Ricardo Cuéllar

Stem cell therapy in the management of shoulder rotator cuff disorders

Rotator cuff tears are frequent shoulder problems that are usually dealt with surgical repair. Despite improved surgical techniques, the tendon-to-bone healing rate is unsatisfactory due to difficulties in restoring the delicate transitional tissue between bone and tendon. It is essential to understand the molecular mechanisms that determine this failure. The study of the molecular environment during embryogenesis and during normal healing after injury is key in devising strategies to get a successful repair. Mesenchymal stem cells (MSC) can differentiate into different mesodermal tissues and have a strong paracrine, anti-inflammatory, immunoregulatory and angiogenic potential. Stem cell therapy is thus a potentially effective therapy to enhance rotator cuff healing. Promising results have been reported with the use of autologous MSC of different origins in animal studies: they have shown to have better healing properties, increasing the amount of fibrocartilage formation and improving the orientation of fibrocartilage fibers with less immunologic response and reduced lymphocyte infiltration. All these changes lead to an increase in biomechanical strength. However, animal research is still inconclusive and more experimental studies are needed before human application. Future directions include expanded stem cell therapy in combination with growth factors or different scaffolds as well as new stem cell types and gene therapy.

Arthroscopic Treatment of Unstable Total Hip Replacement

Hip arthroscopy may be useful in the diagnosis and treatment of apparently well-implanted but unstable total hip replacement prostheses. We present 2 cases of arthroscopically assisted capsular tightening in unstable total hip replacements. Both cases had significant capsular laxity. Case 2 had impingement of the lower part of the acetabulum with the lesser trochanter that caused hip dislocation. Early revision surgery can be avoided with the use of this technique in selected cases of unstable total hip replacements.

Rapid development of osteoarthritis following arthroscopic resection of an “os acetabuli” in a mildly dysplastic hip—a case report

A 42-year-old athletic woman attended our clinic complaining of right groin pain. The pain had begun 2 years previously when jogging. The pain had gradually become worse, limiting her daily activities and any sporting activities. Clinical examination showed a positive impingement test and limitation of internal rotation of up to 20o at 90o of hip flexion. Plain radiogrpahs showed a normal alpha angle, and a 12 × 14 mm “os acetabuli” was present at the superolateral acetabular rim (Figure 1). The joint was mildly dysplastic with a center-edge angle (CEA) (excluding the “os acetabuli”) of 15o (25o in the contralateral hip). The Tonnis angle was 24o. Differential diagnoses were an “os acetabuli” in a dysplastic hip, chronic avulsion fracture of de anteroinferior iliac spine (Larson et al. 2011), stress fracture (Martinez et al. 2006), or enchondroma-like lesion. The CT described the presence of an “os acetabuli” beside the joint surface with an intact anteroinferior iliac spine (Figure 2). Figure 1. Plain AP (A) and lateral view (B) showing a normal alpha angle. A 12 × 14 mm calcified irregular-shaped image was seen at the superolateral acetabular rim. Excluding the “os acetabuli”, the center-edge angle was 15o (25o ... Figure 2. Sagittal plane CT scan image optimized for bone density, showing the “os acetabuli” (arrow). The patient’s pain persisted, and we made a hip arthroscopy. She was placed supine on the traction table. Due to the shape, size, and location of the lesion, access to the central compartment was difficult and an “outside-in” technique with a T-shaped capsulotomy was performed (Horisberger et al. 2010, Cuellar et al. 2013). Dynamic intraoperative assessment showed impingement between the “os acetabuli” and the superior labrum, which was slightly frayed and detached from the acetabulum (Figure 3). The bony lesion was dissected and resected, keeping the underlying labrum intact. The labrum was reinserted with three 2.3-mm Bioraptor bone anchors (Smith and Nephew). The capsule was then repaired with interrupted Ultrabride sutures, with 2 side-to-side sutures. No femoral osteochondroplasty was performed. Figure 3. View of the peripheral compartment from the anteromedial portal with a 30o scope. The close relation between the detached labrum (L) and the “os acetabuli” (O) can be seen. F: femoral head. After surgery, the patient was instructed not to bear weight for 4 weeks and then to resume partial weight bearing for another 4 weeks. Hyperextension was restricted for the first 3 months, to protect capsular healing. At 4-month follow-up, the patient was walking unaided and was free from pain; she had a full range of motion and radiographs confirmed the complete resection of the “os acetabuli”—but a slight joint narrowing was detected. At 6-month follow-up, she had again developed groin pain. At 10 months, radiographs showed a Tonnis-III degenerative stage (Figure 4). A total hip replacement was required at 12 months. During the joint replacement, we found osteoarthritis and a reduction of femoral head coverage. Figure 4. A. At 4-month follow-up, complete resection of the “os acetabuli” and a slight narrowing of the joint space. B. At 10-month follow-up anterosuperior subluxation and clear degenerative joint disease with sclerotic joint line and subchondral ...

