Biagio Zampogna

Bone bruises in anterior cruciate ligament injured knee and long-term outcomes. A review of the evidence.

Background Bone bruises are frequently associated with anterior cruciate ligament (ACL) tears as a result of trauma or direct shear stress of the bone. Purpose To review the evidence regarding the characteristics of the bone bruise associated with ACL tears, its relevance on clinical outcomes, and its progression over time. In particular, the long-term effects of the bone bruise on the knee osteochondral architecture and joint function were evaluated. Study design Review; level of evidence: 4. Methods An electronic search was performed on PubMed. Combinations of keywords included: “bone bruise AND knee”; “bone bruise AND anterior cruciate ligament”; “bone bruise AND osteo-chondral defects”. Any level of evidence studies concerning bone bruises in patients with partial or complete ACL tears were retrieved. Results A total of 25 studies were included; three of them investigated biomechanical parameters, seven were concerned with clinical outcomes, and 15 were radiological studies. Evaluation of the bone bruise is best performed using a fat-saturated T2-weighted fast spin echo exam or a short tau inversion recovery sequence where fat saturation is challenging. The location of the injury has been demonstrated to be more frequent in the lateral compartment of the joint (lateral femoral condyle and lateral tibial plateau). It is associated with ACL tears in approximately 70% of cases, often with collateral ligament or meniscal tears. Mid- and long-term outcomes demonstrated a complete healing of the marrow lesions at magnetic resonance imaging, but chondral defects detected with T1ρ sequences are still present 1 year after the ACL injury. Functional examination of the knee, through clinical International Knee Documentation Committee scores, did not show any correlation with the bone bruise. Conclusion Although bone bruise presence yields to higher pain levels, no correlation with functional outcomes was reported. Most studies have a short-term follow-up (<2 years) compared to the length of time it takes to develop post-traumatic osteoarthritis, so it still remains unclear whether the initial joint injury and bone bruise have a direct relationship to long-term function.

Double Row Repair: Is it Worth the Hassle?

In the operative management of rotator cuff disease, comparable functional results have been reported after open or mini-open repair and arthroscopic fixation. Surgical repair aims to re-establish an anatomical configuration of the tendon-bone construct for restoring its mechanical performance. Single row repair is the most commonly used technique, but recently some authors have proposed to re-establish the rotator cuff footprint with 2 rows of suture anchors (“double row” repair). In regard to imaging assessment, at time zero double row repair results being more anatomic and allows for structurally sound restoration of the rotator cuff footprint. However, this does not seem to translate into superior clinical outcomes for the double row repair when evaluating all different sizes of rotator cuff tears as a whole. The scientific basis for recommending single or double row repair as preferred treatment for patients with rotator cuff tear is questionable, as minimal differences have been measured on clinical and functional rating scales.

Why Do Osteochondral Allografts Survive? Comparative Analysis of Cartilage Biochemical Properties Unveils a Molecular Basis for Durability

Background: Transplantation of osteochondral allografts (OCAs) freshly preserved for ≥30 days has proven to be a reliable technique for cartilage resurfacing. However, the prolonged storage of allografts comes at the expense of chondrocyte viability, which declines precipitously after 14 days under refrigeration. Despite this, radiographic data indicate that most allograft cartilage remains stable for years after implantation. The apparent durability of partially devitalized cartilage begs the question of how the extracellular matrix is maintained. Hypothesis: Compared with patients’ defect cartilage, replacement OCAs freshly preserved for 36 days on average contain significantly lower levels of cartilage matrix–destructive metalloproteinases, which may contribute to the long-term stability of implanted grafts. Study Design: Descriptive laboratory study. Methods: Chondrocyte density was determined by the cell yield from digested cartilage and by double-strand DNA content quantified with PicoGreen assay. Chondrocyte viability was estimated by staining enzymatically isolated chondrocytes with calcein AM and ethidium homodimer–2. Cartilage proteoglycan (PG) content was analyzed with dimethylmethylene blue assay. The in vitro 48-hour release of PG-depleting metalloproteinases including matrix metalloproteinase (MMP)–1, –3, –13, and ADAMTS-5 from cartilage was examined with Western blotting. The data were compared between diseased cartilage from patients and samples from matched grafts. The relative amount of MMP-3 to its endogenous inhibitor, tissue inhibitor of MMP–1 (TIMP-1), was also determined with Western blotting. Results: Chondrocyte density decreased linearly with allograft storage time and declined by an average of 43%. PG content decreased while the percentage of nonviable chondrocytes increased with storage time, with the former showing less linearity. However, PG content remained in the normal range and was significantly higher than that in patients’ defect cartilage. Correspondingly, significantly less PG-depleting metalloproteinases and a much lower MMP-3/TIMP-1 ratio were detected in allograft cartilage than in patients’ diseased cartilage. Conclusion: These findings indicated that, at the time of implantation, fresh-preserved OCAs contained significantly lower levels of PG-depleting metalloproteinases compared with patients’ defect cartilage, which might contribute to their long-term stability in vivo. Clinical Relevance: The comparatively low expression of cartilage-dissolving metalloproteinases in human OCAs freshly preserved over 30 days offers support to the long-term durability of implanted grafts. Based on study data that showed similarity in the response to inflammatory cytokines between patients’ cartilage and OCA cartilage, strategies that can alleviate inflammation may provide extra benefit for the survival of implanted grafts. In terms of the practice of graft preservation, agents that can keep balance between the ATP supply and demand or stabilize the cell membrane or inhibit the activation of metalloproteinases may significantly improve cell viability in fresh-preserved OCAs with a storage time longer than 5 weeks.

