Personalization is a type of medical care in which the treatment is customized for an individual patient. When treating shoulder instability, we need to consider not only soft-tissue damage but also ...the bony lesion and patient characteristics. Of particular importance is the consideration of whether there is anterior glenoid bone loss, together with the presence of a Hill–Sachs lesion, on or off-track, as well as whether the patient is hyperlax and/or is an athlete, in which case in what type of sport. In hyperlax, nonoverhead sport athletes with recurrent anterior instability and glenoid bone loss <15%, Bankart repair with subscapularis augmentation is an effective procedure with a lower risk of complications and arthritis than a bony procedure. This is a perfect example of personalized medicine indicating a particular treatment to the benefit of patients.
Background:
Autologous microfragmented lipoaspirate tissue has been recently introduced in orthopaedics as an easily available source of nonexpanded adipose-derived mesenchymal stem cells. Autologous ...microfragmented lipoaspirate tissue is expected to create a suitable microenvironment for tendon repair and regeneration. Rotator cuff tears show a high incidence of rerupture and represent an ideal target for nonexpanded mesenchymal stem cells.
Purpose:
To evaluate the safety and efficacy of autologous lipoaspirate tissue in arthroscopic rotator cuff repair.
Study Design:
Randomized controlled trial; Level of evidence, 2.
Methods:
Consecutive patients referring to the investigation center for surgical treatment of magnetic resonance imaging–confirmed degenerative posterosuperior rotator cuff tears were assessed for eligibility. Those who were included were randomized to receive a single-row arthroscopic rotator cuff repair, followed by intraoperative injection of autologous microfragmented adipose tissue processed with an enzyme-free technology (treatment group) or not (control group). Clinical follow-up was conducted at 3, 6, 12, 18, and 24 months; at 18 months after surgery, magnetic resonance imaging of the operated shoulder was obtained to assess tendon integrity and rerupture rate.
Results:
An overall 177 patients were screened, and 44 (22 per group) completed the 24-month follow-up. A statistically significant difference in favor of the treatment group in terms of Constant-Murley score emerged at the primary endpoint at 6-month follow-up (mean ± SD; control group, 76.66 ± 10.77 points; treatment group, 82.78 ± 7.00 points; P = .0050). No significant differences in clinical outcome measures were encountered at any of the other follow-up points. No significant differences emerged between the groups in terms of rerupture rate, complication rate, and number of adverse events.
Conclusion:
This prospective randomized controlled trial demonstrated that the intraoperative injection of autologous microfragmented adipose tissue is safe and effective in improving short-term clinical and functional results after single-row arthroscopic rotator cuff repair.
Registration:
NCT02783352 (ClinicalTrials.gov identifier).
Purpose
The goal of this study was to use image analysis recordings to measure the carrying angle of elite male tennis players during the forehand stroke, with the hypothesis that elite tennis ...players overstress their elbow in valgus over the physiological degree in the frontal plane just before ball contact on forehand groundstrokes.
Methods
The carrying angle of male tennis players ranked in the top 25 positions in the ATP ranking was measured on selected video frames with the elbow as close as possible to full extension just before the ball‐racket contact in forehands. These frames were extracted from 306 videos professionally recorded for training purposes by a high‐profile video analyst. All measures were conducted by three independent observers.
Results
Sixteen frames were finally included. The mean carrying angle was 11.5° ± 4.7°. The intraclass correlation coefficient value was 0.703, showing good reliability of the measurement technique. The measured carrying angle was lower than what has been observed in historical cohorts using comparable measurement methodology, suggesting a possible instant varus accommodation mechanism before hitting the ball.
Conclusions
The observed decrease in the carrying angle is a consequence of an increase in elbow flexion position dictated by the transition from a closed to open, semi‐open stances. As the elbow flexes during the preparation phase, it is less constrained by the olecranon and its fossa, increasing the strain on the medial collateral ligament and capsule structures. Moving towards full extension before the ball‐racket contact, the elbow is dynamically stabilised by a contraction of the flexor muscles. These observations could provide a new explanation for medial elbow injuries among elite tennis players and drive specific rehabilitation protocols.
Study Design
Descriptive epidemiology study.
Level of Evidence
Level IV.
