Davide Cucchi

Regenerative Medicine in Rotator Cuff Injuries

Rotator cuff injuries are a common source of shoulder pathology and result in an important decrease in quality of patient life. Given the frequency of these injuries, as well as the relatively poor result of surgical intervention, it is not surprising that new and innovative strategies like tissue engineering have become more appealing. Tissue-engineering strategies involve the use of cells and/or bioactive factors to promote tendon regeneration via natural processes. The ability of numerous growth factors to affect tendon healing has been extensively analyzed in vitro and in animal models, showing promising results. Platelet-rich plasma (PRP) is a whole blood fraction which contains several growth factors. Controlled clinical studies using different autologous PRP formulations have provided controversial results. However, favourable structural healing rates have been observed for surgical repair of small and medium rotator cuff tears. Cell-based approaches have also been suggested to enhance tendon healing. Bone marrow is a well known source of mesenchymal stem cells (MSCs). Recently, ex vivo human studies have isolated and cultured distinct populations of MSCs from rotator cuff tendons, long head of the biceps tendon, subacromial bursa, and glenohumeral synovia. Stem cells therapies represent a novel frontier in the management of rotator cuff disease that required further basic and clinical research.

History of rotator cuff surgery

AbstractPurpose Rotator cuff surgery is a rapidly evolving branch in orthopaedics, which has raised from a minor niche to a fully recognized subspecialty. This article summarizes its history, examining the development of its key principles and the technical advancements.MethodsLiterature was thoroughly searched, and few senior surgeons were interviewed in order to identify the significant steps in the evolution of rotator cuff surgery.ResultsA wide variety of surgical options is available to reduce pain and restore function after rotator cuff tears. Rotator cuff repair surgical techniques evolved from open to arthroscopic and are still in development, with new fixation techniques and biological solutions to enhance tendon healing being proposed, tested in laboratory and in clinical trials. Although good or excellent results are often obtained, there is little evidence that the results of rotator cuff repair are improving with the decades. An overall high re-tear rate remains, but patients with failed rotator cuff repairs can experience outcomes comparable with those after successful repairs.ConclusionsRotator cuff repair techniques evolve at a fast pace, with new solutions often being used without solid clinical evidence of superiority. It is necessary to conduct high-level clinical studies, in which data relating to anatomical integrity, patient self-assessed comfort and function, together with precise description of patient’s condition and surgical technique, are collected.Level of evidenceIV.

Evidence-based indications for hindfoot endoscopy.

AbstractPurpose The 2-portal hindfoot endoscopic technique with the patient in prone position, first introduced by van Dijk et al. (Arthroscopy 16:871–876, 2000), is currently the most used by foot and ankle surgeons to address endoscopically pathologies located in the hindfoot. This article aims to review the literature to provide a comprehensive description of the level of evidence available to support the use of the 2-portal hindfoot endoscopy technique for the current generally accepted indications.Methods A comprehensive review was performed by use of the PubMed database to isolate literature that described therapeutic studies investigating the results of different hindfoot endoscopy treatment techniques. All articles were reviewed and assigned a classification (I–V) of level of evidence. An analysis of the literature reviewed was used to assign a grade of recommendation for each current generally accepted indication for hindfoot endoscopy. A subscale was used to further describe the evidence base for indications receiving a grade of recommendation indicating poor-quality evidence.ResultsOn the basis on the available evidence, posterior ankle impingement syndrome, subtalar arthritis and retrocalcaneal bursitis have the strongest recommendation in favour of treatment (grade Cf).ConclusionAlthough a low level of evidence of the included studies, the review showed that adequate literature to support the use of the 2-portal endoscopic techniques for most currently accepted indications exists. Future “higher quality” evidence could strengthen current recommendations and further help surgeons in evidence-based practice.Level of evidenceLevel V, Review of Level III, IV and V studies.

History of shoulder instability surgery.

AbstractPurposeThe surgical management of shoulder instability is an expanding and increasingly complex area of study within orthopaedics. This article describes the history and evolution of shoulder instability surgery, examining the development of its key principles, the currently accepted concepts and available surgical interventions.Methods A comprehensive review of the available literature was performed using PubMed. The reference lists of reviewed articles were also scrutinised to ensure relevant information was included.ResultsThe various types of shoulder instability including anterior, posterior and multidirectional instability are discussed, focussing on the history of surgical management of these topics, the current concepts and the results of available surgical interventions.ConclusionsThe last century has seen important advancements in the understanding and treatment of shoulder instability. The transition from open to arthroscopic surgery has allowed the discovery of previously unrecognised pathologic entities and facilitated techniques to treat these. Nevertheless, open surgery still produces comparable results in the treatment of many instability-related conditions and is often required in complex or revision cases, particularly in the presence of bone loss. More high-quality research is required to better understand and characterise this spectrum of conditions so that successful evidence-based management algorithms can be developed.Level of evidenceIV.

