Giuseppe Milano

Single-Row Versus Double-Row Arthroscopic Rotator Cuff Repair: A Prospective Randomized Clinical Study

PURPOSE The purpose of this study was to compare the clinical outcome of arthroscopic rotator cuff repair with single-row and double-row techniques. METHODS Eighty patients with a full-thickness rotator cuff tear underwent arthroscopic repair with suture anchors. They were divided into 2 groups of 40 patients according to repair technique: single row (group 1) or double row (group 2). Results were evaluated by use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Work-DASH self-administered questionnaires, normalized Constant score, and muscle strength measurement. On analyzing the results at a 2-year follow-up, we considered the following independent variables: baseline scores; age; gender; dominance; location, shape, and area of cuff tear; tendon retraction; fatty degeneration; treatment of biceps tendon; and rotator cuff repair technique (anchors or anchors and side to side). Univariate and multivariate statistical analyses were performed to determine which variables were independently associated with the outcome. Significance was set at P < .05. RESULTS Of the patients, 8 (10%) were lost to follow-up. Comparison between groups did not show significant differences for each variable considered. Overall, according to the results, the mean DASH scores were 15.4 +/- 15.6 points in group 1 and 12.7 +/- 10.1 points in group 2; the mean Work-DASH scores were 16.0 +/- 22.0 points and 9.6 +/- 13.3 points, respectively; and the mean Constant scores were 100.5 +/- 17.8 points and 104.9 +/- 21.8 points, respectively. Muscle strength was 12.7 +/- 5.7 lb in group 1 and 12.9 +/- 7.0 lb in group 2. Univariate and multivariate analysis showed that only age, gender, and baseline strength significantly and independently influenced the outcome. Differences between groups 1 and 2 were not significant. CONCLUSIONS At short-term follow-up, arthroscopic rotator cuff repair with the double-row technique showed no significant difference in clinical outcome compared with single-row repair. LEVEL OF EVIDENCE Level I, high-quality randomized controlled trial with no statistically significant differences but narrow confidence intervals.

Bone substitutes in orthopaedic surgery: from basic science to clinical practice

Bone substitutes are being increasingly used in surgery as over two millions bone grafting procedures are performed worldwide per year. Autografts still represent the gold standard for bone substitution, though the morbidity and the inherent limited availability are the main limitations. Allografts, i.e. banked bone, are osteoconductive and weakly osteoinductive, though there are still concerns about the residual infective risks, costs and donor availability issues. As an alternative, xenograft substitutes are cheap, but their use provided contrasting results, so far. Ceramic-based synthetic bone substitutes are alternatively based on hydroxyapatite (HA) and tricalcium phosphates, and are widely used in the clinical practice. Indeed, despite being completely resorbable and weaker than cortical bone, they have exhaustively proved to be effective. Biomimetic HAs are the evolution of traditional HA and contains ions (carbonates, Si, Sr, Fl, Mg) that mimic natural HA (biomimetic HA). Injectable cements represent another evolution, enabling mininvasive techniques. Bone morphogenetic proteins (namely BMP2 and 7) are the only bone inducing growth factors approved for human use in spine surgery and for the treatment of tibial nonunion. Demineralized bone matrix and platelet rich plasma did not prove to be effective and their use as bone substitutes remains controversial. Experimental cell-based approaches are considered the best suitable emerging strategies in several regenerative medicine application, including bone regeneration. In some cases, cells have been used as bioactive vehicles delivering osteoinductive genes locally to achieve bone regeneration. In particular, mesenchymal stem cells have been widely exploited for this purpose, being multipotent cells capable of efficient osteogenic potential. Here we intend to review and update the alternative available techniques used for bone fusion, along with some hints on the advancements achieved through the experimental research in this field.

Meniscal allografts: cryopreservation vs deep-frozen technique. An experimental study in goats

Abstract Meniscal transplantation was performed in two groups of 15 adult goats each, using cryopreserved (group I) and deep-frozen (group II) allografts. Animals were killed at 2 weeks, 1, 3, 6 and 12 months, and a gross, histological and biochemical (water and glycosaminoglycan) evaluation of the menisci was performed. The allografts of both groups showed a normal gross appearance and had in most cases healed at the horn attachments and at the peripheral capsular tissue with a dense scar tissue and no signs of rejection. Histological analysis showed that at 2 weeks in group I the cell number was decreased compared with the controls, and the cells were mainly distributed in the superficial layers. In group II at 2 weeks, only a few cells were present at the peripheral attachment of the menisci. At 1 month in both groups, the cell repopulation can be seen extending from the peripheral area to the superficial layers. Cell proliferation and vascularization are particularly evident in both groups in the 3-month samples. At 6 months and 1 year the grafts can be seen to be completely remodelled and morphologically similar to normal menisci in both groups. Biochemical analysis showed in both groups an increase in water content and a progressive decrease in the concentration of glycosaminoglycans. At 1 year in both groups, there were moderate degenerative changes in the articular cartilage of the tibial plateau, which were more evident in the area of exposed cartilage than in that covered by the meniscus. These results suggest that there are no significant differences between the cryopreserved and deep-frozen grafts, and that even if cryopreservation makes it possible to maintain a partial cell viability in the tissue, this does not seem to improve the morphological and biochemical characteristics of the graft.