Proposed aims of patient-specific instrumentation (PSI) for total knee arthroplasty (TKA) are to improve accuracy of component alignment, while reducing blood loss and surgical time. The primary goal ...of this prospective, randomized, controlled, clinical trial is to verify whether PSI improves the rotational alignment of the femoral component in comparison to conventionally implanted TKA.
One-hundred thirty-three consecutive patients were assessed for eligibility. Block randomization was performed to allocated patients in the treatment (PSI) or control group. During hospital stay, surgical times were recorded, and total blood volume loss and estimated red blood cell were calculated. Two months after surgery, a computed tomography of the knee was obtained to measure femoral component rotation to the transepicondylar axis and tibial component slope.
Sixty-nine patients were enrolled. PSI did neither result in a significant improvement in femoral component rotation nor result in a reduction of outliers, as compared with conventional instrumentation.
No significant improvement in terms of tibial slope, blood loss, total surgical time, and ischemia time could be identified. The number of tibial recuts required in the PSI group was significantly higher than in the control group (P = .0003).
PSI does not improve the accuracy of femoral component rotation in TKA in comparison to conventional instrumentation. Moreover, PSI did not appear to influence any of the other variables investigated as secondary goals by this study. The results of this study do not support its routine use during standard TKA.
Level I, randomized, controlled trial.
Autologous biological cellular preparations have materialized as a growing area of medical advancement in interventional (orthopedic) practices and surgical interventions to provide an optimal tissue ...healing environment, particularly in tissues where standard healing is disrupted and repair and ultimately restoration of function is at risk. These cellular therapies are often referred to as orthobiologics and are derived from patient's own tissues to prepare point of care platelet-rich plasma (PRP), bone marrow concentrate (BMC), and adipose tissue concentrate (ATC). Orthobiological preparations are biological materials comprised of a wide variety of cell populations, cytokines, growth factors, molecules, and signaling cells. They can modulate and influence many other resident cells after they have been administered in specific diseased microenvironments. Jointly, the various orthobiological cell preparations are proficient to counteract persistent inflammation, respond to catabolic reactions, and reinstate tissue homeostasis. Ultimately, precisely delivered orthobiologics with a proper dose and bioformulation will contribute to tissue repair. Progress has been made in understanding orthobiological technologies where the safety and relatively easy manipulation of orthobiological treatment tools has been demonstrated in clinical applications. Although more positive than negative patient outcome results have been registered in the literature, definitive and accepted standards to prepare specific cellular orthobiologics are still lacking. To promote significant and consistent clinical outcomes, we will present a review of methods for implementing dosing strategies, using bioformulations tailored to the pathoanatomic process of the tissue, and adopting variable preparation and injection volume policies. By optimizing the dose and specificity of orthobiologics, local cellular synergistic behavior will increase, potentially leading to better pain killing effects, effective immunomodulation, control of inflammation, and (neo) angiogenesis, ultimately contributing to functionally restored body movement patterns.
Background
Large Hill–Sachs lesions are considered a risk factor for recurrence of instability after arthroscopic Bankart repair alone. The aim of this study was to demonstrate that remplissage is a ...safe procedure that effectively reduces the risk of recurrent dislocations without causing fatty degeneration of the infraspinatus at medium-term follow-up.
Methods
Patients who underwent arthroscopic Bankart repair and remplissage with a minimum 3 years of follow-up were included. Constant–Murley (CMS), American Shoulder and Elbow Surgeons (ASES), and Walch–Duplay scores were evaluated. Magnetic resonance imaging (MRI) was performed to detect the appearance of fatty infiltration inside the infraspinatus muscle, the percentage of the Hill–Sachs lesion filled by the tendon and its integration, and the onset of rotator cuff tears.
Results
Thirteen patients (14 shoulders) with a mean follow-up of 55.93 (± 18.16) months were enrolled. The Walch–Duplay score was 95.00 87.25–100.00, with a return to sport rate of 100%. Both the CMS and the ASES indicated excellent results. The affected shoulders showed a statistically significant reduction in active external rotation both with the arm at the side (ER1) and with the arm at 90° of abduction (ER2) (
p
= 0.0005 and
p
= 0.0010, respectively). A reduction in infraspinatus isometric strength was found for both ER1 and ER2, but this reduction was only statistically relevant in ER2 (
p
= 0.0342).
