Eran Maman

The incidence of heterotopic ossification in hip arthroscopy.

PURPOSEnThe purpose of this study was to assess the incidence of heterotopic ossification (HO) after hip arthroscopy.nnnMETHODSnBetween July 2010 and July 2011, 83 patients underwent hip arthroscopy for various etiologies. We prospectively reviewed 50 consecutive hip arthroscopy procedures (31 male and 19 female patients; mean age, 36.7 years) with a mean follow-up of 29.56 weeks (range, 9 to 62 weeks) to assess the incidence of HO and its effect on function and clinical outcome. Preoperative and postoperative evaluation included general assessment by visual analog scoring, modified Harris Hip Score, Hip Outcome Score, and preoperative and postoperative radiographs. Heterotopic bone formation was assessed on radiographs at a minimum of 9 weeks from surgery with the Brooker classification.nnnRESULTSnOf the patients, 22 (44%) had radiographic evidence of postoperative HO (15 male patients): 13 (26%) had Brooker stage 1, 5 (10%) had Brooker stage 2, and 4 (8%) had Brooker stage 3. HO appeared as early as 9 weeks after surgery. No significant difference was found in demographic data, surgery-related data, or clinical and functional scores between patients with HO and patients without HO. No factor was found to significantly affect the incidence of HO after logistic regression. No distinct clinical manifestation was associated with the presence of HO.nnnCONCLUSIONSnThis study shows that the incidence of HO after hip arthroscopy may be underestimated. We could not find a contributing factor to the formation of HO. Although in most cases the presence of HO will have minimal or no clinical and functional significance, it should be sought at a minimum of 9 weeks postoperatively.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

Statins Enhance Rotator Cuff Healing by Stimulating the COX2/PGE2/EP4 Pathway An In Vivo and In Vitro Study

Background: Statins are lipid-lowering drugs with many beneficial pleiotropic effects. Cyclooxygenase (COX2) selective inhibitors that are commonly prescribed in orthopaedic patients may effect healing. Evidence indicates that statins stimulate COX2 activity. Hypothesis: Atorvastatin (ATV) administration will enhance tendon healing by stimulating the acute inflammatory phase via increasing the production of prostaglandin E2 (PGE2). Study Design: Controlled laboratory study. Methods: After experimental rotator cuff (RC) tearing and suturing, 48 Wistar rats were randomly allocated into 4 groups: (1) ATV (20 mg/kg), (2) celecoxib (CEL; COX2 inhibitor) (10 mg/kg), (3) ATV + CEL (20 mg/kg + 10 mg/kg), and (4) saline alone. Animals were sacrificed 3 weeks after RC tears and repair, and tendon integrity was tested biomechanically in tension. To further evaluate the underlying mechanism of action, human and rat primary tenocytes were obtained from the supraspinatus tendon. Cultures were treated with a therapeutic dosage of 5 commonly used statins: CEL, ATV + CEL, PGE2, and a selective antagonist of PGE2 receptor 4 (EP4). Cell proliferation (thymidine incorporation), migration (wound healing assay), and adhesion (iCELLigence) were evaluated. The expression of all PGE2 receptors (EPs) was determined by quantitative reverse transcription polymerase chain reaction. Results: Tension testing of healed tendons demonstrated significantly higher maximal loading and stiffness in the ATV group as compared with the saline (+30% and +20%, respectively; P < .001) and CEL groups (+33% and +50%, respectively; P < .005). Celecoxib alone did not affect tendon healing (P = .88). In line with these in vivo results, tenocytes treated with statins demonstrated significantly higher proliferation rates; CEL abrogated this effect, and PGE2 treatment stimulated tenocyte proliferation even in the presence of CEL. Also, ATV stimulated the migration (wound healing) and adhesion of tenocytes. Among all PGE2 receptors, tenocytes mainly express EP4, and an EP4 selective antagonist blocked the effect of ATV. Conclusion: Results indicate that ATV enhances tendon healing by stimulating tenocyte proliferation, migration, and adhesion via increased COX2 activity and autocrine/paracrine PGE2 signaling. Findings also demonstrate that this effect is mediated by EP4 signaling. Clinical Relevance: Although chronic inflammation contributes to the development of tendinopathy, study results advocate for a positive role of PGE2 in tendon healing during the acute inflammatory phase that follows tendon surgical repair. It is therefore suggested that ATV should be further investigated as a possible modality to improve tendon healing.