The Use of All-Arthroscopic Autologous Matrix-Induced Chondrogenesis for the Management of Humeral and Glenoid Chondral Defects in the Shoulder.

Autologous matrix-induced chondrogenesis (AMIC) is often used for treating chondral defects in different joints. We describe an all-arthroscopic approach for the treatment of glenoid and humeral chondral lesions with this technique. AMIC starts with the use of microfractures of the damaged cartilage, followed by coverage of the defect with a type I/III collagen matrix (Chondro-Gide; Geistlich Pharma, Wolhusen, Switzerland) that is fixed with fibrin glue (Tissucol; Baxter, Warsaw, Poland). In a 1-step approach, the unstable cartilage is debrided, microfractures that penetrate up to the subchondral bone are performed, and the membranes are pasted to the lesion. Our technique reduces morbidity rates compared with traditional open surgery. The arthroscopic AMIC procedure is a viable, cost-effective treatment for the repair of chondral lesions of the shoulder.

The Effect of Knee Flexion Angle on the Neurovascular Safety of All-Inside Lateral Meniscus Repair: A Cadaveric Study

PURPOSE To evaluate if different knee flexion angles can modify the neurovascular injury risk during lateral meniscus repair. METHODS Twenty cadaveric knees were studied. An all-inside suture device (FasT-Fix; Smith & Nephew, Andover, MA) was placed at the posterior horn and at the medial and lateral limits of the popliteal hiatus. The minimal distances between the device and the popliteal artery and peroneal nerve were measured with the knee at 90°, 45°, and 0° of flexion through a limited posterolateral arthrotomy. RESULTS The distance between the device when inserted at the lateral edge of the popliteal hiatus and the peroneal nerve decreased from a median of 26 mm (interquartile range [IQR], 3.5 mm; range, 19 to 29 mm) at 90° to 21.5 mm (IQR, 4.5 mm; range, 14 to 25 mm) at 45° and 15.5 mm (IQR, 6.5 mm; range, 4 to 20 mm) at 0° (significant differences, P < .001). The distance between the device when inserted at the medial edge of the popliteal hiatus and the peroneal nerve decreased from 16 mm (IQR, 3.3 mm; range, 9 to 21 mm) at 90° to 12 mm (IQR, 4.3 mm; range, 9 to 16 mm) at 45° and 7 mm (IQR, 4.0; range, 4 to 15 mm) at 0° (significant differences, P < .001). The distance between the device when inserted at the medial edge of the popliteal hiatus and the popliteal artery decreased from 21 mm (IQR, 5.0 mm; range, 11 to 27 mm) at 90° to 19 mm (IQR, 5.0 mm; range, 10 to 23 mm) at 45° and 16 mm (IQR, 7.5 mm; range, 10 to 23 mm) at 0° (significant differences, P < .001). The distance between the device when inserted 5 mm lateral to the posterior root of the lateral meniscus and the popliteal artery decreased from 13 mm (IQR, 4.3 mm; range, 7 to 27 mm) at 90° to 10.5 mm (IQR, 4.3 mm; range, 4 to 19 mm) at 45° and 5.5 mm (IQR, 4.0 mm; range, 0 to 14 mm) at 0° (significant differences, P < .001). CONCLUSIONS The risk of injury to the popliteal artery or to the peroneal nerve during all-inside repair of the posterior half of the lateral meniscus is lower at 90° of flexion and increases with knee extension to 45° and 0°. CLINICAL RELEVANCE All-inside meniscal repair of the lateral meniscus is safer with the knee at 90° of flexion.

