Fibrocartilaginous metaplasia identified in the long head of the biceps brachii.

BACKGROUND: In the glenohumeral joint, the long head of biceps brachii (LHBB) is exposed to tension and compression loading. The short head of biceps brachii (SHBB) works only in tension. It is known that tendon under compression might develop fibrocartilaginous metaplasia that improves the resistance to compression but reduces the resistance to tension. This study evaluated the presence of cartilage in LHBB and SHBB samples, supporting its possible role in tendon tear. METHODS: Between 2014 and 2016, 13 samples of LHBB and SHBB were collected during surgery for shoulder instability, glenohumeral arthritis, and massive rotator cuff tears. The samples were stained with hematoxylin and eosin, safranin-O, and Alcian blue (pH 1.0) for light microscopy. Immunohistochemistry was performed using anti-S100, anti-collagen I and II, and anti-tenascin-C antibodies. RESULTS: Histochemistry: LHBB samples showed matrix disorganization, with clusters of chondrocyte surrounded by collagen fibers and glycosaminoglycans. Safranin-O showed evident metachromasia. SHBB samples did not show any matrix disorganization or cartilaginous metaplasia. Immunohistochemistry: In all LHBB samples, anti-S100 and anti-collagen II showed cartilage in proximity of the tendon tear. Tenascin C immunostained closely to the disorganized matrix areas. SHBB, however, showed no positive areas for S-100, anti-collagen II, or tenascin C. CONCLUSIONS: According to our results, we hypothesize that the repeated stimulation in compression may induce the formation of fibrous cartilage. However, to date its role in tendon pathology remains to be clearly defined.

Semitendinosus and gracilis free muscle-tendon graft for repair of massive rotator cuff tears: surgical technique.

Massive rotator cuff tears are difficult to treat surgically due to retraction, degeneration and fraying of the ends of torn tendons, severe fatty infiltration and atrophy of the respective muscles. Procedures developed to close the gap between the rotator cuff and the greater tuberosity of the humerus, such as soft tissue release may be inadequate for large tears. Human or porcine dermal allografts still have uncertain benefits, and tendon transfers seem to be associated with poor outcomes, donor site morbidity and altered mechanics. Reverse total shoulder arthroplasty has limited durability and is not indicated in young patients with high functional demands. We developed a new technique for repairing massive rotator cuff tears by semitendinosus and gracilis myotendinous grafting. This novel therapeutic option allows massive rotator cuff tears to be repaired using autologous material that is adequate and adaptable, making it possible to cover any width of defect. The technique is low-invasive and not technically demanding, with minimal donor site morbidity.

Coracoid syndrome: a neglected cause of anterior shoulder pain.

PURPOSE: the present prospective open-label study was designed to gain further insights into a condition thought to constitute a neglected but not uncommon syndrome characterized by anterior shoulder pain and tenderness to palpation over the apex of the coracoid process, not related to rotator cuff or pectoralis minor tendinopathy, long head of the biceps tendon disorders, or instability. The aim was to clarify its prevalence, clinical characteristics, differential diagnosis and response to corticosteroid injections. METHODS: patients with primary anterior shoulder pain precisely reproduced by deep pressure on the apex of the coracoid process were recruited. Patients with clinical or instrumental signs of other shoulder disorders were excluded. Patients were given an injection of triamcinolone acetonide 40 mg/ml 1 ml at the coracoid trigger point. They were evaluated after 15, 30 and 60 days and at 2 years using Equal Visual Analog Scale (EQ-VAS) and the Italian version of the Simple Shoulder Test (SST). RESULTS: between January 1 and December 31 2010, we treated 15 patients aged 26-66 years. The majority were women (86.67%). At 15 days, 6 (40%) patients reported complete resolution of their symptoms, while 9 (60%) complained of residual symptoms and received another injection. At 30 days, 14 (93.33%) patients were pain-free and very satisfied. At 2 years, the 14 patients who had been asymptomatic at 30 days reported that they had experienced no further pain or impaired shoulder function. The analysis of variance for repeated measures showed a significant effect of time on EQ-VAS and SST scores. CONCLUSIONS: the present study documents the existence, and characteristics, of a "coracoid syndrome" characterized by anterior shoulder pain and tenderness to palpation over the apex of the coracoid process and showed that the pain is usually amenable to steroid treatment. This syndrome should be clearly distinguished from anterior shoulder pain due to other causes, in order to avoid inappropriate conservative or surgical treatment. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Nutraceutical supplement in the management of tendinopathies: a systematic review.