In Support of Early Surgery for Hip Fractures Sustained by Elderly Patients Taking Clopidogrel

Background: Early surgical treatment is indicated to reduce mortality and morbidity associated with immobilization due to hip fracture. The judiciousness of postponing surgery to allow withdrawal of clopidogrel and return of normal platelet function (5–10 days) in elderly patients being chronically treated with this antiplatelet medication is a matter of ongoing controversy.Objective: The purpose of this study was to compare the morbidity and mortality rates in elderly patients receiving long-term treatment with clopidogrel who were operated on with or without delay (due to withdrawal of clopidogrel) following a hip fracture.Methods: We compared relevant demographic and medical/surgical parameters in patients receiving long-term treatment with clopidogrel who sustained a hip fracture and underwent either early (n = 30, mean ± SD age 81.6 ± 8.7 years, 17 males [57%]) or delayed (n = 30, mean±SD age 83.3±7.1 years, 13 males [43%]) surgical intervention between May 2007 and February 2010.Results: Both groups were similar with regard to sex, age, co-morbidities and fracture type. The mortality rate was similar in both groups. Patients in the delayed treatment group had more complications associated with prolonged immobilization (pulmonary embolism, pulmonary oedema, decubitus ulcer). Time from admission to surgery and hospitalization stay were significantly longer in the delayed treatment group than in the early treatment group (mean ± SD 7 days and 12 hours ± 2 days and 17 hours compared with 1 day and 16 hours±1 day [p<0.0001] and 17 days and 17 hours±7 days and 5 hours versus 11 days and 2 hours±4 days and 19 hours [p = 0.0002], respectively).Conclusions: Early surgical intervention for hip fracture in patients receiving long-term treatment with clopidogrel appears to be safe in terms of bleeding complications. It has the potential to enable earlier mobilization and shorter hospitalization and may reduce mortality and complications associated with immobilization.

Milch versus Stimson technique for nonsedated reduction of anterior shoulder dislocation: a prospective randomized trial and analysis of factors affecting success

BACKGROUNDnThe shoulder is regarded as the most commonly dislocated major joint in the human body. Most dislocations can be reduced by simple methods in the emergency department, whereas others require more complicated approaches. We compared the efficacy, safety, pain, and duration of the reduction between the Milch technique and the Stimson technique in treating dislocations. We also identified factors that affected success rate.nnnMETHODSnAll enrolled patients were randomized to either the Milch technique or the Stimson technique for dislocated shoulder reduction.nnnRESULTSnThe study cohort consisted of 60 patients (mean age, 43.9 years; age range, 18-88 years) who were randomly assigned to treatment by either the Stimson technique (n = 25) or the Milch technique (n = 35). Oral analgesics were available for both groups. The 2 groups were similar in demographics, patient characteristics, and pain levels. The first reduction attempt in the Milch and Stimson groups was successful in 82.8% and 28% of cases, respectively (P < .001), and the mean reduction time was 4.68 and 8.84 minutes, respectively (P = .007). The success rate was found to be affected by the reduction technique, the interval between dislocation occurrence and first reduction attempt, and the pain level on admittance.nnnCONCLUSIONSnThe success rate and time to achieve reduction without sedation were superior for the Milch technique compared with the Stimson technique. Early implementation of reduction measures and low pain levels at presentation favor successful reduction, which--in combination with oral pain medication--constitutes an acceptable and reasonable management alternative to reduction with sedation.

Timing matters: NSAIDs interfere with the late proliferation stage of a repaired rotator cuff tendon healing in rats

IntroductionRotator cuff (RC) tear is a common problem that causes pain and can limit shoulder function. Non-steroidal anti-inflammatory drugs (NSAIDs) are often prescribed for musculoskeletal pain, including the pain subsequent to RC repair. NSAIDs have been reported to affect bone metabolism and fracture healing, but there is little evidence about their effect on tendon healing. We investigated the effect of meloxicam (non-steroidal anti-inflammatory drug) on the healing of RC tendons when given immediately after surgical repair.Materials and methodsThirty-nine rats underwent acute RC tear and repair. Group A (nxa0=xa013) received daily intraperitoneal (IP) injections of meloxicam for the first 10 postoperative days. Group B (nxa0=xa013) received IP injections of meloxicam starting from postoperative day 11. Group C (nxa0=xa013, controls) received daily IP injections of saline for 3xa0weeks. The animals were killed 3xa0weeks after surgery and the RC was evaluated by gross inspection, biomechanical testing and histological examination.ResultsGroup B displayed a significantly lower mean maximal load at 3xa0weeks than group C (Pxa0=xa00.02) and group A (Pxa0=xa00.05). Stiffness was significantly lower in B group as compared to A group (Pxa0=xa00.05). Qualitative examination of histology specimens did not disclose any apparent differences with respect to cellularity, vascularity, healing, and collagen orientation.ConclusionsWe conclude that meloxicam decreases the biomechanical strength of repaired rat RCs when administered between 11 and 20xa0days after the repair.