There was a traumatic recurrence of instability in two cases (14.28%). MRI evaluation demonstrated an absence of adipose infiltration in 50% of cases and only a minimal amount in the remaining 50%. In 12 cases (85.72%), the capsulotenodesis completely filled the lesion and good tendon–bone integration was observed.
Conclusion
Arthroscopic remplissage provided successful clinical outcomes without fatty infiltration of the infraspinatus and with good healing of the tissues. The low risk of recurrence was associated with an objective limitation on active external rotation, but this did not influence the patients' daily or sports activities.
Level of evidence
: Cohort study, level of evidence 3.
Objective
To describe early prosthesis implantations in a cohort of patients with juvenile idiopathic arthritis (JIA) followed in a tertiary referral hospital and to analyze possible factors ...influencing implant survival.
Methods
This was a retrospective cohort study. Charts of all patients with JIA who underwent total joint replacement at Gaetano Pini Hospital, Milan, Italy from January 1992 to June 2019 were retrieved, and relevant data were analyzed.
Results
Eighty‐five patients met the inclusion criteria for this study, with a median follow‐up period of 17.2 years. The median age at first prosthesis was 22.7 years. The total number of replaced joints was 198 over a period of 27 years. The hip was the most frequently replaced joint, accounting for almost two‐thirds of the total number of implants; the other one‐third refers mostly to knee implants. Polyarticular JIA and systemic JIA were the most represented JIA categories in the study cohort. A significant upward trend of the age at arthroplasty and of disease duration before arthroplasty over decades was found. The rates of implant survival at 5, 10, and 15 years were comparable (from 84% to 89%); 50% of implants lasted ≥20 years.
Conclusion
We reported retrospective data on early joint replacement in a cohort of patients with JIA. We observed a progressive and significant upward trend of both age at arthroplasty and disease duration before the first arthroplasty over time. The JIA category, year of implant, and presence of complications significantly affected implant survivorship.
Background
Knee osteoarthritis (OA) is a chronic disease associated with a severe impact on quality of life. However, unfortunately, there are no evidence-based guidelines for the non-surgical ...management of this disease. While recognising the gap between scientific evidence and clinical practice, this position statement aims to present recommendations for the non-surgical management of knee OA, considering the available evidence and the clinical knowledge of experienced surgeons. The overall goal is to offer an evidenced-based expert opinion, aiding clinicians in the management of knee OA while considering the condition, values, needs and preferences of individual patients.
Methods
The study design for this position statement involved a preliminary search of PubMed, Google Scholar, Medline and Cochrane databases for literature spanning the period between January 2021 and April 2023, followed by screening of relevant articles (systematic reviews and meta-analyses). A Società Italiana Ortopedia e Traumatologia (SIOT) multidisciplinary task force (composed of four orthopaedic surgeons and a rheumatologist) subsequently formulated the recommendations.
Results
Evidence-based recommendations for the non-surgical management of knee OA were developed, covering assessment, general approach, patient information and education, lifestyle changes and physical therapy, walking aids, balneotherapy, transcutaneous electrical nerve stimulation, pulsed electromagnetic field therapy, pharmacological interventions and injections.
Conclusions
For non-surgical management of knee OA, the recommended first step is to bring about lifestyle changes, particularly management of body weight combined with physical exercise and/or hydrotherapy. For acute symptoms, non-steroidal anti-inflammatory drugs (NSAIDs), topic or oral, can be used. Opioids can only be used as third-line pharmacological treatment. Glucosamine and chondroitin are also suggested as chronic pharmacological treatment. Regarding intra-articular infiltrative therapy, the use of hyaluronic acid is recommended in cases of chronic knee OA platelet-rich plasma (PRP) as second line), in the absence of active acute disease, while the use of intra-articular injections of cortisone is effective and preferred for severe acute symptoms.
Highlights
NSAIDs (topical or oral formulations) are a better choice for acute symptoms, compared with acetaminophen in knee osteoarthritis non-surgical treatment.
SIOT recommend opioid use only while patients are waiting for surgical treatment, if NSAIDs are ineffective against pain.