Outcome evaluation after Achilles tendon ruptures. A review of the literature.

The optimal treatment and the best rehabilitation protocol after an acute Achilles tendon rupture (ATR) remain a matter of controversy in orthopaedic and sports medicine. The use of validated injury-specific outcome instruments is the only way to clarify these issues, in order to ensure that patients receive the best possible treatment. This article describes the most commonly reported outcome measures used to assess patients treated for ATR. On the basis of the available evidence, the Achilles tendon Total Rupture Score (ATRS) is the most appropriate outcome measure for evaluating the management of acute ATR.

Hill-Sachs lesion is not a significant prognostic factor for recurrence of shoulder redislocation after arthroscopic Bankart repair

Importance Humeral head defects are a common finding after acute and recurrent shoulder dislocations. Different hypotheses exist on the real significance of these defects and on their relevance in predicting dislocations after surgical repair. Objective This review study was designed to evaluate if humeral head defects are a negative prognostic factor for recurrence after arthroscopic Bankart repair. Evidence review A systematic review of the available literature (1980–2015) was performed using EMBASE and MEDLINE databases. The reference lists of reviewed articles were also scrutinised to ensure relevant information was included. Findings A meta-analysis on instability recurrence risk after arthroscopic Bankart repair and recurrence rate stratification for time from intervention were not possible for lack of data. 23 studies were eligible for inclusion. The ratio between recurrence cases and total cases was 0.1254. This ratio rose to 0.1314 in the group with Hill-Sachs lesions and dropped to 0.1044 in the group without. 10 patients reported the dimension of the Hill-Sachs encountered and 6 reported precisely the time to instability recurrence in presence or absence of Hill-Sachs lesions. Conclusions and relevance A Hill-Sachs lesion could not be confirmed as a statistically significant negative prognostic factor after arthroscopic Bankart repair. With increased follow-up length, a slight tendency to higher redislocation rates was observed in presence of a Hill-Sachs lesion. Higher quality studies with repair survival analysis are needed to assess recurrence risk after arthroscopic Bankart repair and evaluate the prognostic relevance of the presence of a Hill-Sachs lesion.

New Insights in Diagnosis and Treatment of Distal Biceps Pathology

Biceps brachii is composed of two separate heads and is innervated by a branch of the musculocutaneous nerve [1]. The proximal tendon of the long head is attached to the supraglenoid tubercle, and the proximal tendon of the short head is attached to the coracoid process. The biceps (muscle and tendon) rotates 90° externally from origin to insertion onto the bicipital tuberosity [2] and acts on three joints: the glenohumeral, ulnohumeral, and proximal radioulnar joints. A completely bifurcated distal tendon insertion is not uncommon [3, 4]. The short head of the distal biceps tendon was reported to insert more distally, and the long head was inserted more eccentric and medial. The moment arm of the long head was higher in supination, and the short head had a higher moment arm in neutral position and pronation [5]. These findings may allow functional independence and isolated rupture of each portion and may have consequences for restoring the native anatomy during a surgical repair. Several authors reported an isolated rupture of one of the two tendons in cases of bifurcated distal biceps tendons [4].

Reliability of anterior medial collateral ligament plication of the elbow

AbstractPurposeThe aim of this study is to describe a new surgical procedure to plicate the anterior bundle medial collateral ligament (aMCL) into its humeral footprint using a suture anchor, and to present the results of a preliminary clinical series. MethodsEight patients with posttraumatic medial elbow pain and signs of medial elbow instability underwent aMCL plication with suture anchors and decompression of ulnar nerve. Arthroscopic evaluation permitted to define signs of minor medial elbow instability; 70°-scope was used to document from an intra-articular point of view of the aMCL status. The patients were then retrospectively evaluated with the Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPI) and single-assessment numeric evaluation (SANE) by an independent examiner.ResultsIn all cases, the 70°-scope allowed direct visualization of the aMCL. Lateral subluxation of the coronoid process into the trochlea was observed in all patients. Postoperative median SANE was 50 [35–74.5] points; postoperative median OES was 17 [15.5–31.5] points; postoperative median MEPI was 65 [57.5–72.5] points. None of the patients reported further episodes of medial elbow instability or pain and all patients returned to normal daily activities.ConclusionsThe 70°-scope arthroscopic evaluation of the joint allows a direct evaluation of the inner aMCL status. Lateral subluxation of the coronoid process into the trochlea was observed and can be considered a sign of minor medial elbow instability. Mini-open suture anchor aMCL plication is an original technique that enables an anatomic and minimally invasive ligament retension.Clinical relevanceThe authors introduce a valid and safe treatment of posttraumatic medial elbow laxity.

