Riccardo D’Ambrosi

Regenerative Medicine in Rotator Cuff Injuries

Rotator cuff injuries are a common source of shoulder pathology and result in an important decrease in quality of patient life. Given the frequency of these injuries, as well as the relatively poor result of surgical intervention, it is not surprising that new and innovative strategies like tissue engineering have become more appealing. Tissue-engineering strategies involve the use of cells and/or bioactive factors to promote tendon regeneration via natural processes. The ability of numerous growth factors to affect tendon healing has been extensively analyzed in vitro and in animal models, showing promising results. Platelet-rich plasma (PRP) is a whole blood fraction which contains several growth factors. Controlled clinical studies using different autologous PRP formulations have provided controversial results. However, favourable structural healing rates have been observed for surgical repair of small and medium rotator cuff tears. Cell-based approaches have also been suggested to enhance tendon healing. Bone marrow is a well known source of mesenchymal stem cells (MSCs). Recently, ex vivo human studies have isolated and cultured distinct populations of MSCs from rotator cuff tendons, long head of the biceps tendon, subacromial bursa, and glenohumeral synovia. Stem cells therapies represent a novel frontier in the management of rotator cuff disease that required further basic and clinical research.

Optimal glenoid component inclination in reverse shoulder arthroplasty. How to improve implant stability

PurposeThe purpose of this study is to demonstrate that inferior inclination of the glenosphere is a protecting factor from joint dislocation in reverse total shoulder replacement. The hypothesis is that an average of 10° of inferior inclination of the glenoid component would determine a significant inferior rate of dislocation as compared to neutral inclination.MethodsA retrospective case (dislocation)–control (stability of the implant) study was performed. Inclusion criteria were the homogeneity of the prosthetic model and availability of pre- and postoperative imaging of the shoulder, including antero-posterior and axillary X-ray views. Glenoid and glenosphere inclination were calculated according to standardized methods. Difference in between the angles determined the inferior tilt.ResultsThirty-three cases fit the inclusion criteria. Glenoid and glenosphere inclination measured, respectively, 74.1° and 83.5°. The average tilt of the glenosphere measured 9.4°. The average tilt in stable patients was 10.2°. Tilt in patients with atraumatic dislocation measured, respectively, −6.9° (superior tilt) and 2.4°, while it was 8.3° for the patient with traumatic instability. The association between the tilt of glenosphere and atraumatic dislocation was significant.ConclusionsA 10° inferior tilt of the glenoid component in reverse shoulder arthroplasty is associated with a reduced risk of dislocation when compared to neutral tilt.

Combining Microfractures, Autologous Bone Graft, and Autologous Matrix-Induced Chondrogenesis for the Treatment of Juvenile Osteochondral Talar Lesions

Background: The purpose of this study was to evaluate the clinical and radiologic outcomes of patients younger than 20 years, treated with the arthroscopic-talus autologous matrix-induced chondrogenesis (AT-AMIC) technique and autologous bone graft for osteochondral lesion of the talus (OLT). Methods: Eleven patients under 20 years (range 13.3-20.0) underwent the AT-AMIC procedure and autologous bone graft for OLTs. Patients were evaluated preoperatively (T0) and at 6 (T1), 12 (T2), and 24 (T3) months postoperatively, using the American Orthopaedic Foot & Ankle Society Ankle and Hindfoot (AOFAS) score, the visual analog scale and the SF-12 respectively in its Mental and Physical Component Scores. Radiologic assessment included computed tomographic (CT) scan, magnetic resonance imaging (MRI) and intraoperative measurement of the lesion. A multivariate statistical analysis was performed. Results: Mean lesion size measured during surgery was 1.1 cm3 ± 0.5 cm3. We found a significant difference in clinical and radiologic parameters with analysis of variance for repeated measures (P < .001). All clinical scores significantly improved (P < .05) from T0 to T3. Lesion area significantly reduced from 119.1 ± 29.1 mm2 preoperatively to 77.9 ± 15.8 mm2 (P < .05) at final follow-up as assessed by CT, and from 132.2 ± 31.3 mm2 to 85.3 ± 14.5 mm2 (P < .05) as assessed by MRI. Moreover, we noted an important correlation between intraoperative size of the lesion and body mass index (BMI) (P = .011). Conclusions: The technique can be considered safe and effective with early good results in young patients. Moreover, we demonstrated a significant correlation between BMI and lesion size and a significant impact of OLTs on quality of life. Level of Evidence: Level IV, retrospective case series.

