Edoardo Franceschetti

Remplissage Repair—New Frontiers in the Prevention of Recurrent Shoulder Instability A 2-Year Follow-up Comparative Study

Background: An engaging Hill-Sachs lesion is a defect of the humeral head, large enough to cause locking of the humeral head against the anterior corner of the glenoid rim when the arm is at 90° of abduction and more than 30° of external rotation. Hypothesis: When Bankart lesions are associated with engaging Hill-Sachs defects, simultaneous Bankart repair and remplissage provide lower recurrence rates than does Bankart repair alone. Study Design: Cohort study; Level of evidence, 3. Methods: Fifty patients (36 men, 14 women) with combined engaging Hill-Sachs and Bankart lesions were evaluated, before and after arthroscopic management, at a minimum follow-up of 2 years. After imaging and arthroscopic assessment, 25 patients underwent remplissage and Bankart repair, and 25 patients received Bankart repair alone. Patients were evaluated using the UCLA, Constant, and Rowe scores, and range of motion was measured using a goniometer. Postoperatively, all patients underwent magnetic resonance imaging to assess the status of healing of the anterior labrum and whether the tenodesis of the infraspinatus covered the Hill-Sachs defect. Results: At the last appointment, active forward elevation, external rotation beside the body, internal rotation, and all administered scores were significantly improved compared with baseline assessment, with no statistically significant intergroup differences. A new posttraumatic dislocation occurred in 5 patients, all from the Bankart-only group (20%). Conclusion: Remplissage is a safe, relatively short procedure that allows the surgeon to address large humeral defects with a low postoperative recurrence rate. Humeral head large defects predispose to recurrent instability of the shoulder and deserve surgical management.

Stem Cells and Gene Therapy for Cartilage Repair

Cartilage defects represent a common problem in orthopaedic practice. Predisposing factors include traumas, inflammatory conditions, and biomechanics alterations. Conservative management of cartilage defects often fails, and patients with this lesions may need surgical intervention. Several treatment strategies have been proposed, although only surgery has been proved to be predictably effective. Usually, in focal cartilage defects without a stable fibrocartilaginous repair tissue formed, surgeons try to promote a natural fibrocartilaginous response by using marrow stimulating techniques, such as microfracture, abrasion arthroplasty, and Pridie drilling, with the aim of reducing swelling and pain and improving joint function of the patients. These procedures have demonstrated to be clinically useful and are usually considered as first-line treatment for focal cartilage defects. However, fibrocartilage presents inferior mechanical and biochemical properties compared to normal hyaline articular cartilage, characterized by poor organization, significant amounts of collagen type I, and an increased susceptibility to injury, which ultimately leads to premature osteoarthritis (OA). Therefore, the aim of future therapeutic strategies for articular cartilage regeneration is to obtain a hyaline-like cartilage repair tissue by transplantation of tissues or cells. Further studies are required to clarify the role of gene therapy and mesenchimal stem cells for management of cartilage lesions.

Obesity as a Risk Factor for Tendinopathy: A Systematic Review

Purpose. In the last few years, evidence has emerged to support the possible association between increased BMI and susceptibility to some musculoskeletal diseases. We systematically review the literature to clarify whether obesity is a risk factor for the onset of tendinopathy. Methods. We searched PubMed, Cochrane Central, and Embase Biomedical databases using the keywords “obesity,” “overweight,” and “body mass index” linked in different combinations with the terms “tendinopathy,” “tendinitis,” “tendinosis,” “rotator cuff,” “epicondylitis,” “wrist,” “patellar,” “quadriceps,” “Achilles,” “Plantar Fascia,” and “tendon.” Results. Fifteen studies were included. No level I study on this subject was available, and the results provided are ambiguous. However, all the 5 level II studies report the association between obesity measured in terms of BMI and tendon conditions, with OR ranging between 1.9 (95% CI: 1.1–2.2) and 5.6 (1.9–16.6). Conclusions. The best evidence available to date indicates that obesity is a risk factor for tendinopathy. Nevertheless, further studies should be performed to establish the real strength of the association for each type of tendinopathy, especially because the design of the published studies does not allow identifying a precise cause-effect relationship and the specific role of obesity independently of other metabolic conditions.

Mesenchymal Stem Cell for Prevention and Management of Intervertebral Disc Degeneration

Intervertebral disc degeneration (IVD) is a frequent pathological condition. Conservative management often fails, and patients with IVD degeneration may require surgical intervention. Several treatment strategies have been proposed, although only surgical discectomy and arthrodesis have been proved to be predictably effective. The aim of biological strategies is to prevent and manage IVD degeneration, improve the function, the anabolic and reparative capabilities of the nucleus pulposus and annulus fibrosus cells, and inhibit matrix degradation. At present, clinical applications are still in their infancy. Further studies are required to clarify the role of mesenchymal stem cells and gene therapy for the prevention and treatment of IVD degeneration.

Hip arthroscopy: state of the art

INTRODUCTION The unique anatomy of the hip is challenging, and has slowed the progress of hip arthroscopy. The aim of this review is to provide an updated synthesis of existing clinical evidence on hip arthroscopy. SOURCES OF DATA A systematic computerized literature search was conducted by two independent reviewers using an iterative manipulation process of the keywords used singularly or in combination. The following databases were accessed on 30th November, 2009: PubMed (http://www.ncbi.nlm.nih.gov/sites/entrez/); Ovid (http://www.ovid.com); and Cochrane Reviews (http://www.cochrane.org/reviews/). Case reports, literature reviews, letters to editors and articles not including outcome measures were excluded. Twenty-three publications met the inclusion criteria and were included. AREAS OF AGREEMENT Hip arthroscopy can provide an alternative to traditional arthrotomy with great therapeutic potential. However, the available data do not allow definitive conclusion on its routine use. AREAS OF CONTROVERSY It is still unclear whether arthroscopy is superior to open surgery in the management of femoroacetabular impingement and labral lesions. GROWING POINTS Rather than providing strong evidence for or against the use of hip arthroscopy, this study generates potential areas for additional prospective investigations to evaluate the role of hip arthroscopy in clinical practice. AREAS TIMELY FOR DEVELOPING RESEARCH There is a need to perform appropriately planned and powered studies to clarify the role of arthroscopy in hip pathology.