Acute lymphoblastic leukemia in children: correlation of musculoskeletal manifestations and immunophenotypes

PurposeStudies on musculoskeletal manifestations (MSM) of childhood acute lymphoblastic leukemia (ALL) have yielded variable findings with regard to their clinical impact. We investigated the significance for differential diagnosis, treatment and outcome of musculoskeletal complaints as presenting symptoms of ALL, and their correlation with leukemia immunophenotypes, for which data is lacking.MethodsData on 783 children in the national study for childhood ALL between 1984 and 2003 were reviewed retrospectively. Statistical analysis examined possible relationships between MSM at the time of diagnosis and demographic and clinical data, biological features of leukemia (peripheral blood counts, immunophenotype and main cytogenetic aberration), response to initial prednisone treatment, and outcome.ResultsOf 765 children with data on orthopaedic complaints, 240 presented with MSM (31.4%). Among these children, B cell precursor (BCP) was much more common (209/576, 36.3%) than T cell ALL (25/176, 14.2%). Patients with MSM had lower white blood cell counts (WBC) (median of 9 vs. 20xa0×xa0109/L, Pxa0<xa00.001) and percentage of blast cells in the peripheral blood at diagnosis compared to those without (median of 27 vs. 53%, Pxa0<xa00.001). Hepatomegaly and splenomegaly were less common in MSM group (67 vs. 53% <3xa0cm, Pxa0<xa00.001, and 63 vs. 50% <3xa0cm, Pxa0<xa00.001, respectively). Poor response to initial treatment with prednisone was recorded in 7.1% of patients with MSM versus 11.5% of those without (Pxa0=xa00.086). The analysis revealed no independent effect of MSM on event-free survival (EFS), after correcting for differences in EFS related to immunophenotype or initial WBC.ConclusionsMSM occur mostly in children with BCP ALL who present with less involvement of extramedullary organs, low peripheral blood blasts and white blood cells counts. These findings highlight the importance of including ALL in the differential diagnosis of MSM even in the presence of an apparently normal peripheral blood count. Our study also suggests that MSM are caused by leukemic cells with enhanced biological propensity to remain relatively confined within the intramedullary bone-marrow space.

The response of cells derived from the supraspinatus tendon to estrogen and calciotropic hormone stimulations: in vitro study.

ABSTRACT Purpose: The most frequent complications after rotator cuff repair (RCR) are non-healing and re-tear. Age and gender are both proven risk factors for faulty RCR. This study analyzed the effects of female sex steroids and calciotropic hormones on tendon-derived cell characteristics. Methods: Tendon-derived cells from rat supraspinatus were treated with estradiol-17β (E2); soy isoflavones (daidzein, genistein, biochainin A); raloxifene and estrogen receptors α and β agonists and antagonists; and less-calcemic vitamin-D analog, parathyroid hormone, and vehicle control for 24 h. Cell proliferation and mRNA expression of estrogen receptor α and β, vitamin-D receptor (VDR), scleraxis, and collagen-1 were assessed. Results: E2, Biochainin A, raloxifene, and vitamin-D significantly increased tendon-derived cell proliferation. Estrogen receptor α antagonists neutralized tendon-derived cells response to estradiol 17-β; however, estrogen receptor β antagonists did not have an effect. Scleraxis expression decreased following estradiol 17-β and vitamin-D treatments. Vitamin-D significantly reduced collagen-1 expression, while estradiol 17-β had no effect. Vitamin-D and estradiol 17-β upregulated VDR expression. Conclusions: Significant tendon-derived cell proliferation can be achieved with commonly prescribed female sex and calciotropic hormones. However, collagen-1 expression remained constant or decreased following the administration of these hormones. Female sex steroids and vitamin-D promoted tendon-derived cell proliferation via estrogen receptor α and VDR, not estrogen receptor β. Amplified cell proliferation was not associated with increased scleraxis and collagen-1 expression. These results have important implications to the properties of healing tendon and possible pharmaceutical therapies for patients with torn RC. Further research is warranted to expose the underling mechanisms of these effects.