Arthroscopic Reinsertion of Lateral Collateral Ligament, Anterior Capsular Plication, and Coronoid Tunneling Technique for Chronic Elbow Posterolateral Rotatory Instability

Posterolateral rotatory instability (PLRI) of the elbow is a chronic condition that results from lateral collateral ligament complex injury and presents with pain, clicking, and subluxation within the flexion and extension arcs of elbow motion. The primary cause involves a lesion of the lateral collateral ligament complex and its avulsion from the lateral epicondyle. In most cases, it is the result of trauma such as a fall on an outstretched hand or any other mechanism that imparts axial compression, valgus force, and supination. Several surgical techniques have been described for the treatment of PLRI, but there is no consensus regarding the ideal surgical treatment. The advantages of an arthroscopic approach for the treatment of PLRI are first diagnostic. Arthroscopy allows for visualization and diagnosis of every compartment of the elbow. The main steps of the surgical procedure consist of reinsertion of the lateral collateral ligament, anterior capsular plication, and coronoid tunneling. By use of this technique, it is possible to perform an anatomic repair and provide stability of the elbow.

The Impact of Weight on Arthroscopic Osteochondral Talar Reconstruction

Background: The purpose of the study was to assess the functional and radiologic outcomes after AT-AMIC (arthroscopic talus autologous matrix–induced chondrogenesis) in 2 weight groups of patients with osteochondral lesions of the talus (OLTs): patients with BMI <25 (Healthy Weight Group [HG]) and with BMI ≥25 (Overweight Group [OG]). Methods: Thirty-seven patients were evaluated. HG was composed of 21 patients (BMI = 21.90 ± 1.94), whereas OG consisted of 16 patients (BMI = 27.41 ± 1.98). All patients were treated with AT-AMIC repair for OLTs. Magnetic resonance imaging (MRI), computed tomography (CT), Visual Analgoue Scale (VAS) for pain, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle and Hindfoot score and Short-Form Health Survey (SF-12) were administered preoperatively (T0) and at 6 (T1), 12 (T2), and 24 (T3) months postoperatively. Results: In both groups, we found a significant difference for clinical and radiologic parameters with analysis of variance for repeated measures through 4 time points (P < .001). In HG, AOFAS increased at every follow-up (P < .05), whereas in OG, AOFAS improved only between T2 and T3 (P = .0104). In OG we found a significant difference comparing CT and MRI at each follow-up; in HG this difference was found only at T0 (P < .0001) and T1 (P = .0492). Finally, OG presented a significantly larger lesion measured with MRI at T0 (P = .033). Conclusions: OLTs in overweight patients were characterized by a larger preoperative size. At final follow-up, both groups showed a significant clinical improvement. AT-AMIC can be considered a safe and reliable procedure, regardless of weight, with a significant improvement also in quality of life. Level of Evidence: Level III, comparative study.

Adipose-derived stem cells in orthopaedic pathologies

Introduction To examine the current literature regarding the clinical application of adipose-derived stem cells (ADSCs) for the management of orthopaedic pathologies. Sources of data MEDLINE,SCOPUS, CINAHL and EMBASE (1950 to April 14, 2017) were searched by two independent investigators for articles published in English. Reviews, meta-analyses, expert opinions, case reports, mini case series and editorials were excluded. Furthermore, we excluded animal studies, cadaveric studies and in vitro studies. Areas of agreement ADSCs seem to produce excellent clinical results. However, the length and modalities of follow-up in the different conditions are extremely variable. Nevertheless, it appears that the use of adipose-derived stem cells is associated with subjective and objective clinical improvements and minimal complication rates. Areas of controversy None of the studies identified is a randomized double-blinded trial, and most of the selected studies present major limitations, and different methods, confounding the results of our review. Growing points It is necessary to conduct more and better studies to ascertain whether ADSCs really play a role in orthopaedic surgery with particular attention to ADSCs harvesting method, type of administration and the conditions treated. Areas timely for developing research The current literature regarding the use of ADSCs for orthopaedic pathologies is limited. At present, long-term safety is the biggest challenge of ADSCs based regenerative medicine. Level of evidence Level IV-Study of Level I, II, III, IV.