Graft healing after anterior cruciate ligament reconstruction in rabbits

Anterior cruciate ligament reconstruction with patellar tendon was performed in 50 rabbits (two groups of 25 animals) by the outside-in (Group I) and the inside-out (Group II) techniques. Five animals from each group were sacrificed at different times (2 weeks, 1, 3, 6, and 9 months). Histologic analysis showed that the intraarticular part of the graft was morphologically similar to a normal ligament in both groups at 9 months. In Group 1, a newly formed bone-graft junction along the tunnel walls was observed inside the femoral tunnel. At 6 months, this junction resembled a direct type junction. The old bone-tendon junction showed an early disappearance of the fibrocartilage and was differentiated as a direct junction only at 9 months. In Group 2, at the site of the old bone-tendon junction a fibrocartilaginous layer was present during the whole process of remodeling, and at 6 months this area resembled a direct junction. These observations would suggest that when the junction is placed inside the tunnel (outside-in technique) the process of remodeling is more dramatic and slower than when it is placed at the intraarticular exit of the tunnel (inside-out technique), probably because of the formation of a new bone-graft junction along the tunnel walls that partially unload the old junction.

Clinical and radiographic results of ACL reconstruction: a 5- to 7-year follow-up study of outside-in versus inside-out reconstruction techniques

This study compared the clinical outcome of anterior cruciate ligament (ACL) reconstruction between the inside-out and the outside-in techniques and assessed radiographically whether surgical technique affects the position and direction of the bone tunnels. A patellar tendon ACL reconstruction was performed in 141 patients with inside-out (group I, n=78) and outside-in technique (group II, n=63). Clinical results were evaluated using the International Knee Documentation Committee (IKDC) form; radiographic study was performed in anteroposterior, lateral, and notch views. Overall results in group I were normal in 23% of cases, nearly normal in 55%, and abnormal in 22%; in group II there were normal results in 19% of cases, nearly normal in 57%, abnormal in 19%, and severely abnormal in 5%. Radiographic examination identified important differences between the two groups. The main differences between the two surgical techniques were related to the positioning of the femoral tunnel. With the inside-out technique the femoral tunnel was significantly more vertical, both in the frontal and the sagittal planes. Moreover, the femoral tunnel was higher when drilled from the inside, but the difference between the two techniques was not statistically significant. The differences found between the two techniques regarding the tibial tunnel were not significant, although in the inside-out group the tibial tunnel seemed slightly more lateral, vertical, and posterior. Moreover, we observed a greater risk of bone-screw divergence on the femur in the inside-out group. This divergence was greatest in the sagittal plane. However, we observed no effect of this bone-screw divergence on the stability of the knee at follow-up.

Histological analysis of the coracoacromial arch: correlation between age-related changes and rotator cuff tears

The purpose of this study was to analyze age-related changes in the coracoacromial arch and correlate these degenerative changes with rotator cuff tears. We obtained 80 shoulders from 40 cadavers. The mean age at death was 58.4 years. We performed a gross examination of the rotator cuff and the acromion and histological examination of the coracoacromial ligament. The statistical significance of any difference for each group considered was determined by Students t-test. The rotator cuff was normal in 66 specimens; there was an articular-side partial tear in 4 cases, a bursal-side partial tear in 6 cases, and a full-thickness tear in 4 cases. Age was correlated with increasing incidence and severity of cuff tears. We noted age-related degenerative changes in the coracoacromial ligament, degeneration of the acromial bone-ligament junction, and acromial spur formation. Anterior acromial spur was not related to the morphology of the acromion. We observed an increased incidence of bursal-side and complete cuff tears when the acromion was curved or beaked. Degenerative changes in the undersurface of the acromion were also present when the rotator cuff was normal. Bursal-side and complete cuff tears were associated with severe degenerative changes in the acromion in 100% of cases. Articular-side cuff tears were not related either to acromial morphology or degenerative changes in the coracoacromial arch. The association between cuff tears and acromial spur was more evident in the presence of a type III acromion. Our results would suggest that the incidence and severity of rotator cuff tears are correlated with aging and with the morphology of the acromion. Rotator cuff tears that involve the bursal side are often associated with changes in the coracoacromial ligament and the undersurface of the acromion. However, degenerative changes in the coracoacromial arch are always related to aging, also in the presence of a normal rotator cuff. Articular-side partial tears do not cause damage to the undersurface of the acromion.

Efficacy of marrow-stimulating technique in arthroscopic rotator cuff repair: a prospective randomized study.