I.S.Mu.L.T - Rotator cuff tears guidelines

Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.

Double-Row Repair Lowers the Retear Risk After Accelerated Rehabilitation

Background: Recently, an accelerated rehabilitation protocol after rotator cuff (RC) repair has been proposed for patients at risk of postoperative stiffness. Purpose: To investigate, in patients undergoing early accelerated mobilization, whether double-row (DR) repair provides better clinical outcomes and a lower retear rate compared with single-row (SR) configurations. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 58 patients were randomized to undergo either SR or DR repair. After 2 years of follow-up, 12 men and 13 women (mean age, 61.8 years; range, 52-67 years) in the SR group and 15 men and 10 women (mean age, 58.9 years; range, 51-69 years) in the DR group were evaluated. To assess the retear rate, magnetic resonance imaging of the shoulder was performed at 2-year follow-up. The clinical evaluation was based on the modified University of California, Los Angeles (UCLA) shoulder score and range of motion (ROM) measurements. Results: Magnetic resonance arthrography showed a significantly lower full-thickness retear rate for the DR group than for the SR group (8% vs 24%, respectively; P < .05). Conversely, at both 6-month and 2-year follow-up, there was no statistically significant difference in terms of the rate of stiffness in the SR and DR groups (8% vs 12% and 0% vs 0%, respectively; P > .05). No clinical differences were recorded regarding the UCLA score (SR group: mean, 32.6 [range, 30-35]; DR group: mean, 33.3 [range, 29-35]; P = .61) and ROM. Conclusion: In selected patients at a high risk of shoulder stiffness and therefore necessitating accelerated postoperative rehabilitation, DR repair of the RC could lower retear rates.

Growth factors and anticatabolic substances for prevention and management of intervertebral disc degeneration.

Intervertebral disc (IVD) degeneration is frequent, appearing from the second decade of life and progressing with age. Conservative management often fails, and patients with IVD degeneration may need surgical intervention. Several treatment strategies have been proposed, although only surgical discectomy and arthrodesis have been proved to be predictably effective. Biological strategies aim to prevent and manage IVD degeneration, improving the function and anabolic and reparative capabilities of the nucleus pulposus and annulus fibrosus cells and inhibiting matrix degradation. At present, clinical applications are still in their infancy. Further studies are required to clarify the role of growth factors and anticatabolic substances for prevention and management of intervertebral disc degeneration.

Volar locking plates versus K-wire/pin fixation for the treatment of distal radial fractures: a systematic review and quantitative synthesis.

INTRODUCTION Volar locking plate and Kirschner wire/pin fixations are the most commonly used methods for surgical fixation of distal radius fractures. SOURCES OF DATA A literature search was performed using PubMed, CINAHL, Cochrane Central and Embase Biomedical databases, selecting studies comparing two or more different surgical treatments including Kirschner wire fixation and volar locking-plate fixation. This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Methodological quality of all selected articles was assessed. AREAS OF AGREEMENT A total of 14 publications (1306 patients) were included in this review, 10 of which were prospectively designed (8 randomized controlled trial). A total of 659 (50.5%) patients underwent volar locking plating (VLP group), while 647 of 1306 (49.5%) were treated with Kirschner wire/pin fixation (KW group). No differences were recorded in terms of ROM, grip strength, radiographic variables and total rate of complications. There is no clear superiority of either fixation method for the surgical management of distal radius fractures. AREAS OF CONTROVERSY At a pooled analysis, VLP obtained statistically significant better DASH value compared to KW (18.1 ± 7.8 vs. 12.8 ± 6.4%, P = 0.026). Costs and surgical times were significantly higher for plate fixation. GROWING POINTS Both techniques provide excellent clinical and radiographic results, without a clear superiority of either fixation method for the surgical management of distal radius fractures. RESEARCH There is a need for more randomized trials performing standardized measurements at fixed follow-up, with results divided by subtypes of distal radius fractures.

Surgical management of osteonecrosis of the humeral head: a systematic review

PurposeOsteonecrosis of the humeral head is a rare diagnosis. The aim of this systematic review was to identify published studies and analyse the best clinical evidence available related to the surgical management of osteonecrosis of the humeral head.MethodsA systematic electronic search was performed using the PubMed (MEDLINE), EMBASE and Cochrane Library databases. Published studies that reported the outcomes for adult patients treated surgically for osteonecrosis of the humeral head were included. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was followed.ResultsTwelve studies were included: five prospective case series and seven retrospective case series. A total of 309 patients, comprising 382 shoulders, were included. Three main surgical procedures were evaluated: core decompression, hemi-arthroplasty and total shoulder arthroplasty.ConclusionsBased on the current available data, core decompression is a safe and effective option for treating low-grade osteonecrosis of the humeral head, while hemi-arthroplasty and total shoulder arthroplasty should be considered for high-grade osteonecrosis. More studies and better-designed trials are needed in order to enrich the evidence and enable researchers to draw stronger conclusions. Since osteonecrosis is an uncommon, though challenging disease, a proper knowledge of its treatment is needed.Level of evidenceIV.