Preoperative Risk Factors for, and Incidence of Delayed Surgery in Elective Primary Total Knee Arthroplasty After Hospital Admission: The ACS-NSQIP

BACKGROUND Approximately 600,000 total knee arthroplasties (TKA) are performed every year in the United States and the number of procedures has increased substantially every year. These demands may further strain the government, insurers, and patients struggling with increasing healthcare spending. A delay in proceeding to surgery after hospital admission may affect the overall healthcare costs. To our knowledge, the current literature has not addressed the incidence of, and preoperative risk factors for, a surgical delay in TKA. METHODS The ACS-NSQIP 2011 database was reviewed to identify patients undergoing elective primary total knee arthroplasty (TKA) using the Current Procedural Terminology (CPT) code 27447. 14,881 cases were no delay in proceeding to surgery after hospital admission while 139 cases were delayed for TKA. Risk factors or comorbidities contributing to surgical delay in TKA were identified. A univariate analysis of all patient parameters was conducted to measure the difference between the two cohorts. Finally, a multivariate logistic regression analysis was then conducted to identify risk factors or comorbidities for surgical delay. RESULTS There were 139 cases of surgical delay in TKA (0.93%). Congestive heart failure (P = 0.017), bleeding disorder (P <0.0001), sepsis (P <0.0001), a prior operation in the past 30 days (P <0.0001), dependent functional status (P <0.0001), ASA class 3 (P = 0.046), and hematocrit <38% (P <0.0001) were independent risk factors for a surgical delay. Postoperative medical complication (2.2% vs 0.8%, P < 0.0001) in surgical delay was significantly higher than non-delayed cohort. CONCLUSION The optimization of preoperative modifiable risk factors appears to be one of the best strategies to reduce delayed surgery and therefore costs in TKA.

Single- and double-row repair for rotator cuff tears - biology and mechanics.

OBJECTIVES We critically review the existing studies comparing the features of single- and double-row repair, and discuss suggestions about the surgical indications for the two repair techniques. DATA SOURCES All currently available studies comparing the biomechanical, clinical and the biological features of single and double row. MAIN RESULTS Biomechanically, the double-row repair has greater performances in terms of higher initial fixation strength, greater footprint coverage, improved contact area and pressure, decreased gap formation, and higher load to failure. Results of clinical studies demonstrate no significantly better outcomes for double-row compared to single-row repair. Better results are achieved by double-row repair for larger lesions (tear size 2.5-3.5 cm). CONCLUSIONS Considering the lack of statistically significant differences between the two techniques and that the double row is a high cost and a high surgical skill-dependent technique, we suggest using the double-row technique only in strictly selected patients.

Are Platelet Rich Plasma Injections More Effective in Tendinopathy orEnthesopathy

Introduction: Chronic overuse insertional tendinopathy (entesopathy) is highly prevalent, but is an extremely difficult condition that generates a high medical expense. Alternative and co-adjuvant therapies to improve the quality of life and physical function of affected patients are currently being sought. Materials and Methods: A total of 31 patients affected by entesopathy at different anatomical sites (elbow tendinopathy, greater trochanter pain syndrome and plantar fasciopathy) were treated with three peritendinous injections of autologous platelet rich plasma (PRP) and included in the present investigation. VAS scale and segmental scores for the affected site before the first injection of PRP and at 6 months after the last injection were used. One hundred and seven patients that underwent the same injection protocol in the same time lapse were used as a control group, and were represented by patients with non-insertional tendinopathy (shoulder and at Achilles tendon). Results: Significantly lower values between pre-treatment and follow-up pain scores at all-time points were found in the patients affected by entesopathy compared to tendinopathy (p<0.001). As a confirmative finding, the segmental scores at the shoulder and ankle did not improve overtime, differently from what occurred in patients with entesopathy. Conclusion: At 6 months following peritendinous injections of PRP in patients with entesopathy there was a significant reduction of pain, associated to a significant improvement in recorded segmental scores. Conversely, the treatment was not effective in patients with pure tendinopathy at the shoulder and ankle level. These favorable findings point to consider PRP as a promising therapy for patients affected by entesopathy.

