soft tissue. Bone morphogenetic proteins (BMP) are among factors that may lead to HO. The purpose of the study was to evaluate correlations between BMP-4 gene expression and HO and the influence of those factors on outcomes of cementless total hip replacement (THR). PATIENTS AND METHODS A series of sixty-four (64) patients were enrolled. The patients were at a mean age of 52.3 years and all of them had undergone unilateral THR. Mean duration of follow-up was 56.74 months. At the last follow-up visit, 1 ml blood samples were collected and BMP-4 gene expression was measured by the RT-PCR technique. Hip radiographs were also obtained and a clinical examination was performed during that visit. RESULTS A strong statistical correlation was observed between HO grades according to Brookers scale and BMP-4 expression levels (rho=0.946, p<0.0001), while there was no correlation between clinical outcomes according to the Harris Hip Score (HHS) and Brookers grades (rho= -0.188, p=0.3) as well as between Harris hip scores and BMP-4 expression levels (rho=0.1, p=0.6). CONCLUSIONS BMP-4 expression strongly correlates with HO as measured by Brookers scale and may play a role in the aetiology of this condition. The over-expression of BMP-4 may exert a certain influence on ectopic bone formation after total hip arthroplasty.

Platelet-Rich Plasma for Elbow Pathologies: a Descriptive Review of Current Literature

Purpose of ReviewPlatelet-rich plasma is used in many orthopedic pathologies such as tendinopathies and ligament injuries. The clinical results reported in the scientific literature are, however, confusing. The aim of this manuscript is to provide a narrative literature review regarding the role of PRP in the most common elbow soft tissue pathologies.Recent FindingsThe response to PRP seems to be favorable when compared to steroid injection for pain management and for patient-reported outcomes in lateral epicondylitis. PRP injection does not seem to have the potential complications associated with a steroid injection such as skin atrophy, discoloration, and secondary tendon tears. Only a few manuscripts comparing the results of PRP treatment with either extracorporeal shockwave (ESW), dry needling, or even surgical treatments in lateral epicondylitis exist. The use of PRP in other elbow pathologies such as golfer’s elbow, ulnar collateral ligament injury, and distal biceps and triceps pathology is examined in few studies, with unclear recommendations.SummaryRegarding elbow pathologies, PRP injections in tennis elbow seems to be the best-studied intervention. A major limitation in these studies is the significant heterogeneity in the methods used for preparing PRP, for example employing leukocyte-rich, leukocyte-poor preparations, PRP with or without activation, which makes the results of the studies difficult to compare. Results of this review show that more studies on larger cohorts, with comparable formulations, and with longer follow-up are required to give optimal suggestions concerning the use of PRP in elbow pathologies.

All-inside Arthroscopic Meniscal Repair Technique Using a Midbody Accessory Portal

Treatment of symptomatic meniscal tears continues to evolve as we improve our understanding of the biomechanical role of the meniscus and its long-term importance to the health of the knee joint. Suture repair of meniscal tears is challenging, yet the incidence of repairs among our colleagues continues to rise as we aim to preserve meniscal tissue. Many elements of performing a repair are tedious and difficult, including proper meniscal preparation, reduction, mattress suture placement, and fixation. The tear pattern and location present another layer of difficulty. The most widely used all-inside repair devices are harpoon-style devices and present their own challenges in using them without causing harm to the meniscus and surrounding cartilage. In this article, we describe a simple all-inside meniscal repair technique to improve the reproducibility and reliability of meniscal repairs using an accessory midbody meniscal portal and a surgical probe. This ensures proper placement of mattress sutures in a reduced meniscus, with a reduced risk of collateral injury to the meniscus and articular cartilage. Furthermore, this surgical technique is adaptable to any meniscal fixation method to the medial or lateral meniscus.