Effect of preemptive intra-articular morphine and ketamine on pain after arthroscopic rotator cuff repair: a prospective, double-blind, randomized controlled study

BackgroundRotator cuff tear is a leading etiology of shoulder pain and disability. Surgical treatment is indicated in patients with persistent pain who fail a trial of non-surgical treatment. Pain reduction following rotator cuff repair, particularly within the first 24–48xa0h, is a major concern to both doctors and patients. This study aimed to compare the postoperative antinociceptive additive effects of pre-incisional intra-articular (IA) ketamine when combined with morphine with two times the dose of morphine or saline.MethodsIn this prospective, randomized, double blind, controlled trial patients undergoing arthroscopic rotator cuff tear repair (ARCR) under general anesthesia were enrolled. Patients were randomly assigned to one of the three intervention groups. Twenty minutes prior to incision, morphine (20xa0mg/10xa0ml), ketamine (50xa0mgxa0+xa0morphine 10xa0mg/10xa0ml), or saline (0.9xa0% 10xa0ml) (nxa0=xa015/group), were administered to all patients. First 24xa0h postoperative analgesia consisted of intravenous patient controlled analgesia (IV-PCA) morphine and oral rescue paracetamol 1000xa0mg or oxycodone 5xa0mg. 24-h, 2-week and 3-month patient rated pain numeric rating scale (NRS) and analgesics consumption were documented.ResultsPatients’ demographic and perioperative data were similar among all groups. The 24-h and the 2-week NRSs were significantly (pxa0<xa00.05) lower in both treatment groups compared to placebo, but were not significantly different between the two intervention groups. PCA-morphine and oral analgesics were consumed similarly among the groups throughout the study phases.ConclusionsPre-incisional intra-articular morphine reduced pain in the first 2xa0weeks after arthroscopic rotator cuff repair. Further research is warranted to elucidate the optimal timing and dosing of IA ketamine and morphine for postoperative analgesic effects.

Rotator interval closure has no additional effect on shoulder stability compared to Bankart repair alone

PurposeArthroscopic Bankart repair (ABR) provides satisfactory results for recurrent anterior shoulder instability, but the high recurrence rate post-ABR remain a concern. One of the adjunct procedures proposed to improve ABR results is arthroscopic rotator interval closure (ARIC). This study prospectively evaluated the outcomes of ABRs alone compared to combined ABRu2009+u2009ARIC and identified risk factors related to failure of each procedure.MethodsThirty-nine consecutive patients (mean age 23.1 (18.3–37.5)xa0years; 37 males) underwent arthroscopic stabilization for recurrent anterior traumatic shoulder instability. Twenty patients underwent ABR alone and 19 underwent ABRu2009+u2009ARIC. Remplissage was added when glenoid engagement was observed during surgery. All patients were prospectively followed, and their postoperative courses were reviewed and functionally assessed at the last visit.ResultsThe re-dislocation rate was higher in the ABRu2009+u2009ARIC group compared to the ABR only group at a mean follow-up of 4.2 (2–5.6)xa0years (3 vs. 0, Pu2009=u20090.06). More subluxations were found in the ABR only group (2 vs. 1, respectively; Pu2009=u20090.58). The final limitation of range of motion (ROM) compared with the preoperative ROM was similar in both groups. Remplissage procedures were performed more often in the ABR only group [12 (60%) vs. 4 (21%), Pu2009=u20090.013].ConclusionsARIC performed as an adjunct to ABR showed no superiority in attaining value-added stability compared to ABR alone. Adding a remplissage procedure may achieve better stability.Level of evidenceLevel 2.

Surgical approach for open reduction and internal fixation of clavicle fractures: a comparison of vertical and horizontal incisions

PurposeThis study was designed to compare the results of clavicle fracture open reduction internal fixation (ORIF) with standard horizontal incision versus vertical incision.MethodsORIF surgery performed between October 2012 and August 2016 was included. The surgical approach was chosen according to surgeon preference as vertical or horizontal. Functional outcomes, fracture union, complications, scar appearance, skin irritation, and denervation around the scar were assessed at a minimum follow-up of three months.ResultsThirty-eight patients, age 39u2009±u200912xa0years, were operatedxa0upon, 22 through vertical incisions and 16 through horizontal incisions. There were no significant group differences in functional scores, fracture union, or complications. Two patients in the vertical incision group had a post-operative haematoma. The scar length was significantly shorter when a vertical incision was used (6.75u2009±u20091.25xa0cm vs 8.9u2009±u20092.3xa0cm, Pu2009=u20090.001). The typical distribution of hypoesthetic skin area distal and lateral to the scar represented iatrogenic damage to the supraclavicular nerves and was found in 66% of patients. The mean hypoesthetic surface area was smaller in the vertical incision group (38u2009±u200929xa0cm2 vs 48u2009±u200928xa0cm2, Pu2009=u2009non-significant).ConclusionVertical incision results in shorter scars but may be associated with increased incidence of haematomas. Meticulous closure of the subcutaneous tissue is recommended.