Stefano D'Adamio

Meniscal root tears: from basic science to ultimate surgery

BACKGROUND In meniscal root tears (MRTs), the disruption of collagen fibers that provide hoop strength results in extrusion of the menisci, altering their biomechanical properties. Clinical diagnosis is difficult, but magnetic resonance imaging usually allows to identify the lesion. Located into the vascularized zone of the meniscus, management is preferentially arthroscopic, aimed at repairing the lesions with arthroscopic transosseous sutures or suture anchors. SOURCES OF DATA PubMed, Cochrane Library, Google Scholar and Ovid Medline were searched in July 2012 to find literature on MRT tears. We reviewed the literature on biomechanics, imaging features and current treatments of these tears. Twenty-seven appropriate articles were identified and included in the study: 6 biomechanical studies, 11 imaging-based investigations for diagnosis, 1 study on clinical diagnosis and 9 studies about treatment. AREAS OF AGREEMENT MRTs are infrequent, accounting for 10.1% of all arthroscopic meniscectomies. When the damage occurs to the roots, the transmission of the circumferential hoop tension is impaired and, consequently, the menisci tend to be displaced anteriorly and posteriorly, altering the biomechanics and possibly the kinematics of the knee. AREAS OF CONTROVERSY Although the importance of the integrity of the meniscal roots is well established, their diagnosis and treatment are still controversial. GROWING POINTS Biomechanical and clinical studies demonstrate that surgical repair of acute, traumatic meniscal root injuries fully restores the biomechanical features of the menisci, leading to pain relief and functional improvement. The current available surgical techniques for the meniscal root repair (suture anchors and pullout repair) are comparable. Level of evidence IV.

Augmentation techniques for rotator cuff repair

INTRODUCTION There is a high rate of recurrence of tear and failed healing after rotator cuff repair. Several strategies have proposed to augment rotator cuff repairs to improve postoperative outcome and shoulder performance. We systematically review the literature on clinical outcome following rotator cuff augmentation. SOURCES OF DATA We performed a comprehensive search of Medline, CINAHL, Embase and the Cochrane Central Registry of Controlled Trials, from inception of the database to 20 June 2012, using various combinations of keywords. The reference lists of the previously selected articles were then examined by hand. Only studies focusing on clinical outcomes of human patients who had undergone augmented rotator cuff repair were selected. We then evaluated the methodological quality of each article using the Coleman methodology score (CMS), a 10 criteria scoring list assessing the methodological quality of the selected studies (CMS). AREAS OF AGREEMENT Thirty-two articles were included in the present review. Two were retrospective studies, and 30 were prospective. Biologic, synthetic and cellular devices were used in 24, 7 and 1 studies, respectively. The mean modified Coleman methodology score was 64.0. AREAS OF CONTROVERSY Heterogeneity of the clinical outcome scores makes it difficult to compare different studies. GROWING POINTS None of the augmentation devices available is without problems, and each one presents intrinsic weaknesses. There is no dramatic increase in clinical and functional assessment after augmented procedures, especially if compared with control groups. RESEARCH More and better scientific evidence is necessary to use augmentation of rotator cuff repairs in routine clinical practice.

Scaffolds for partial meniscal replacement: an updated systematic review

INTRODUCTION Meniscectomy, a most common orthopaedic procedure, results in increased contact area of the articular surfaces of tibia and femur leading to early osteoarthritis. We systematically review the literature on clinical outcomes following partial meniscal replacement using different scaffolds. SOURCES OF DATA We performed a comprehensive search of Medline, CINAHL, Embase and the Cochrane Central Registry of Controlled Trials. The reference lists of the selected articles were then examined by hand. Only studies focusing on investigation of clinical outcomes on patients undergoing a partial meniscal replacement using a scaffold were selected. We then evaluated the methodological quality of each article using the Coleman methodology score (CMS), a 10 criteria scoring list assessing the methodological quality of the selected studies (CMS). AREAS OF AGREEMENT Fifteen studies were included, all prospective studies, but only 2 were randomized controlled trials. Biological scaffolds were involved in 12 studies, 2 studies investigated synthetic scaffolds, whereas 1 remaining article presented data from the use of both classes of device. The mean modified CMS was 64.6. AREAS OF CONTROVERSY Several demographic and biomechanical factors could influence the outcomes of this treatment modality. GROWING POINTS Partial replacement using both classes of scaffolds achieves significant and encouraging improved clinical results when compared with baseline values or with controls when present, without no adverse reaction related to the device. RESEARCH There is a need for more and better designed randomized trials, to confirm with a stronger level of evidence the promising preliminary results achieved by the current research.

