Giuseppe Giannicola

Use of platelet-leukocyte membrane in arthroscopic repair of large rotator cuff tears: a prospective randomized study.

BACKGROUND Arthroscopic rotator cuff repair generally provides satisfactory results including decreased shoulder pain and improved shoulder motion. Unfortunately, imaging studies demonstrate that the retear rate associated with the available arthroscopic techniques may be high. The purpose of this study was to evaluate the clinical and magnetic resonance imaging (MRI) results of arthroscopic rotator cuff repair with and without the use of platelet-leukocyte membrane in patients with a large posterosuperior rotator cuff tear. METHODS Eighty consecutive patients with a large full-thickness posterosuperior rotator cuff tear were enrolled. All tears were repaired using an arthroscopic single-row technique. Patients were randomized to treatment either with or without a platelet-leukocyte membrane inserted between the rotator cuff tendon and its footprint. In patients treated with this membrane, one membrane was utilized for each suture anchor. The primary outcomes were the difference between the preoperative and postoperative Constant scores and the repair integrity assessed by MRI according to the Sugaya classification. The secondary outcome was the difference between the preoperative and postoperative Simple Shoulder Test (SST) scores. RESULTS The only significant differences between the two groups involved the patient age and the preoperative and postoperative Constant scores; the differences in the Constant score were due to differences in the shoulder pain subscore. At a mean of thirteen months of follow-up, rotator cuff retears were observed only in the group of patients in whom the membrane had not been used, and a thin but intact tendon was observed more frequently in this group as well. The use of the membrane was associated with significantly better repair integrity (p = 0.04). CONCLUSIONS The use of the platelet-leukocyte membrane in the treatment of rotator cuff tears improved repair integrity compared with repair without membrane. However, the improvement in repair integrity was not associated with greater improvement in the functional outcome. In fact, the Constant scores of the two groups would have been similar if the shoulder pain component (which had differed preoperatively) had been excluded.

No Identical "Mesenchymal Stem Cells" at Different Times and Sites: Human Committed Progenitors of Distinct Origin and Differentiation Potential Are Incorporated as Adventitial Cells in Microvessels

Summary A widely shared view reads that mesenchymal stem/stromal cells (“MSCs”) are ubiquitous in human connective tissues, can be defined by a common in vitro phenotype, share a skeletogenic potential as assessed by in vitro differentiation assays, and coincide with ubiquitous pericytes. Using stringent in vivo differentiation assays and transcriptome analysis, we show that human cell populations from different anatomical sources, regarded as “MSCs” based on these criteria and assumptions, actually differ widely in their transcriptomic signature and in vivo differentiation potential. In contrast, they share the capacity to guide the assembly of functional microvessels in vivo, regardless of their anatomical source, or in situ identity as perivascular or circulating cells. This analysis reveals that muscle pericytes, which are not spontaneously osteochondrogenic as previously claimed, may indeed coincide with an ectopic perivascular subset of committed myogenic cells similar to satellite cells. Cord blood-derived stromal cells, on the other hand, display the unique capacity to form cartilage in vivo spontaneously, in addition to an assayable osteogenic capacity. These data suggest the need to revise current misconceptions on the origin and function of so-called “MSCs,” with important applicative implications. The data also support the view that rather than a uniform class of “MSCs,” different mesoderm derivatives include distinct classes of tissue-specific committed progenitors, possibly of different developmental origin.

Experimental posterolateral spinal fusion with porous ceramics and mesenchymal stem cells

Alternatives to autogenous bone graft for spinal fusion have been investigated for many years. It has been shown that osteoconductive materials alone do not give a rate of fusion which is comparable to that of autogenous bone graft. We analysed the effectiveness of porous ceramic loaded with cultured mesenchymal stem cells as a new graft material for spinal fusion in an animal model. Posterolateral fusion was carried out at the L4/L5 level in 40 White New Zealand rabbits using one of the following graft materials: porous ceramic granules plus cultured mesenchymal stem cells (group I); ceramic granules plus fresh autogenous bone marrow (group II); ceramic granules alone (group II); and autogenous bone graft (group IV). The animals were killed eight weeks after surgery and the spines were evaluated radiographically, by a manual palpation test and by histological analysis. The rate of fusion was significantly higher in group I compared with group III and higher, but not significantly, in group I compared with groups II and IV. In group I histological analysis showed newly formed bone in contact with the implanted granules and highly cellular bone marrow between the newly formed trabecular bone. In group II, thin trabeculae of newly formed bone were present in the peripheral portion of the fusion mass. In group III, there was a reduced amount of newly formed bone and abundant fibrous tissue. In group IV, there were thin trabeculae of newly formed bone close to the decorticated transverse processes and dead trabecular bone in the central portion of the fusion mass. In vitro cultured mesenchymal stem cells may be loaded into porous ceramic to make a graft material for spinal fusion which appears to be more effective than porous ceramic alone. Further studies are needed to investigate the medium- to long-term results of this procedure, its feasibility in the clinical setting and the most appropriate carrier for mesenchymal stem cells.

