Maria Chiara Vulpiani

Platelet-Rich Plasma Versus Focused Shock Waves in the Treatment of Jumper’s Knee in Athletes

Background: Tendinopathies represent a serious challenge for orthopaedic surgeons involved in treatment of athletes. Purpose: To compare the effectiveness and safety of platelet-rich plasma (PRP) injections and focused extracorporeal shock wave therapy (ESWT) in athletes with jumper’s knee. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Forty-six consecutive athletes with jumper’s knee were selected for this study and randomized into 2 treatment groups: 2 autologous PRP injections over 2 weeks under ultrasound guidance (PRP group; n = 23), and 3 sessions of focused extracorporeal shock wave therapy (2.400 impulses at 0.17-0.25 mJ/mm2 per session) (ESWT group; n = 23). The outcome measures were Victorian Institute of Sports Assessment–Patella (VISA-P) questionnaire, pain visual analog scale (VAS), and modified Blazina scale. A reviewer who was blinded as to the group allocation of participants performed outcome assessments before treatment and at 2, 6, and 12 months after treatment. Nonparametric tests were used for within-group (Friedman/Wilcoxon test) and between-group (Kruskal-Wallis/Fisher test) testing, and the significance level was set at .05. Results: The 2 groups were homogeneous in terms of age, sex, level of sports participation, and pretreatment clinical status. Patients in both groups showed statistically significant improvement of symptoms at all follow-up assessments. The VISA-P, VAS, and modified Blazina scale scores showed no significant differences between groups at 2-month follow-up (P = .635, .360, and .339, respectively). The PRP group showed significantly better improvement than the ESWT group in VISA-P, VAS scores at 6- and 12-month follow-up, and modified Blazina scale score at 12-month follow-up (P < .05 for all). Conclusion: Therapeutic injections of PRP lead to better midterm clinical results compared with focused ESWT in the treatment of jumper’s knee in athletes.

Regeneration of the Semitendinosus Tendon Harvested for Anterior Cruciate Ligament Reconstruction: Evaluation Using Ultrasonography*:

In a prospective study, 40 consecutive patients who underwent anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendon autografts were examined pre- and postoperatively by ultrasound to investigate the anatomy of the donor site before and after the harvest of the tendons. The patients underwent ultrasonography at 2 weeks and 1, 2, 3, 6, 12, 18, and 24 months postoperatively. A total of 298 postoperative sonographic evaluations were performed. The semitendinosus tendon was imaged in the sagittal and axial planes: structure and margins were evaluated with the sagittal views; thickness and width were measured with the axial views. In all cases the following sequence of healing was documented: 2 weeks after surgery the semitendinosus tendon site was occupied by an area of increased thickness and decreased echogenicity, suggesting the presence of traumatic edema of the soft tissue surrounding the tenotomy. At 1 month, an irregular hypoechoic structure appeared in a near-anatomic position; at 2 months after surgery, thickness, width, and cross-sectional area of this structure were significantly greater than preoperatively. The amount of regenerated tissue increased up to that seen in the tissue of the 6-month examinations, which also showed a more uniform echostructure. The scans performed at 1 year showed distinct edges and reduction in thickness and width. At 18 and 24 months the echogenicity of the structure occupying the donor site was very similar to that of the normal semitendinosus tendon. However, this structure was clearly identified about 4 cm proximal to the pes anserinus, revealing a more proximal insertion of the regenerated semitendinosus tendon.

Riluzole in patients with hereditary cerebellar ataxia: a randomised, double-blind, placebo-controlled trial