PURPOSE To evaluate the efficacy of a marrow-stimulating technique with microfractures of the greater tuberosity during arthroscopic rotator cuff repair. METHODS Eighty patients with a full-thickness rotator cuff tear underwent an arthroscopic single-row repair. Patients were divided into 2 groups of 40 cases each. In group 1, standard repair was performed; in group 2, microfractures of the greater tuberosity were performed to enhance tendon repair. Clinical outcome was assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score and normalized Constant score. Tendon integrity was assessed with magnetic resonance imaging. Multivariate analysis was performed to determine which predictors were independently associated with the outcome. Significance was set at P < .05. RESULTS The mean follow-up was 28.1 ± 3 months. Seven patients were lost to follow-up (2 in group 1 and 5 in group 2). Comparison between groups did not show significant differences for baseline characteristics. The mean DASH score was 28.6 ± 21.3 points in group 1 and 23.3 ± 20.1 points in group 2. Although the difference was not statistically significant, the confidence interval included a 10-point value (minimal clinically important difference) in favor of the microfracture group. The difference in the Constant score between groups was not significant. The tendon healing rate was 52.6% in group 1 and 65.7% in group 2, without a significant difference between groups. Subgroup analysis for tear size showed that group 2 had a significantly greater healing rate than group 1 for large tears (P = .040). Multivariate analysis showed that age, timing of symptoms, tear location, tendon retraction, and fatty infiltration significantly affected the outcomes. CONCLUSIONS Postoperative magnetic resonance imaging did not show any significant difference between groups in structural integrity. However, subgroup analysis showed a significantly greater healing rate in the microfracture group for large tears involving the supraspinatus and infraspinatus. LEVEL OF EVIDENCE Level I, high-quality randomized controlled trial with no statistically significant difference but narrow confidence intervals.

Intra-observer and interobserver reliability of the ‘Pico’ computed tomography method for quantification of glenoid bone defect in anterior shoulder instability

ObjectiveTo evaluate the intra-observer and interobserver reliability of the ‘Pico’ computed tomography (CT) method of quantifying glenoid bone defects in anterior glenohumeral instability.Materials and methodsForty patients with unilateral anterior shoulder instability underwent CT scanning of both shoulders. Images were processed in multiplanar reconstruction (MPR) to provide an en face view of the glenoid. In accordance with the Pico method, a circle was drawn on the inferior part of the healthy glenoid and transferred to the injured glenoid. The surface of the missing part of the circle was measured, and the size of the glenoid bone defect was expressed as a percentage of the entire circle. Each measurement was performed three times by one observer and once by a second observer. Intra-observer and interobserver reliability were analyzed using intraclass correlation coefficients (ICCs), 95% confidence intervals (CIs), and standard errors of measurement (SEMs).ResultsAnalysis of intra-observer reliability showed ICC values of 0.94 (95% CI = 0.89–0.96; SEM = 1.1%) for single measurement, and 0.98 (95% CI = 0.96–0.99; SEM = 1.0%) for average measurement. Analysis of interobserver reliability showed ICC values of 0.90 (95% CI = 0.82–0.95; SEM = 1.0%) for single measurement, and 0.95 (95% CI = 0.90–0.97; SEM = 1.0%) for average measurement.ConclusionMeasurement of glenoid bone defect in anterior shoulder instability can be assessed with the Pico method, based on en face images of the glenoid processed in MPR, with a very good intra-observer and interobserver reliability.

Analysis of Risk Factors for Glenoid Bone Defect in Anterior Shoulder Instability

Background: Glenoid bone defect is frequently associated with anterior shoulder instability and is considered one of the major causes of recurrence of instability after shoulder stabilization. Hypothesis: Some risk factors are significantly associated with the presence, size, and type of glenoid bone defect. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: One hundred sixty-one patients affected by anterior shoulder instability underwent morphologic evaluation of the glenoid by computed tomography scans to assess the presence, size, and type of glenoid bone defect (erosion or bony Bankart lesion). Bone loss greater than 20% of the area of the inferior glenoid was considered “critical” bone defect (at risk of recurrence). Outcomes were correlated with the following predictors: age, gender, arm dominance, frequency of dislocation, age at first dislocation, timing from first dislocation, number of dislocations, cause of first dislocation, generalized ligamentous laxity, type of sport, and manual work. Results: Glenoid bone defect was observed in 72% of the cases. Presence of the defect was significantly associated with recurrence of dislocation compared with a single episode of dislocation, increasing number of dislocations, male gender, and type of sport. Size of the defect was significantly associated with recurrent dislocation, increasing number of dislocations, timing from first dislocation, and manual work. Presence of a critical defect was significantly associated with number of dislocations and age at first dislocation. Bony Bankart lesion was significantly associated with male gender and age at first dislocation. Conclusion: The number of dislocations and age at first dislocation are the most significant predictors of glenoid bone loss in anterior shoulder instability.

Arthroscopic treatment of malunited and nonunited avulsion fractures of the anterior tibial spine

Ten patients, presenting with a 10 degrees to 25 degrees deficit of knee extension after an avulsion fracture of the anterior tibial spine, were arthroscopically treated with debridement and abrasion of the anterior spine. Notchplasty was also performed in five cases where there was a more severe deficit of extension. At follow-up (mean: 39.4 months) eight patients had recovered the full articular range of motion of the knee whereas two had a slight residual deficit of extension of between 3 degrees and 5 degrees. In no case was ligament stability compromised as compared with preoperative assessment.