Contralateral recurrent lumbar disc herniation. Results of discectomy compared with those in primary herniation.

STUDY DESIGN The surgical outcomes of patients who underwent discectomy for contralateral recurrent herniation and primary herniation were evaluated. OBJECTIVE To assess whether the clinical results in patients undergoing surgery for contralateral recurrent disc herniation may be as good as those reported after primary discectomy. SUMMARY OF BACKGROUND DATA No retrospective or prospective investigation has been conducted on the surgical treatment of contralateral recurrent lumbar disc herniation. METHODS Sixteen patients who underwent surgery for recurrent disc herniation at the same level as primary disc excision, but on the opposite side, were analyzed prospectively from the recurrence of contralateral radicular pain (Group 1). All patients had reported a satisfactory results after primary discectomy. Fifty consecutive patients who underwent disc excision during the study period, who did not report recurrent radicular pain, were analyzed for comparison (Group 2). Overall patient satisfaction, pain severity, functional outcome, and work status were evaluated. RESULTS At the 2-year follow-up, the clinical outcome was rated as satisfactory in 14 of 16 patients in Group 1 and in 45 of 50 in Group 2 (P > 0.05). Twelve patients in Group 1 and 42 in Group 2 had resumed their work or daily activities at the same level as before the operation (P > 0.05). Radicular pain was significantly improved in both groups at the 6-month and 2-year follow-ups. At the 6-month follow-up, low back pain was significantly improved only in the patients in Group 2; however, at the 2-year follow-up, low back pain was significantly improved in both groups. CONCLUSIONS Clinical results in patients reoperated on for contralateral recurrent lumbar disc herniation compare favorably with those reported after primary discectomy. The improvement of pain in the low back and lower limbs reported by the majority of patients 2 years after reoperation suggests that fusion is not needed in this patient population.

Management of complex elbow instability.

Complex elbow instability is a challenging injury even for expert elbow surgeons. The preoperative radiographs should be carefully evaluated to recognize all lesions that may occur in complex elbow instabilities. Recognizing all the possible lesions is critical to achieve an optimal outcome. The most common types of injuries are as follows: (1) radial head fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation); (2) Coronoid fractures and lateral collateral ligament lesion (with or without elbow dislocation); (3) Terrible Triad; (4) Transolecranon fracture-dislocation; (5) Monteggia-like-lesions; and (6) Humeral Shear fractures associated with lateral and medial collateral ligaments lesions (with or without elbow dislocation). A correct evaluation includes X-rays, CT scan with 2D and 3D reconstruction and stability test under fluoroscopy. The treatment is always surgical and is challenging, and outcomes are not predictable. The goals of treatment are (1) to perform a stable osteosynthesis of all fractures, (2) to obtain concentric and stable reduction of the elbow and (3) to allow early motion. The proximal ulna must be anatomically reduced and fixed; the radial head must be repaired or replaced, and the coronoid fractures must be repaired or reconstructed. With respect of soft tissue lesions, the LUCL must be reattached with suture anchors or trans-osseous suture. The next critical step is the intra-operative assessment of elbow stability. If the elbow remains unstable, MCL repair and/or application of hinged external fixator must be considered. The most recent clinical and experimental studies have significantly expanded our knowledge of elbow instability and its management. Definite treatment protocols may improve the clinical results of such complex injuries.