BACKGROUND Our previous study in patients with cerebellar ataxias of different causes showed significant benefit of riluzole after 8 weeks. We aimed to confirm these results in patients with spinocerebellar ataxia or Friedreichs ataxia in a 1-year trial. METHODS Patients with spinocerebellar ataxia or Friedreichs ataxia (2:1 ratio) from three Italian neurogenetic units were enrolled in this multicentre, double-blind, placebo-controlled trial, and randomly assigned to riluzole (50 mg orally, twice daily) or placebo for 12 months. The randomisation list was computer-generated and a centralised randomisation system was implemented. Participants and assessing neurologists were masked to treatment allocation. The primary endpoint was the proportion of patients with improved Scale for the Assessment and Rating of Ataxia (SARA) score (a drop of at least one point) at 12 months. An intention-to-treat analysis was done. This trial is registered at ClinicalTrials.gov, number NCT01104649. FINDINGS Between May 22, 2010, and Feb 25, 2013, 60 patients were enrolled. Two patients in the riluzole group and three in the placebo group withdrew their consent before receiving treatment, so the intention-to-treat analysis was done on 55 patients (19 with spinocerebellar ataxia and nine with Friedreichs ataxia in the riluzole group, and 19 with spinocerebellar ataxia and eight with Friedreichs ataxia in the placebo group). The proportion with decreased SARA score was 14 (50%) of 28 patients in the riluzole group versus three (11%) of 27 in the placebo group (OR 8·00, 95% CI 1·95-32·83; p=0·002). No severe adverse events were recorded. In the riluzole group, two patients had an increase in liver enzymes (less than two times above normal limits). In two participants in the riluzole group and two participants in the placebo group, sporadic mild adverse events were reported. INTERPRETATION Our findings lend support to the idea that riluzole could be a treatment for cerebellar ataxia. Longer studies and disease-specific trials are needed to confirm whether these findings can be applied in clinical practice. FUNDING Agenzia Italiana del Farmaco.

Extracorporeal shock wave therapy promotes cell proliferation and collagen synthesis of primary cultured human tenocytes

PurposeThe aim of this study was to investigate whether the effects of extracorporeal shock wave therapy (ESWT) could affect the behavior of primary cultured human tenocytes over a 12-day period.MethodsIn this controlled laboratory study, primary human tenocytes were established from semitendinosus tendons collected from 3 patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction. Cell viability, overall cell morphology, cell proliferation, and collagen synthesis following ESWT have been evaluated.ResultsESWT significantly interferes with the overall cell morphology, by impairing dedifferentiation of the cells. Furthermore, a shock wave-mediated growth-promoting effect was measured by the MTT (tetrazolium) colorimetric assay and by the proliferation marker Ki67. Lastly, a significant increase in collagen (mainly type I) synthesis by ESWT-tenocytes compared with control cells was found.ConclusionsShock wave treatment promoted cell growth and collagen synthesis of primary cultured human tenocytes. The clinical benefits of ESWT may be ascribed to an increased efficiency of tendon repair after injury.

Extracorporeal Shock Wave Treatment (ESWT) Improves In Vitro Functional Activities of Ruptured Human Tendon-Derived Tenocytes

In vitro models of human tenocytes derived from healthy as well as from ruptured tendons were established, characterized and used at very early passage (P1) to evaluate the effects of Extracorporeal Shock Wave Treatment (ESWT). The molecular analysis of traditional tenocytic markers, including Scleraxis (Scx), Tenomodulin (Tnm), Tenascin-C (Tn-C) and Type I and III Collagens (Col I and Col III), permitted us to detect in our samples the simultaneous expression of all these genes and allowed us to compare their levels of expression in relationship to the source of the cells and treatments. In untreated conditions, higher molecular levels of Scx and Col I in tenocytes from pathological compared to healthy samples have been detected, suggesting – in the cells from injured tendon – the natural trigger of an early differentiation and repairing program, which depends by Scx and requires an increase in collagen expression. When ESWT (at the dose of 0.14 mJ/mm2) was applied to cultured tenocytes explanted from injured source, Scx and Col I were significantly diminished compared to healthy counterpart, indicating that such natural trigger maybe delayed by the treatment, in order to promote cellular repair. Herein, we show for the first time that ESWT enhances in vitro functional activities of ruptured tendon-derived tenocytes, such as proliferation and migration, which could probably contributes to tendon healing in vivo.

Extracorporeal Shock Wave Treatment (ESWT) enhances the in vitro-induced differentiation of human tendon-derived stem/progenitor cells (hTSPCs).

Extracorporeal shock wave therapy (ESWT) is a non-invasive and innovative technology for the management of specific tendinopathies. In order to elucidate the ESWT-mediated clinical benefits, human Tendon-derived Stem/Progenitor cells (hTSPCs) explanted from 5 healthy semitendinosus (ST) and 5 ruptured Achilles (AT) tendons were established. While hTSPCs from the two groups showed similar proliferation rates and stem cell surface marker profiles, we found that the clonogenic potential was maintained only in cells derived from healthy donors. Interestingly, ESWT significantly accelerated hTSPCs differentiation, suggesting that the clinical benefits of ESWT may be ascribed to increased efficiency of tendon repair after injury.