Pharmacological interventions for the treatment of Achilles tendinopathy: a systematic review of randomized controlled trials.

INTRODUCTION Several pharmacological interventions have been proposed for the management of Achilles tendinopathy, with no agreement on which is the overall best option available. This systematic review investigates the efficacy and safety of different local pharmacological treatments for Achilles tendinopathy. SOURCES OF DATA We included only randomized controlled studies (RCTs) focusing on clinical and functional outcomes of therapies consisting in injection of a substance or local application. Assessment of the methodological quality was performed using a modified version of the Coleman methodology score (CMS) to determine possible risks of bias. AREAS OF AGREEMENT Thirteen RCTs were included with a total of 528 studied patients. Eleven studies reported the outcomes of injection therapies. Two studies examined the outcomes of patients who applied glyceryl trinitrate patch. The mean modified CMS was 70.6 out of 90. AREAS OF CONTROVERSY There was no significant evidence of remarkable benefits provided by any of the therapies studied. GROWING POINTS There is not univocal evidence to advise any particular pharmacological treatment as the best advisable non-operative option for Achilles tendinopathy as equivalent alternative to the most commonly used eccentric loading rehabilitation program. However, potential was shown by the combination of different substances administered with physical therapy. RESEARCH There is a need for more long-term investigations, studying large enough cohort with standardized scores and evaluations shared by all the investigations to confirm the healing potential, and provide a stronger statistical comparison of the available treatments.

Hamstring Tendon Regeneration After Harvest for Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE To assess whether the portions of the semitendinosus and gracilis tendons harvested for anterior cruciate ligament reconstruction have the potential to regenerate and, if so, to evaluate the histologic properties and actual function of this newly formed tissue. METHODS We performed a comprehensive search of CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, Medline, the Cochrane Central Registry of Controlled Trials, and SPORTDiscus from inception of the databases to July 2014, using various combinations of keywords. Studies focusing on hamstring tendon and muscle regeneration through imaging and histology, as well as on the related functional outcomes, were selected. We included studies assessing evidence of tissue regeneration with imaging (magnetic resonance imaging, 3-dimensional computed tomography, ultrasonography) or with histologic examination of biopsy samples (or a combination thereof). RESULTS Nineteen articles were included in this review, with a total of 400 patients observed. The overall rate of tissue regeneration was 86.0%, with similar values shown in most studies regardless of the methodology of the assessment. Biopsy confirmed that the tissue found at the site in 74% of the cases showed typical histologic features of the tendon. The mean modified Coleman Methodology Score of the studies included was 52.7 points, showing a modest methodologic quality for the studies published to date. CONCLUSIONS In over 85% of the cases analyzed, regeneration signs of the harvested tendon were found through different imaging and histologic methodologies. A torque deficit in deep knee flexion is always present postoperatively, but the cause for this is still unclear. There is a need for better-designed trials featuring a higher level of evidence to further investigate this matter, and the effects of postoperative care and the surgical approach used on the regeneration process should be analyzed in the future. LEVEL OF EVIDENCE Level IV, systematic review of Level II, III, and IV studies.