BACKGROUND: nutraceuticals are common support therapy for management of tendinopathies. Even if they are widely diffused, our knowledge is still poor. The aim of this systematic review is to analyze the most commonly used nutraceuticals and their effects on tendons. METHODS: glucosamine and chondroitin sulphate, vitamin C, hydrolazed type 1 collagen, arginine alpha-keto-glutarate, bromelain, curcumin, boswellic acid, and methil-sulfonil-methane were considered. During the last week of Dicember 2015 a comprehensive research of main databases for each substance was made in relation with tendinopathy. Repeated articles, articles not in English nor in Italian, not common nutraceuticals, and articles not related with tendons or tenocytes were excluded. Clinical article quality was assessed independently by two reviewers using the modified Coleman methodology score. RESULTS: preclinical and clinical data from 46 articles from all databases were analyzed. All these nutraceuticals demonstrated several effects on normal and pathological tendons. Preclinical and clinical studies showed a possible role on collagen synthesis, inflammation, mechanical properties, and maturation of collagen bundles, antioxidant effect, edema, and analgesia. The majority clinical studies had some methodological limitations with an average Modified Coleman Methodology Score of 51.3 points and SD of 20.5 points. In particular, there were very low values in power, error, outcome assessment, and clinical effect. CONCLUSION: preclinical results are very encouraging, however they are not fully confirmed by clinical studies. There are few clinical papers on the use of nutraceuticals in tendon disorders, and their methodological quality is poor. Furthermore, in most of the studies more than one supplement was administered at the same time. This may bias the results, and the effect of each single component cannot be determined. Furthermore, the interactions between nutraceuticals and drugs, or other dietary supplements (especially at high doses) has not been evaluated, neither their effects on chronic diseases. For these reasons, it is not possible to draw any definitive raccomendations on the use of nutraceutical supplementation in tendinopathies.

Homologous platelet-rich plasma for the treatment of knee osteoarthritis in selected elderly patients: an open-label, uncontrolled, pilot study.

OBJECTIVE: The objective of this study was to evaluate the safety and the effect of platelet-rich plasma (PRP) intra-articular injections obtained from blood donors (homologous PRP) on elderly patients with early or moderate knee osteoarthritis (OA) who are not candidates for autologous PRP treatment. METHODS: A total of 60 symptomatic patients, aged 65-86 years, affected by hematologic disorders and early or moderate knee OA, were treated with 5 ml of homologous PRP intra-articular injections every 14 days for a total of three injections. Clinical evaluations before the treatment, and after 2 and 6 months were performed by International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) and Equal Visual Analogue Scale (EQ VAS) scores. Adverse events and patient satisfaction were recorded. RESULTS: No severe complications were noted during the treatment and the follow-up period. A statistically significant improvement from basal evaluation to the 2-month follow-up visit was observed, whereas a statistically significant worsening from the 2-month to the 6-month follow-up visit was showed. The overall worst results were observed in patients aged 80 years or over and in those affected by minor bone attrition. It was found that 90% of patients were satisfied at the 6-month evaluation. CONCLUSIONS: Homologous PRP has an excellent safety profile but offers only a short-term clinical improvement in selected elderly patients with knee OA who are not candidates for autologous PRP treatment. Increasing age and developing degeneration result in a decreased potential for homologous PRP injection therapy. Further studies are needed to confirm these findings.

Physical properties imparted by genipin to chitosan for tissue regeneration with human stem cells: A review.

Genipin is a fully assessed non-cytotoxic crosslinking compound. The chitosan|genipin physical properties such as morphology, roughness, porosity, hydrophilicity, ζ-potential, surface area and surface energy exert control over cell adhesion, migration, phenotype maintenance and intracellular signaling in vitro, and cell recruitment at the tissue-scaffold interface in vivo. For example a therapy using fucose|chitosan|genipin nanoparticles encapsulating amoxicillin, based on the recognition of fucose by H. pylori, leads to sharply improved clinical results. A bioactive scaffold sensitive to environmental stimuli provides an alternative approach for inducing adipose stem cell chondrogenesis: the expression of specific genes, the accumulation of cartilage-related macromolecules and the mechanical properties are comparable to the original cartilage-derived matrix (CDM), thus making the CDM|genipin a contraction-free biomaterial suitable for cartilage tissue engineering. For the regeneration of the cartilage, chitosan|genipin permits to modulate matrix synthesis and proliferation of chondrocytes by dynamic compression; chondrocytes cultured on the composite substrate produce much more collagen-II and sulfated GAG. The main advantages gained in the bone regeneration area with chitosan|genipin are: acceleration of mineral deposition; enhancement of adhesion, proliferation and differentiation of osteoblasts; promotion of the expression of osteogenic differentiation markers; greatly improved viability of human adipose stem cells.

Genipin-Crosslinked Chitosan Gels and Scaffolds for Tissue Engineering and Regeneration of Cartilage and Bone.

The present review article intends to direct attention to the technological advances made since 2009 in the area of genipin-crosslinked chitosan (GEN-chitosan) hydrogels. After a concise introduction on the well recognized characteristics of medical grade chitosan and food grade genipin, the properties of GEN-chitosan obtained with a safe, spontaneous and irreversible chemical reaction, and the quality assessment of the gels are reviewed. The antibacterial activity of GEN-chitosan has been well assessed in the treatment of gastric infections supported by Helicobacter pylori. Therapies based on chitosan alginate crosslinked with genipin include stem cell transplantation, and development of contraction free biomaterials suitable for cartilage engineering. Collagen, gelatin and other proteins have been associated to said hydrogels in view of the regeneration of the cartilage. Viability and proliferation of fibroblasts were impressively enhanced upon addition of poly-l-lysine. The modulation of the osteocytes has been achieved in various ways by applying advanced technologies such as 3D-plotting and electrospinning of biomimetic scaffolds, with optional addition of nano hydroxyapatite to the formulations. A wealth of biotechnological advances and know-how has permitted reaching outstanding results in crucial areas such as cranio-facial surgery, orthopedics and dentistry. It is mandatory to use scaffolds fully characterized in terms of porosity, pore size, swelling, wettability, compressive strength, and degree of acetylation, if the osteogenic differentiation of human mesenchymal stem cells is sought: in fact, the novel characteristics imparted by GEN-chitosan must be simultaneously of physico-chemical and cytological nature. Owing to their high standard, the scientific publications dated 2010-2015 have met the expectations of an interdisciplinary audience.