Radial head, radiocapitellar and total elbow arthroplasties: A review of recent literature

The outcome of prosthetic elbow surgery is continually evolving. We thoroughly reviewed the literature on this issue to analyse the indications, outcomes and complications of the numerous types of implants currently in use. Radial head replacement is recommended in comminuted fractures of the radial head and in post-traumatic conditions. Medium- and long-term results prove to be satisfactory in the majority of cases, with no evidence to indicate that some prostheses (monopolar vs. bipolar; cemented vs. press-fit) are more effective than others; nonetheless, the bipolar-cemented implant was found to be associated with a lower revision rate than other prostheses. Unicompartmental arthroplasty has recently been used for the treatment of osteoarthritis and rheumatoid arthritis when the lateral compartment is prevalently involved; the results reported to date have been encouraging, although further studies are warranted to confirm the validity of these implants. Total elbow arthroplasty is performed in a range of conditions, including distal humerus fractures in the elderly and elbow arthritis. In the former condition, linked elbow replacement yields excellent results with few complications and a low revision rate. In elbow arthritis, total elbow arthroplasty is indicated when patients suffer from disabling pain, stiffness and/or instability that prevent them from performing daily activities. Unlinked elbow arthroplasty, which is used above all in rheumatoid arthritis, also yields satisfactory results, although the risk of instability persists. The use of linked elbow arthroplasty, which yields similar results but lower revision rates, has consequently increased. Lastly, the results yielded by linked elbow prosthesis in post-traumatic conditions are good, although not quite as good as those obtained in rheumatoid arthritis. Early mechanical failure may occur in younger and more active patients after elbow arthroplasty. However, the careful selection of patients who are prepared to accept functional limitations imposed by elbow implants will enable indications for elbow arthroplasty to be extended to young subjects, particularly when no other therapeutic options are available.

Thigh pain, subsidence and survival using a short cementless femoral stem with pure metaphyseal fixation at minimum 9-year follow-up.

BACKGROUND Short femoral stems designed to spare bone stock and improve load transfer at the proximal femur level have been introduced in recent years. However, little is known on the long-term outcomes of these stems. HYPOTHESIS Short cementless stems have low rate of thigh pain and subsidence as well as few revision needs at mid-term follow-up. MATERIALS AND METHODS We prospectively followed 64 patients (72 hips) undergoing total hip arthroplasty with a femoral stem designed to achieve a pure metaphyseal fixation. Patients with hip fracture, femoral neck deformity and osteoporotic bone were excluded. Clinical evaluations were performed annually until the last follow-up, a minimum of 9 years after surgery. At each follow-up, implant positioning was assessed on conventional plain films with a computer assisted radiographic evaluation. RESULTS The Harris hip score improved from 43 points (range 19-50) before surgery to 88 points (range 73-100) at the final follow-up (P=0.001), and the Womac score averaged 47 points (range 35-56 points) preoperatively and 76 points (range 63-84) at the last follow-up (P=0.001). Thigh pain was reported by five patients (8%) at the 2-year follow-up, but only in two (3%) was still present, and related to the prosthesis, at last follow-up. Computer assisted radiographic analysis showed a neutral alignment of the stem in 56% of cases, a varus-valgus alignment less than 5° in 36% and equal to 5° in 8%. Stem subsidence was observed in 12 hips but was less than 4mm in all cases (range 0-3mm). Calcar height remained unchanged over time. Adaptive bone remodelling, including proximal bone resorption and distal cortical hypertrophy were not observed at follow-up. No patients had aseptic loosening of the stem nor were radiolucent lines detectable at the level of the porous coating. Survivorship analysis showed a 100% survival rate of the stem at nine years. DISCUSSION This study showed that a femoral stem designed to achieve a pure metaphyseal fixation may obtain, in a selected group of patients with adequate bone quality, satisfactory clinical outcomes without compromising implant stability. The limited periprosthetic bone remodelling observed after a minimum of 9 years follow-up suggests that this type of implant may improve mechanical stresses on host bone compared with standard stems requiring diaphyseal fixation. LEVEL OF EVIDENCE Level IV. Historical series.