Significant differences between manufacturer and surgeon in the accuracy of final component size prediction with CT-based patient-specific instrumentation for total knee arthroplasty

PurposePatient-specific instrumentation (PSI) for total knee arthroplasty (TKA) may improve component sizing. Little has been reported about accuracy of the default plan created by the manufacturer, especially for CT-based PSI. The goal of this study was to evaluate the reliability of this plan and the impact of the surgeon’s changes on the final accuracy of the guide sizes.MethodsForty-five patients eligible for primary TKA were prospectively enrolled. The planned implant sizes were prospectively recorded from the initial manufacturer’s proposal and from the final plan adjusted in light of the surgeon’s evaluation; these two sizes where then compared to the actually implanted sizes. Fisher’s exact test was used to test differences for categorical variables. Agreement between pre-operative plans and final implant was evaluated with the Bland–Altman method.ResultsThe manufacturer’s proposal differed from the final implant in 9 (20.0%) femoral and 23 (51.1%) tibial components, while the surgeon’s plan in 6 (13.3%, femoral) and 12 (26.7%, tibial). Modifications in the pre-operative plan were carried out for five (11.1%) femoral and 23 (51.1%) tibial components (p = 0.03). Appropriate modification occurred in 22 (88.0%) and 19 (76.0%) cases of femoral and tibial changes. The agreement between the manufacturer’s and the surgeon’s pre-operative plans was poor, especially with regard to tibial components.ConclusionThe surgeon’s accuracy in predicting the final component size was significantly different from that of the manufacturer and changes in the initial manufacturer’s plan were necessary to get an accurate pre-operative plan of the implant sizes.Clinical relevanceCareful evaluation of the initial manufacturer’s plan by an experienced knee surgeon is mandatory when planning TKA with CT-based PSI.Level of evidenceII.

A combination of an anteromedial, anterolateral and midlateral portals is sufficient for 360° exposure of the radial head for arthroscopic fracture fixation

PurposeArthroscopic fixation of radial head fractures is an alternative to open reduction and internal fixation; the latter, however, presents the advantage of minimal soft-tissue damage. The exposure of the radial head for adequate screw placement can be technically challenging. The aim of this study was to evaluate the inter-observer agreement on the effective contact arc in the axial plane of the radial head of three different elbow arthroscopy portals.MethodsA fresh-frozen cadaver specimen was obtained and prepared in an arthroscopic setting. Standard anterolateral (AL), anteromedial (AM), and midlateral (ML) portals were established and a circular reference system was marked on the radial head. Ten orthopaedic surgeons were then asked to move the forearm from maximal supination to maximal pronation and indicate with a Kirschner wire from each portal the extension in which they would feel confident in placing a cannulated screw passing through the centre of the articular plane of the radial head (axial contact arc). The Shapiro–Wilk normality test was used to evaluate the normal distribution of the sample. A coefficient of variation (CoV) was calculated to determine agreement among observers.ResultsThe average arc of axial contact arc that could be contacted from the AM portal measured 150 ± 14.1°, or 41.7% of the radial head circumference; the one from the AL portal measured 257 ± 29.5°, or 71.4% of the radial head circumference; that from the ML portal measured 212.5 ± 32.6°, or 59.0% of the radial head circumference. Considering all three portals, the whole radial head circumference could be contacted. The AM portal showed the smallest CoV (9.4%) as compared to the AL (11.5%), and the ML (15.3%) portals.ConclusionsWith an appropriate use of the standard AL, AM, and ML portals, the whole radial head circumference can be effectively exposed for adequate fixation of radial head fractures. The contact arc of the AM portal presents the smallest variability among different observers and the AL portal shows a superiority in axial contact arc. This information is important for pre-operative planning, and helps to define the limits of arthroscopic radial head fracture fixation.