Effectiveness of Vitamin-E-Doped Polyethylene in Joint Replacement: A Literature Review.

Since polyethylene is one of the most frequently used biomaterials, such as in bearing components in joint arthroplasty, strong efforts have been made to improve the design and material properties over the last decades. Antioxidants, such as vitamin-E, seem to be a promising alternative to further increase durability and reduce polyethylene wear and degradation in the long-term. Nevertheless, even if several promising in vitro results are available, there is yet no clinical evidence that vitamin-E polyethylenes show these advantages in vivo. The aim of this paper was to provide a comprehensive overview on the current knowledge regarding the biological and mechanical proprieties of this biomaterial, underlying the in vitro and in vivo evidence for effectiveness of vitamin-E-doped polyethylene in joint arthroplasty.

The role of arthroscopy in articular fracture management: the lower limb.

The management of articular fracture is always a matter of concern. While each articular fracture is different from one another, besides the classification system used and the surgical or non-surgical indication given by the specialist, main goals remain the same: anatomical reduction, stable fixation, loose body removal, and minimal invasiveness. Open procedures are the actual compromise, but unfortunately, it is not always possible to perfectly meet every treatment goal, associated lesions could pass unnoticed or delayed in treatment, and even in a best-case scenario, there could be several complications developing in the long term. In the last decades, arthroscopic joint surgery underwent an exponential evolution, expanding its application also in the trauma field with the development of arthroscopic and arthroscopically assisted reduction and internal fixation (ARIF) techniques; main advantages are an accurate diagnosis of fracture and associated soft tissue involvement, the potential for concomitant treatments, anatomical reduction, and minimal invasiveness. ARIF techniques have been applied to treat fractures affecting several joints: shoulder, elbow, wrist, hip, knee, and ankle. The purpose of this paper was to provide a review of the most recent literature about arthroscopic and arthroscopically assisted reduction and internal fixation for articular and periarticular fractures of the lower limb, analyzing the results and suggesting clinical applications.

The amnion muscle combined graft (AMCG) conduits: a new alternative in the repair of wide substance loss of peripheral nerves.

The use of autologous sural nerve grafts is still the current gold standard for the repair of peripheral nerve injuries with wide substance losses, but with a poor rate of functional recovery after repair of mixed and motor nerves, a limited donor nerve supply, and morbidity of donor site. At present, tubulization through the muscle vein combined graft, is a viable alternative to the nerve autografts and certainly is a matter of tissue engineering still open to continuous development, although this technique is currently limited to a critical gap of 3 cm with less favorable results for motor function recovery. In this report, we present a completely new tubulization method, the amnion muscle combined graft (AMCG) technique, that consists in the combination of the human amniotic membrane hollow conduit with autologous skeletal muscle fragments for repairing the substance loss of peripheral nerves and recover both sensory and motor functions. In a series of five patients with loss of substance of the median nerve ranging 3-5 cm at the wrist, excellent results graded as S4 in two cases, S3+ in two cases, and S3 in one case; M4 in four cases and M3 in one case were achieved. No iatrogenic damage due to withdrawal of a healthy nerve from donor site was observed. This technique allows to repair extensive loss of substance up to 5 cm with a good sensory and motor recovery. The AMCG thus may be considered a reasonable alternative to traditional nerve autograft in selected clinical conditions.

Oral chondroprotection with nutraceuticals made of chondroitin sulphate plus glucosamine sulphate in osteoarthritis.

Oral supplementation of chondroitin sulphate plus glucosamine helps repair the articular surface in osteoarthritis. Chondroitin-S reduces the concentration of the pro-inflammatory cytokines and transcription factor involved in inflammation. GlcN.S enhances cartilage specific matrix components and prevents collagen degeneration in chondrocytes by inhibiting hydrolytic enzymes, and preventing the oxidation of lipids and proteins. Chondroitin-S plus GlcN.S are slow-acting drugs that alleviate pain and partly restore joint function in OA patients. Orally administered pharmaceutical-grade chondroitin-S plus GlcN.S stabilize the joint space narrowing and significantly decrease the number of patients with new erosive OA. They are safe and no adverse events have ever been reported; they are recommended by EULAR and OARSI. The cost/effectiveness of the oral chondroitin-S plus GlcN.S therapy derives from the reduction of costs for physiotherapy, and for gastroprotective and non-steroidal drugs. The synergistic association of these two world-widely preferred nutraceuticals is a step forward in the management of OA.