Distal Biceps Brachii Injury

Distal biceps ruptures occur most commonly in middle-aged males and result from an eccentric extension load that is applied to the elbow. The injury typically presents with pain and a tearing sensation in the antecubital fossa with resultant weakness in flexion and supination strength. The biceps squeeze and hook tests are specific maneuvers by which to diagnose distal biceps ruptures on physical examination. Magnetic resonance imaging (MRI) or ultrasound is helpful to distinguish between partial and complete tears.

New Insights in Diagnosis and Treatment of Distal Biceps Pathology

Biceps brachii is composed of two separate heads and is innervated by a branch of the musculocutaneous nerve [1]. The proximal tendon of the long head is attached to the supraglenoid tubercle, and the proximal tendon of the short head is attached to the coracoid process. The biceps (muscle and tendon) rotates 90° externally from origin to insertion onto the bicipital tuberosity [2] and acts on three joints: the glenohumeral, ulnohumeral, and proximal radioulnar joints. A completely bifurcated distal tendon insertion is not uncommon [3, 4]. The short head of the distal biceps tendon was reported to insert more distally, and the long head was inserted more eccentric and medial. The moment arm of the long head was higher in supination, and the short head had a higher moment arm in neutral position and pronation [5]. These findings may allow functional independence and isolated rupture of each portion and may have consequences for restoring the native anatomy during a surgical repair. Several authors reported an isolated rupture of one of the two tendons in cases of bifurcated distal biceps tendons [4].

Scientific Production and total ankle arthroplasty: results and findings from National Joint Registers

Category: Ankle Arthritis Introduction/Purpose: The purpose of this systematic review was to report clinical outcomes on total ankle replacement (TAR) whose data were extracted from national registers. Methods: A systematic review of the literature, to identify all studies reporting outcomes after total ankle replacement, was performed. Two independent investigators performed the research using MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase and Cochrane Databases (1950 to December 2017). Results: Analysis of the literature included 18 articles from 2007 to 2017. Of these 5 articles performed a comprehensive analysis of the national registers, 5 articles evaluated complications and reasons of failure after TAR, 6 articles made a specific outcome register analysis, one article compared TAR and ankle arthrodesis while the last one analysed the role of TAR in patients with rheumatoid arthritis. Conclusion: Scientific publications extracted from national joint registers for total ankle replacement provide useful but heterogeneous information on implants survivorship, implant models and risk factors. There is still a discrepancy between the data reported by designers in clinical studies and the data reported by the registries. The centralization of registers in specialized hospitals with dedicated surgeons, the use of patient reported outcomes (PROMs) in association with surgeon assessments and periodical publications can improve the development of registries and consequently of the literature in this regard.

Successful treatment of infected wound dehiscence after minimally invasive locking-plate osteosynthesis of tibial pilon and calcaneal fractures by plate preservation, surgical debridement and antibiotics

OBJECTIVE The aim is to present a case series that illustrates possible benefits from combining minimally invasive plate osteosynthesis (MIPO), plastic surgery and antibiotic therapy, in order to treat and eradicate infection in patients with tibial pilon or calcaneal fractures. METHODS Eleven consecutive patients with dehiscence of the surgical wound in outcomes MIPO using a Locking Compression Plate (LCP) for tibial pilon, or calcaneus fractures. The patients had developed a documented infection of the surgical wound. All patients were treated and followed-up by the multidisciplinary team with the orthopedic surgeon, the plastic surgeon and the infectious disease physician. All patients were followed by the plastic surgeon to treat the wound dehiscence, as well as by the orthopedic surgeon until fracture consolidation. The duration of the antibiotic therapy was from 4 to 6 months. After 6 weeks, the intravenous treatment was replaced by oral administration. The follow-up intervals were 15 days, 40 days, and 3 months. RESULTS The average time of wound closure was 109±60 days. The antibiotics used were chosen according to the antibiogram. The antibiotic therapy had a duration of 4-6 months, and after 6 weeks, the therapy switched to oral administration. At the 3-month follow-up, all patients had excellent outcomes and had returned to their normal activity of daily living. CONCLUSION The patients in this study responded positively to a combination of MIPO, plastic surgery and antibiotic therapy, confirming that multidisplinary treatment in association with titanium devices are able to eradicate infection in short time.