Nicola Maffulli

Biological Therapies in Regenerative Sports Medicine.

Regenerative medicine seeks to harness the potential of cell biology for tissue replacement therapies, which will restore lost tissue functionality. Controlling and enhancing tissue healing is not just a matter of cells, but also of molecules and mechanical forces. We first describe the main biological technologies to boost musculoskeletal healing, including bone marrow and subcutaneous fat-derived regenerative products, as well as platelet-rich plasma and conditioned media. We provide some information describing possible mechanisms of action. We performed a literature search up to January 2016 searching for clinical outcomes following the use of cell therapies for sports conditions, tendons, and joints. The safety and efficacy of cell therapies for tendon conditions was examined in nine studies involving undifferentiated and differentiated (skin fibroblasts, tenocytes) cells. A total of 54 studies investigated the effects of mesenchymal stem-cell (MSC) products for joint conditions including anterior cruciate ligament, meniscus, and chondral lesions as well as osteoarthritis. In 22 studies, cellular products were injected intra-articularly, whereas in 32 studies MSC products were implanted during surgical/arthroscopic procedures. The heterogeneity of clinical conditions, cellular products, and approaches for delivery/implantation make comparability difficult. MSC products appear safe in the short- and mid-term, but studies with a long follow-up are scarce. Although the current number of randomized clinical studies is low, stem-cell products may have therapeutic potential. However, these regenerative technologies still need to be optimized.

Surgical Treatment for Failure of Repair of Patellar and Quadriceps Tendon Rupture With Ipsilateral Hamstring Tendon Graft.

Tears of the patellar and quadriceps tendon are common in the active population, especially in athletes. At present, several techniques for surgical repair and reconstruction are available. When reruptures occur, a reconstruction is mandatory. In the present paper, we describe a surgical technique for patellar and quadriceps tendon reconstruction using ipsilateral hamstring autograft. After routine hamstring tendon harvesting, the tendon ends are prepared using a whip stitch. A transverse tunnel is drilled in the midportion of the patella, the hamstring graft is passed through the patella, and firmly secured to the patellar tunnel openings with sutures. The details of the technique are fully described. Autologous ipsilateral hamstring tendon grafts provide a secure sound means to manage these challenging injuries.

The effectiveness of prolotherapy in treating knee osteoarthritis in adults: a systematic review.

Introduction Osteoarthritis (OA) often leads to symptoms such as pain, stiffness and decreased function. OA is treated with a wide range of modalities, both conservatively and surgically. Prolotherapy has been used to treat various musculoskeletal problems and has shown some promise. Sources of data Searches of the electronic databases, PubMed, ISI web of science, PEDro and SPORTDiscus, were conducted for all Level 1-4 studies published from inception through to December 2016. Areas of agreement Ten studies were evaluated and results show significant improvement in scores for pain, function and range of motion, both in the short term and long term. Patient satisfaction was also high in these patients (82%). Areas of controversy Meta-analysis was not possible due to heterogeneity of outcome measures and populations. Growing points Moderate evidence suggests that prolotherapy is safe and can help achieve significant symptomatic control in individuals with OA. Areas for developing research Future research should focus on larger sample size, standardization of treatment protocol and basic science evidence.

Apoptosis and rotator cuff tears: scientific evidence from basic science to clinical findings

Introduction Excessive apoptosis has been hypothesized as possible cause of tendinopathy and tear in the tendons of the rotator cuff (RC). Different mechanisms and molecules play a key role in cell regulation. Biological interventions can affect the process of apoptosis to control the tendinopathy process, and may be useful to design new treatments. Source of data We identified basic science, in vitro and in vivo preclinical and clinical studies listed in the Pubmed Google Scholar, CINAHL, Cochrane Central and Embase Biomedical databases in English, Spanish, Italian and French concerning the effects of apoptosis on RC tendons. Areas of agreement The homeostasis between the apoptotic and inflammatory processes is dynamic and controlled by pro- and anti-apoptotic mechanisms and signals, with variable balance in different areas of the RC tendons in human specimens. Areas of controversy Apoptosis can be identified along the whole tendon, not only in the area of the lesion. Therefore, it is not necessary to undertake wide debridement of the torn edges of the tendon when undertaking a repair. Growing points The identification of the various factors that control apoptosis and its mechanisms can help to design new treatments and exert positive effects in the recovery from tendon tears. Areas timely for developing research Further studies are needed to produce clear guidelines to determine how to balance the apoptosis process to reduce the failed healing response found in non-traumatic RC tears.

