Francesco Franceschi

Circulating substance P levels and shoulder joint contracture after arthroscopic repair of the rotator cuff

Objective: To determine the plasma levels of substance P (SP) in patients with postoperative stiffness after arthroscopic rotator cuff repair. Design: Plasma samples were obtained at 15 months from surgery from two groups of patients who underwent arthroscopic repair of a rotator cuff tear. In group 1, 30 subjects (14 men, 16 women; mean age 64.6 years, range 47 to 78) with shoulder stiffness 15 months after arthroscopic rotator cuff repair were recruited. In group 2, 30 patients (11 men, 19 women; mean age 57.8 years, range 45 to 77) were evaluated 15 months after successful arthroscopic rotator cuff repair. Immunoassays were performed with commercially available assay kits to measure the plasma levels of SP. Results: Plasma levels of SP in patients with postoperative stiffness were significantly greater than those in the control group (mean 81.06 (SD 27.76) versus 23.49 (5.64), p<0.05). Conclusions: The plasma concentrations of substance P in patients with shoulder stiffness after arthroscopic rotator cuff repair are higher compared with plasma levels of SP in patients with a good postoperative outcome. The neuronal upregulation of SP shown in the plasma of patients with postoperative shoulder stiffness may underlie not only the symptoms but also its development of adhesive capsulitis.

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.

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.

Endothelial dysfunction and tendinopathy: how far have we come?

Symptomatic tendon tears are one of the most important causes of pain and joint dysfunction. Among the intrinsic causes, vascularization recently gained a major role. Endothelial function is indeed a key factor, as well as vascular tone and thrombotic factors, in the regulation of vascular homeostasis and the composition of vascular wall. In this review, we studied systematically whether there is a relationship between endothelial dysfunction and tendinopathy. A literature search was performed using the isolated or combined keywords endothelial dysfunction and tendon,’ ‘nitric oxide (NO) and tendinopathy,’ and ‘endothelial dysfunction in tendon healing.’ We identified 21 published studies. Of the selected studies, 9 were in vivo studies, 2 focusing on animals and 7 on humans, while 12 reported about in vitro evaluations, where 7 were carried out on humans and 5 on animals. The evidence about a direct relationship between tendinopathy and endothelial dysfunction is still poor. As recent studies have shown, there is no significant improvement in clinical and functional assessments after treatment with NO in patients suffering from tendinopathy in different locations. No significant differences were identified in the outcomes reported for experiment group when compared with controls treated with conventional surgical procedures or rehabilitation programs. Nitric oxide could be a marker to quantify the response of the endothelium to mechanical stress or hypoxia indicating the final balance between vasodilatating and vasoconstricting factors and their effects, but more ad stronger evidence is still needed to fully support this practice.

Failed AC Joint Treatment: Case Examples

The most important lessons during our surgical activities result from the evaluation of our failures. In acromioclavicular (AC) joint disease, several factors should be evaluated before deciding on the best treatment. Patient’s age, type of injury, and timing of injury (acute or chronic) are all factors that influence the type of treatment and then treatment outcome. Nowadays various surgical techniques are used, and in recent years, the role of arthroscopy has taken a leading role with the aid of devices that allow us, if used correctly, to achieve a stable fixation.

Shoulder Anterior Instability

Anterior glenohumeral instability is a common injury among athletes, with a higher incidence compared to the general population, especially among contact athletes. Anterior dislocations account for about 95 % of instances, while posterior and inferior represent together less than 5 %. The most common lesion following an anterior traumatic dislocation is the Bankart lesion, in which the anteroinferior capsulolabral complex is torn away from the glenoid rim. This injury can also come with a bony fragment from the anteroinferior edge of the glenoid. The treatment of anterior shoulder instability is a heavily debated issue. A lot of factors enter in the decision-making process: age and level of activity of the patient, the kind of sport and the role of the athlete (overhead/thrower vs nonoverhead/nonthrower), the type of lesion (soft tissue or soft tissue and bony lesion), number of dislocations, and timing with respect to sport season. Immobilization, physical therapy, and bracing, with a delayed return to activity, are the basis of nonoperative management. Nearly 90 % of shoulder stabilization surgeries are arthroscopically performed, while a significant decline in the incidence of open Bankart repair has been observed in the United States.