Soft tissue tumour causing coracoid impingement syndrome

Abstract Coracoid impingement syndrome results from subscapularis tendon entrapment between the humerus and the coracoid. This syndrome is an uncommon cause of shoulder pain that has many different aetiologies. Although synovial cysts have been reported as cause of coracoid impingement at this level, solid tumoural lesions are a rare cause of symptoms in this location. Two cases of benign soft tissue solid tumours are presented. Both patients developed symptoms compatible with coracoid impingement syndrome. The lesions were fully resected under arthroscopic visualization. Both patients had complete resolution of the symptoms and are asymptomatic at 2-year follow-up. Arthroscopic removal of benign soft tissue tumours that cause coracoid impingement syndrome has good results. Level of evidence Case series with no comparison group, Level IV.

Arthroscopic Technique for the Treatment of Patellar Chondral Lesions With the Patient in the Supine Position

We describe an arthroscopic approach for the treatment of patellar chondral lesions with the patient in the supine position. This approach can be used to perform certain procedures such as matrix autologous chondrocyte implantation and autologous matrix-induced chondrogenesis. It is possible to perform these arthroscopic techniques working at an angle perpendicular to the patellar joint surface. First, with the patient in the supine position, arthroscopic longitudinal sectioning of the lateral patellar retinaculum is performed, and the patella is reverted with the help of a Codivilla forceps. It is then possible to place the chondral surface perpendicular to the floor, and it can be accessed directly through a lateral parapatellar portal. Short-term follow-up has shown the benignity of opening the patellar retinaculum. This procedure reduces morbidity compared with the traditional open surgery.

Screw Fixation of Os Acetabuli: An Arthroscopic Technique

An os acetabuli (OA) increases the contact area and surface area of the acetabulum and is important to maintain congruity of the hip joint. Thus preservation of this ossicle is important to prevent loss of contact area and ensure containment of the femoral head. We describe an all-arthroscopic approach to the fixation of OA with a compression screw. Initially, the fibrous tissue is debrided between the acetabular rim and the OA, a guidewire is placed through the OA up to the acetabular rim, and a screw is inserted over the wire. Compression of the OA is achieved with bone-to-bone contact. This technique prevents loss of femoral head coverage, reducing the risk of subluxation and subsequent osteoarthritis.

Anatomy and biomechanics of the unstable shoulder

Purpose: To review the anatomy of the shoulder joint and of the physiology of glenohumeral stability is essential to manage correctly shoulder instability. Methods: It was reviewed a large number of recently published research studies related to the shoulder instability that received a higher Level of Evidence grade. Results: It is reviewed the bony anatomy, the anatomy and function of the ligaments that act on this joint, the physiology and physiopathology of glenohumeral instability and the therapeutic implications of the injured structures. Conclusion: This knowledge allows the surgeon to evaluate the possible causes of instability, to assess which are the structures that must be reconstructed and to decide which surgical technique must be performed.

Management of humeral defects in anterior shoulder instability.

Background: A Hill Sachs lesion is a posterior-superior bony defect of the humeral head caused by a compression of the hard glenoid rim against the soft cancellous bone in the context of an anterior instability episode. The presence of these humeral defects increases with the number of dislocations and larger lesions are associated with a greater chance of development of recurrent instability and recurrence after surgery. Also its location and pattern, in particular the so-called engaging Hill-Sachs, are associated with poor prognosis. Methods: There is a lack of consensus in terms of classification and management algorithm, although lesions greater than 25% of the humeral head had been suggested to need more than a simple Bankart repair to avoid recurrence. The concept of glenoid track has turned the attention to location and shape and not only size of the humeral defect. Moreover, the glenoid bone loss is crucial when choosing a treatment option as it contributes to decrease the glenoid track as well. A thorough revision of treatment options has been performed. Results: Numerous treatment options have been proposed including remplissage, glenoid or humeral head augmentation, bone desimpaction, humeral rotational osteotomy and arthroplasty. Conclusion: Humeral defects treatment should be individualized. Determination of size and location of the defect and its relation with glenoid track is mandatory to achieve satisfactory results.