Hemilateral resurfacing arthroplasty in posttraumatic degenerative elbow resulting from humeral capitellum malunion

Secondary osteoarthritis, malunion, or nonunion associated with stiffness are common conditions in elbows after trauma. These conditions may be treated by various surgical methods when the elbow joint is severely compromised. In young, active patients with extensive joint destruction, interposition or distraction arthroplasty may be considered, whereas in the presence of malunited or ununited intra-articular fractures, open reduction and internal fixation can restore joint congruity. In the elderly with limited functional demand, these conditions may be treated by total elbow arthroplasty. When the lesion is only or essentially represented by malunion or nonunion of the capitellum, reconstruction can be performed as an alternative to excision of the bone fragment. Recently, Pooley has developed the hemilateral and the lateral resurfacing elbow (LRE) procedure for the treatment of osteoarthritis or early rheumatoid arthritis primarily affecting the radiocapitellar joint. We report a case of malunion of the capitellum associated with degenerative changes and stiffness of the elbow in which a hemi-LRE procedure was performed in association with extensive releases. To our knowledge, no previous report has been published on the use of hemi-LRE in posttraumatic elbow conditions.

Critical time period for recovery of functional range of motion after surgical treatment of complex elbow instability: Prospective study on 76 patients

INTRODUCTION AND AIM Complex elbow instability (CEI) is one of the most troublesome pathologies that orthopaedic surgeons have to face. One of the key requirements regarding the CEI surgical treatment is an early rehabilitation programme to avoid the elbow stiffness caused by a long period of immobilisation. Although this is well known, no study has ever examined how, and to what extent, the functional range of motion (ROM) is recovered during the various stages of a prompt rehabilitation. Our aims were: (1) to prospectively analyse the pattern of ROM recovery in a series of patients with CEI who underwent early rehabilitation and (2) to identify the period of time during rehabilitation in which the greatest degree of motion recovery is obtained. MATERIALS AND METHODS A total of 76 patients (78 elbows) with CEI were followed up for 2 years. All the patients underwent anatomical and stable ostheosynthesis of all the fractures, radial head replacement in Mason III fractures, ligament injuries reconstruction and early rehabilitation that started 2 days after surgery. Two surgeons evaluated the ROM with a hand-held goniometer every 3 weeks for the first 3 months, then at 6, 12 and 24 months after surgery. RESULTS At the 3-week follow-up, the mean flexion (F), extension (E), pronation (P) and supination (S) were 113°, 29°, 60° and 62°, respectively. At the 6-week and 9-week follow-up, F, E, P and S were 119°, 23°, 70° and 69° and 123°, 24°, 72° and 71°, respectively. At the 3-month follow-up, these values were 131°, 18°, 76° and 72°, while at the 6-month follow-up they were 136°, 15°, 79° and 77°, respectively. Thereafter, the ROM improvement was not significant. DISCUSSION This study shows that the first 6 months represent the critical rehabilitation period to obtain a functional elbow; indeed, 70% of the patients recovered functional ROM between the third and sixth month, though the recovery of flexion proved to be slower than that of the other elbow movements. Thereafter, improvement continued, though at a lower rate, until the end of the first year, when approximately 80% of the patients had recovered the functional ROM. CONCLUSIONS Following CEI surgical treatment, a rehabilitation programme needs to be started promptly and continued for at least 6 months because a significant improvement of ROM occurs prevalently in this period, which should be considered the critical time period to obtain a functional elbow in a majority of patients.

Open reduction and internal fixation combined with hinged elbow fixator in capitellum and trochlea fractures: A retrospective study of 15 patients followed for 29 months

Background and purpose The current surgical treatment for displaced fracture of the capitellum and trochlea is open reduction and internal fixation (ORIF), but the results are often unsatisfactory, particularly with complex fractures. Furthermore, the surgical approach, the kind of osteosynthesis, and postoperative management are controversial. We evaluated the results of internal fixation combined with hinged external fixation. Methods We analyzed 15 patients with a mean age of 47 (18–65) years. Based on the Bryan-Morrey-McKee classification, the fractures were identified as type I in 6 cases and type IV in 9. Active and passive motion was started and activities of daily living were permitted on the second postoperative day. The mean follow-up time was 29 (12–49) months. Results In 13 cases, functional range of motion was obtained within 6 weeks of surgery. At final follow-up, 14 patients had a stable, pain-free elbow with a mean active range of motion of 13° to 140°. The average score on the Mayo elbow performance score was 98. Interpretation The use of the hinged fixator allows early motion of the elbow while preserving joint stability. It may have additional value in complex articular fractures when stable internal fixation cannot be obtained with ORIF, and in the presence of severe ligamentous injuries.