Metallic or bioabsorbable interference screw for graft fixation in anterior cruciate ligament (ACL) reconstruction

BACKGROUND Approximately 100,000 anterior cruciate ligament (ACL) reconstructions are performed in the USA each year. Interference screw fixation is considered the standard for rigid fixation of the graft and provides higher fixation strength compared with other devices such as staples or buttons. The present study summarizes the latest evidence comparing the effectiveness of the available classes of interference screws for fixation of ACL grafts. SOURCES A comprehensive search of the CINAHL, PubMed, Google Scholar, Embase Biomedical databases and the Cochrane Central Registry of Controlled Trials was performed in March 2013. Twelve studies met our inclusion criteria. AREAS OF AGREEMENT Most studies showed no intergroup difference in terms of outcomes measured with validated clinical scores such as IKDC (International Knee Documentation Committee), Lysholm score and Tegner activity level. There was no significant difference regarding range of motion. Knee stability as evaluated with pivot shift and KT arthrometer showed a significant difference only in one study, favouring metallic interference screws. Tunnel widening is much more evident and marked patients who underwent ACL reconstruction with bioabsorbable screws, with no influence on the final clinical results achieved. Complication rates between the two screw classes were similar. The average modified Coleman methodology score was 74.67. AREAS OF UNCERTAINTY/RESEARCH NEED: The data comparing the outcomes achieved by two different materials for fixation, bioabsorbable and metallic, to be used during single-bundle ACL reconstruction, showed no significant difference in the final patient outcomes, in terms of clinical scores, clinical evaluation and imaging.

Home-based vs supervised rehabilitation programs following knee surgery: a systematic review

INTRODUCTION Following knee surgery, rehabilitation can dramatically affect the postoperative course and the final outcomes of the procedure. We systematically reviewed the current literature comparing clinical outcomes of home-based and outpatient supervised rehabilitation protocols following knee surgery. SOURCES OF DATA We searched Medline, CINAHL, Embase, Google Scholar, The Cochrane Library and SPORTDiscus. The reference lists of the previously selected articles were then examined by hand. Only studies comparing clinical outcomes of patients who had undergone knee surgery followed by different rehabilitation programs were selected. Then the methodological quality of each article was evaluated using the Coleman methodology score (CMS), a 10-criterion scoring list assessing the methodological quality of the selected studies. AREAS OF AGREEMENT Eighteen studies were evaluated in the present review. Three were retrospective studies. The remaining 15 studies were prospective randomized clinical trials. The supervised and home-based protocols did not show an overall significant difference in the outcomes achieved within the studies reviewed. The mean CMS was 77.2. AREAS OF CONTROVERSY The heterogeneity of the rehabilitation protocols used in the studies reviewed makes it difficult to draw definite conclusion on the subject. GROWING POINTS Supervision and location does not seem to directly determine the final outcomes. Numerous variables, including comorbidities and motivation, could influence the results and deserve to be accounted for in future investigations. RESEARCH Better designed studies are needed to show a clear superiority of one rehabilitation approach over another and its applicability to the various surgical procedures involving the knee.

The Arthroscopic Treatment of Shoulder Instability: Bioabsorbable and Standard Metallic Anchors Produce Equivalent Clinical Results

PURPOSE To investigate whether there are any differences in clinical outcomes and complications between absorbable and nonabsorbable suture anchors in the treatment of shoulder instability. METHODS We performed a comprehensive search of Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, and the Cochrane Central Registry of Controlled Trials, from inception of the databases, using various combinations of keywords. Only studies focusing on clinical outcomes of patients who underwent arthroscopic shoulder stabilization with suture anchors were selected. Two authors (R.P. and L.D.B.) then evaluated the methodologic quality of each article using the Coleman Methodology Score. RESULTS Ten articles were included. Four were prospective randomized studies, 2 were prospective cohort studies, and 4 were case series. The mean modified Coleman Methodology Score was 76.2. CONCLUSIONS Given the overall good results reported after arthroscopic stabilization of the shoulder using different suture anchors, it is not possible to draw a definite and solid suggestion on which class of device is better advised for routine use. Thus the decision to use one of the anchor systems available may mostly depend on its cost-effectiveness, which should be the focus of future comprehensive research. LEVEL OF EVIDENCE Level IV, systematic review of Level I to IV studies.

Small joints replacement for hand osteoarthritis: a systematic review.