Considering intra-articular infiltrative therapy, the use of hyaluronic acid is recommended in cases of chronic knee OA in the absence of active acute disease, while the use of intra-articular injections of cortisone is effective and preferred for severe acute symptoms.
The use of growth factor injections and/or PRP in symptomatic knee OA is only favoured in highly specialised centres
Background:
An elongation of the radial lateral collateral complex (R-LCL) can provoke symptomatic minor instability of the lateral elbow leading to lateral elbow pain. Biomechanical models ...investigating the effects of elongation and partial or complete lesions of the R-LCL on lateral elbow stability are lacking.
Purpose:
To evaluate how partial and complete R-LCL release affects radiocapitellar joint stability in a setting of controlled varus load and progressive soft tissue release.
Study Design:
Controlled laboratory study.
Methods:
Ten fresh-frozen cadaveric specimens were obtained and mounted on a custom-made support to control elbow flexion and extension and to allow for controlled varus loading. Stress tests were performed on all intact specimens under gravity load alone, a 0.5-kg load applied to the hand, and a 1-kg load applied to the hand. After load application, anteroposterior radiographs were obtained. The following release sequence was applied to all specimens: release of the anterior half of the common extensor origin, pie crusting of the R-LCL, and R-LCL release. After each release, stress tests and radiographs were performed. The varus joint angulation of the elbow (α) was measured by 2 examiners as the main outcome parameter.
Results:
Significant changes in α from the initial condition occurred after each release, and a significant effect of varus load on α was documented for all release steps. A significant effect of the releases on α could be documented for all identical varus load conditions. A linear regression model was generated to describe the effect of varus load on α.
Conclusion:
Varus loads simulating everyday activities produce changes in the varus joint angulation of the elbow already in the intact specimen, which are linearly dependent on the applied moment and persist after release of the lateral stabilizing structures. With progressive load, a pie crusting of the R-LCL is the minimal procedure able to provoke a significant change in the varus joint angulation, and a complete R-LCL release produces additional increase in the varus joint angulation in all testing conditions.
Clinical Relevance:
These findings confirm the role of the R-LCL as static lateral stabilizer, supporting a pathological model based on its insufficiency and culminating with a symptomatic minor instability of the lateral elbow.
Background
Calcific tendinitis of the shoulder has a tendon involvement that could evolve to rotator cuff tear and shoulder osteoarthritis. This study aimed to evaluate the prevalence of glenohumeral ...osteoarthritis and rotator cuff tears in patients affected by calcific tendinitis at a minimum follow-up of 10 years after diagnosis.
Methods
Patients diagnosed with calcific tendinitis of the shoulder with a minimum follow-up of 10 years were contacted and invited for a clinical and radiological evaluation. Information on the demographics, affected and dominant side, bilateral shoulder pain, type of treatment, habits, systemic or musculoskeletal diseases, reoperation of the index shoulder, and subjective satisfaction was collected. The clinical evaluation was performed using Constant–Murley score (CMS), American Shoulder and Elbow Surgeons Score (ASES), and numerical rating scale (NRS); isometric strength in forwarding flexion and abduction was also measured. Each patient also underwent an ultrasound examination to evaluate rotator cuff tendon integrity and a shoulder radiograph to evaluate osteoarthritis.
Results
Seventy-nine patients were available for a phone interview, and 35 agreed to be examined. The mean age was 58.89 (± 7.9) years at follow-up. The prevalence of glenohumeral osteoarthritis was 17.14% in the study population, with significant progression in 14.29% of the cases, without rotator cuff full-thickness tears. x-Ray examination showed residual calcifications in 31 patients, with a mean diameter of 5.54 mm. In 30 cases, there was a reduction of the diameter; in 4 cases, the calcification increased in size; and in 1 case, the size did not change. The mean ASES score was 74.1 (± 22.7) in the group with calcifications larger than 2 mm and 89.4 (± 8.2) in patients with smaller calcifications (
p
= 0.08) without correlation with the type of treatment performed.
Conclusions
Calcific tendinitis is a self-resolving disease without rotator cuff tears at long-term follow-up or degenerative glenohumeral progression.
Level of Evidence: 3, cohort study.
PDF