Posterior Ankle and Subtalar Arthroscopy: Safety, Efficacy, and Expanding Indications

Over the last decade, arthroscopy in the prone position for hindfoot pathology has gained popularity in addition to open and supine anterior arthroscopic approaches. Open approaches to the hindfoot limits visualization and may increase surgical morbidity, leading to slower rehabilitation and return to sport activity. The posterior aspect of the ankle joint is difficult to access effectively with the traditional anterior arthroscopic approach, and does not allow exploration of the subtalar joint, requiring to switch the patient from the supine to the prone position to better access the hindfoot by posterior arthroscopy. The principal advantages of posterior hindfoot arthroscopy include less postoperative pain, improved visualization of the pathology, decreased risk for complications, and optimal recovery in the early postoperative phase. A combination of posterolateral and posteromedial portals allows the surgeon to visualize and access effectively periarticular structures around the tibiotalar and subtalar joints, the posterior half of the ankle, and the posterior subtalar facet. Preoperative evaluation of the patient with clear surgical indications is essential for optimal surgical outcomes. In addition to a detailed physical examination, radiographic assessment should include a complete series with standing anteroposterior and lateral view of the foot and ankle, and a Saltzman hindfoot alignment view. Despite the relatively recent experience with prone arthroscopy and using posteromedial portals, improvement in arthroscopic techniques and development of suitable instrumentation have had an important role in making prone arthroscopy a safe and reliable procedure. Level of Evidence: Diagnostic Level 4. See Instructions for Authors for a complete description of levels of evidence.

Accelerated Rehabilitation After Rotator Cuff Repair: Does Double Row Repair Lower The Risk For Re-Tear?

Introduction:Shoulder stiffness is the second most frequent complication affecting patients underwent rotator cuff repair. Even though it’s transient feature, it is substantial comorbidity and to the failure of surgical treatment, it is responsible for a substantial comorbidity and for surgical failure. It especially occurs in patients with one or more predisposing factors. In recent times it has been proposed an accelerated rehabilitation protocol to overcome the risk for stiffness development. It consists of starting closed-chain, passive overhead range of motion exercises and passive external rotation exercises (for those without subscapularis repairs) during the first 6 weeks. One trouble of the accelerated protocol is an higher risk for the tendon-to-bone failure, leading to re-tear, and consequently to surgical failure. Thus, the use of this special protocol has been restricted only for those patients with high risk for stiffness development. We advanced the hypothesis that the repair technique (single or double row) could affect the risk for post-operative re-tear rate. Methods: We compared two groups of patients undergoing rotator cuff repair and accelerated postoperative rehabilitation, one group treated with single row repair (SR group) and the other with double row (DR group). We evaluated the outcomes in terms of re-tear rate. From a total of 78 eligible patients, 60 (30 per groups) were enrolled in our prospective randomized clinical trails. Inclusion criteria were (1) night pain; (2) absence of shoulder instability; (3) no fractures of the glenoid and of the greater and smaller tuberosity; (4) failure of a 6-month period of conservative measures (NSAIDs, intrarticular injection of corticosteroids and physiotherapy); (5) strength loss. To assess the re-tear rate, patients underwent to shoulder MRI at the sixth post-operative month. Clinical evaluation was based on Constant-Murley and UCLA shoulder score. Results: In the overall cohort, a significative improvement was recorded from the preoperative to the postoperative time. Preoperative UCLA mean values were 12 (4-23) for SR group and 13 (5-26) for DR group; at the final follow-up UCLA mean values were 31 (8-35) for SR group and 33 (11-38) for DR group, without significative intergroup differences. Re-tear occurred in 8 patients out of 30 in SR group and in 3 patients in DR group (p<0.005). Our results demonstrated as double row repair lead to a stronger tendon-to-bone construct, resulting in a significant lower retear rate Discussion and Conclusion:We are aware that clinical advantages of the double row repair are still troublesome compared to the single row, considering the cost benefits ratio. For this reason we suggest to restrict the use of this repair technique only for patients at high risk of shoulder stiffness development and consequently necessitating International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine 9 th Biennial ISAKOS Congress • May 12-16, 2013 • Toronto, Canada ISAKOS