Conservative treatment for insertional achilles tendinopathy: Platelet-rich plasma and focused shock waves. A retrospective study

BACKGROUND Insertional Achilles tendinopathy (IAT) represents a serious challenge for both physiatrists and surgeons. Here we analyse the results obtained by two conservative treatments [platelet-rich plasma (PRP) injections and focused extracorporeal shock-wave therapy (ESWT)] in physically active patients with IAT. METHODS During two consecutive periods, 45 consecutive patients with IAT were treated with 3 sessions of ESWT (2400 impulses at 0.17-0.25 mJ/mm2 per session) (24 cases between September 2011 and July 2013) or with 2 autologous PRP injections over two weeks (21 cases between September 2013 and July 2015). All patients were evaluated at 0, 2-, 4-, 6-month follow-up after therapy. The outcome measures were VISA-A, VAS, Patient Satisfaction. RESULTS Intra-group analysis showed a significant improvement of VISA-A and VAS scores in both groups at all time-points. No differences between groups were observed for VAS and VISA-A scores at all time-points, excepted for VISA-A at 4-months in favour of ESWT group (P=0.049). Patient satisfaction increased progressively (>70% at 6 months) and with no differences between two groups. CONCLUSION Both ESWT and PRP therapy are effective and safe. Our study confirms the success of these conservative treatments in Achilles tendinopathy, even in the insertional one. LEVEL OF EVIDENCE IIIa.

I.S.Mu.L.T. First-time patellar dislocation guidelines

Primary traumatic patellar dislocation is common, particularly in young active individuals. A consensus on its management is still lacking. The present work provides easily accessible guidelines to be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, to improve the quality of care and rationalize the use of resources. LEVEL OF EVIDENCE Ia.

Extracorporeal shock wave therapy vs cryoultrasound therapy in the treatment of chronic lateral epicondylitis. One year follow up study

BACKGROUND the purpose of this study is to compare the therapeutic effects of extracorporeal shock wave therapy (ESWT) to those of cryoultrasound (Cryo-US) therapy in chronic lateral epicondylitis during a 12-month period. METHODS single-blinded, randomized, controlled study of 80 participants treated for chronic LE with 3 ESWT sessions at 48/72-hours intervals (n=40) or 12 Cryo-US therapy sessions (4 sessions per week) (n=40). VAS and satisfactory results, considered as the sum of excellent and good scores in the Roles and Maudsley score, were used as outcome measures at baseline and 3, 6 and 12 months post-treatment. RESULTS the results show statistically significant differences in VAS between the two groups at 6 (p<0.001) and 12 months (p<0.001) in favour of the ESWT Group. At 12 months, a difference of more than 2 points in the VAS between the two groups is demonstrated in favour of the ESWT Group. Considering satisfactory results, significant differences between the two groups are observed at 6 (p=0.003) and 12 months (p <0.001) in favour of the ESWT Group where patients achieve a satisfactory rate over 50%. CONCLUSIONS ESWT has better clinical therapeutic results at 6- and 12-month follow-up as compared to Cryo-US therapy. LEVEL OF EVIDENCE 1B.

MMPI-2 profiles and illness perception in fibromyalgia syndrome: The role of therapeutic exercise as adapted physical activity

BACKGROUND Control of pain management is an important up-stream process in fibromyalgia (FM) mechanisms. OBJECTIVE To investigate whether adapted physical activity (APA) could change the illness perception in relation to the FM personality profile. METHODS Thirty-seven women with FM allocated randomly: 19 treatment group (TG) and 18 control group (CG). Interventions: exercises program included ten sessions, two times for week for one hour each and observation for CG. Scales: Illness Perception Questionnaire-revisited (IPQ-r) for the mental representation of the disease, Minnesota Multiphasic Personality Inventory profiles (MMPI-2) for personality tool and Fibromyalgia Impact Questionnaire (FIQ) for function, impact and symptoms. Outcome assessments were performed before rehabilitation treatment (T0) than at the end (T1), and a follow-up 12 weeks after treatment (T2). RESULTS APA was efficacy to improve FIQ values in TG at T1 and T2 test days (P = 0.014). Changes in IPQ-R values in T2 were not significant. All patients presented a baseline T-score≥65 in at least one of the basic and content MMPI-2 scales (Hy, D, Hs and Hea and Anx). CONCLUSION APA was efficacy in FM, but further research to differentiate between illness experience rather than focus ona strict personality profile are necessary.