INTRODUCTION Small joints replacement is a valid treatment for moderate to severe osteoarthritis of the hand. Several design and materials are now available for prostethic procedures with very different clinical and functional outcomes. SOURCES OF DATA An online search was carried out using Medline, Cochrane and Google scholar online databases, searching for studies on small joints replacement in hand surgery. AREAS OF AGREEMENT Good functional and clinical outcomes can be achieved with silicone and pyrolitic carbon implants, either for trapeziometacarpal and metacarpophalangeal joints. In particular, the silicone spacer seems to be very effective for trapeziometacarpal osteoarthrosis, while the pyrolitic carbon total joint prosthesis produces excellent outcomes if used for metacarpophalangeal replacement. Major complications, such as persistent pain and implant loosening, have still a variable rate of occurrence. AREAS OF CONTROVERSY Heterogeneity in the methodology of the assessments in the studies reviewed and the implants and techniques involved makes it difficult to carry out a complete and effective comparative analysis of the data collected. GROWING POINTS Larger cohorts treated with the same implant should be investigated in better designed trials, to draw more clinically relevant conclusions from the evidences presented. Better methodology is also a goal to achieve, since the average Coleman Methodology Score measured for the articles included was 54.9 out of 100. RESEARCH More and better designed studies are needed to produce clear guidelines to define the better implant in terms of clinical outcomes, function and complications for trapeziometacarpal and metacarpophalangeal joints.

Accelerated Rehabilitation After Rotator Cuff Repair: Does Double Row Repair Lower The Risk For Re-Tear?

Introduction:Shoulder stiffness is the second most frequent complication affecting patients underwent rotator cuff repair. Even though it’s transient feature, it is substantial comorbidity and to the failure of surgical treatment, it is responsible for a substantial comorbidity and for surgical failure. It especially occurs in patients with one or more predisposing factors. In recent times it has been proposed an accelerated rehabilitation protocol to overcome the risk for stiffness development. It consists of starting closed-chain, passive overhead range of motion exercises and passive external rotation exercises (for those without subscapularis repairs) during the first 6 weeks. One trouble of the accelerated protocol is an higher risk for the tendon-to-bone failure, leading to re-tear, and consequently to surgical failure. Thus, the use of this special protocol has been restricted only for those patients with high risk for stiffness development. We advanced the hypothesis that the repair technique (single or double row) could affect the risk for post-operative re-tear rate. Methods: We compared two groups of patients undergoing rotator cuff repair and accelerated postoperative rehabilitation, one group treated with single row repair (SR group) and the other with double row (DR group). We evaluated the outcomes in terms of re-tear rate. From a total of 78 eligible patients, 60 (30 per groups) were enrolled in our prospective randomized clinical trails. Inclusion criteria were (1) night pain; (2) absence of shoulder instability; (3) no fractures of the glenoid and of the greater and smaller tuberosity; (4) failure of a 6-month period of conservative measures (NSAIDs, intrarticular injection of corticosteroids and physiotherapy); (5) strength loss. To assess the re-tear rate, patients underwent to shoulder MRI at the sixth post-operative month. Clinical evaluation was based on Constant-Murley and UCLA shoulder score. Results: In the overall cohort, a significative improvement was recorded from the preoperative to the postoperative time. Preoperative UCLA mean values were 12 (4-23) for SR group and 13 (5-26) for DR group; at the final follow-up UCLA mean values were 31 (8-35) for SR group and 33 (11-38) for DR group, without significative intergroup differences. Re-tear occurred in 8 patients out of 30 in SR group and in 3 patients in DR group (p<0.005). Our results demonstrated as double row repair lead to a stronger tendon-to-bone construct, resulting in a significant lower retear rate Discussion and Conclusion:We are aware that clinical advantages of the double row repair are still troublesome compared to the single row, considering the cost benefits ratio. For this reason we suggest to restrict the use of this repair technique only for patients at high risk of shoulder stiffness development and consequently necessitating International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine 9 th Biennial ISAKOS Congress • May 12-16, 2013 • Toronto, Canada ISAKOS