The Management of Extensor Mechanism Disruption After Total Knee Arthroplasty: A Systematic Review

We performed a literature search on PubMed, Web of Science, Science Direct/Scopus, Google Scholar, and Google to evaluate results of several techniques to manage disruption of the extensor mechanism after total knee arthroplasty. Different methods to manage extensor mechanism disruption are available at present, with no level I studies informing surgeons in an evidence-based fashion. Primary repair is not indicated. Allograft reconstruction could be effective, providing that appropriate surgical technique and allograft tensioning are implemented.

Preoperative planning for ACL revision surgery

The number of patients undergoing revision surgery following failure of anterior cruciate ligament (ACL) reconstruction has increased over the recent past, following the overall increased number of primary ACL reconstruction performed. Failure of primary ACL reconstruction can be attributed to technical errors, biological failures, or new traumatic injuries. Technical errors include femoral and/or tibial tunnels malposition, untreated associated ligaments insufficiencies, uncorrected lower limb malalignment, and graft fixation failures. Candidates for revision surgery should be carefully selected, and the success of ACL revision requires precise preoperative planning to obtain successful results. Preoperative planning begins with the analysis of the mechanisms of ACL reconstruction failure, and information regarding previous surgery, such as the type of graft implanted, and the position of existing hardware. Appropriate imaging is necessary to evaluate the position of the femoral and tibial tunnels, and abnormal tunnel widening. On the basis of clinical examination and imaging, surgeon can perform an ACL revision procedure in 1 or 2 stages.

Revision Surgery for Failed Patellar Tendinopathy Exploration

Chronic patellar tendinopathy affects athletes, with a higher incidence in high-impact sporting activities. It can seriously impair sports activities. Many patients respond well to conservative treatment, but about 10% of them are refractory to conservative treatment. In these cases, surgery is indicated. Multiple surgical techniques have been reported, including both open and arthroscopic procedures with good results. However, in a small percentage of patients surgery is unsuccessful. This group of patients presents a major challenge, as options are limited. We describe our surgical approach in the management of recalcitrant patellar tendinopathy.

Therapeutic Ultrasound in Navicular Stress Injuries in Elite Track and Field Athletes

Objective: To ascertain whether therapeutic ultrasound (TUS) can be used to assess the progression of conservative management in navicular stress injuries. Design: This is a prospective, clinical case series. Level of evidence IV. Setting: All participants were examined and followed up in a private Sports Injury Clinic. Participants: Ten elite track and field athletes with severe dorsal midfoot pain over the navicular bone participated in this study. Interventions: All patients underwent both TUS and magnetic resonance imaging (MRI) evaluation. The painful threshold of TUS on initial evaluation was a mean of 0.707 ± 149 W/cm2, and MRI detected a navicular stress injury in all patients. The athletes received conservative treatment and underwent sequential TUS evaluations at 4, 8, 12 and 16 weeks. Main Outcome Measures: Therapeutic ultrasound pain threshold values were recorded, and the patients were additionally asked to grade local tenderness on a Visual Analogue Scale. Time to return to play was also recorded. Results: The level of pain produced by the application of TUS on a navicular stress fracture seemed to correlate well with Visual Analogue Scale scores and the grade of fracture demonstrated on MRI. The initial low TUS painful mean value increased to a normal mean value of 1.97 ± 0.067 W/cm2 by 16 weeks. When clinical and TUS findings had returned to normal, the patients were allowed to return to sports activities, with no recurrences experienced during the study period. Conclusions: The production of pain associated with the application of TUS on a navicular stress fracture is a safe and reproducible method of monitoring the resolution of these fractures. We have used it successfully in making return-to-play decisions for elite level track and field athletes.