Superior Capsular Reconstruction Using 3-layered Fascia Lata Autograft Reinforced with a Nonresorbable Suture Mesh.

PURPOSE: The purpose of this study was to evaluate the short-term clinical outcomes and the complications related to arthroscopic superior capsular reconstruction (SCR) using a 3-layered fascia lata autograft (FLA) reinforced with a nonresorbable suture mesh, in the treatment of irreparable massive rotator cuff tears (MRCTs). METHODS: Consecutive patients with irreparable MRCTs (Goutallier 4, Hamada grade 1-2, Bateman 3-4) who were treated with arthroscopic SCR using reinforced FLA in 2018 were included. Patients with an irreparable subscapularis/infraspinatus, serious cardiovascular condition, systemic infection, rheumatic disease, and known alcohol/drug abuse were excluded from the study. Range of motion and Shoulder Pain and Disability Index (SPADI) scores were assessed preoperatively, at 6 months, and at 12 months postoperatively. A simple t test was used to compare the outcomes. P values <.05 were considered significant. Complications and revision surgeries were registered. RESULTS: A total of 24 consecutive patients (15 males, 9 females) with a mean age of 61 years (range, 41-76) were enrolled. Twenty (83%) patients achieved minimal clinically important difference in the SPADI score (>18) and 14 (58%) experienced substantial clinical benefit in SPADI (>45). The mean SPADI score improved from 59.0 to 9.7 (P < .0001) at 1-year follow-up. Active abduction improved from 59.5° to 154.3° (P < .0001) and active forward flexion improved from 67.0° to 160.3° (P < .0001) at 1-year follow-up. Eighteen (75%) patients achieved substantial clinical benefit in active abduction (>28.5°) and active forward flexion (>35.4°). Complications included progression of osteoarthritis in 2 cases, tear of the graft in 1 case, and pullout of the anchor in another. Two patients experienced donor site morbidity after harvesting the fascia lata autograft. CONCLUSIONS: Eighty-three percent of the patients achieved minimal clinically important difference and were successfully treated with arthroscopic SCR using a FLA reinforced with a suture mesh. The procedure had a complication rate of 17% and 8.5% of the patients experienced donor site morbidity. All complications occurred in patients who were previously treated with an attempted rotator cuff repair. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Day-Case Opening Wedge High Tibial Osteotomy With Intraosseous PEEK Implant.

PURPOSE: To evaluate the short-term clinical outcomes, complications, hospitalization time, and readmission rate related to day-case opening wedge high tibial osteotomy (OWHTO) with intraosseous PEEK (polyether ether ketone) implant, in the treatment of knee osteoarthritis. METHODS: An observational study on patients treated with OWHTO using intraosseous PEEK implant was performed with a period of 12 months follow-up. Grade of Knee Injury and Osteoarthritis Outcome Score (KOOS) was assessed preoperatively, at 6 months, and at 12 months postoperatively. A simple t test was used to analyze the outcomes. P values <.05 were considered significant. Complications and revision surgeries were registered. RESULTS: In the period from 2016 to 2017, a consecutive group of 40 patients (13 female, 27 male) with symptomatic medial knee osteoarthritis and varus malalignment were included in the study. The average age of the patients was 54.9 (± 7.6) years. In total, 30 (77%) patients met the criterion for minimal clinically important difference in KOOS scores. The KOOS symptoms improved from 58.1 ± 20 to 78.5 ± 16.5 (P < .0001), pain from 48.1 ± 18.2 to 78.6 ± 18.5 (P < .0001), activities of daily living from 59.0 ± 19.5 to 84.1 ± 15.2 (P < .0001), sport from 23.2 ± 17.6 to 55.6 ± 26.3 (P < .0001), and quality of life from 28.4 ± 12.8 to 61.5 ± 22.5 (P < .0001) at 1-year follow-up. The average hospitalization time at the Day Surgery Unit was 5.6 ± 0.7 hours, and 4 (10%) patients had to be readmitted to the hospital within 2 weeks postoperatively. The overall complication rate was 18%. Complications that required revision surgery were registered in 4 patients (10%), including 2 non-unions and 2 progressions of osteoarthritis. CONCLUSIONS: The day-case OWHTO with intraosseous PEEK implant was a success in 77% of the cases. The results and complications were comparable with other published studies. Despite a short hospitalization time, the readmission rate was low. LEVEL OF EVIDENCE: IV, therapeutic case series.

Arthroscopic Superior Capsular Reconstruction With Acellular Porcine Dermal Xenograft for the Treatment of Massive Irreparable Rotator Cuff Tears.

PURPOSE: To evaluate the short-term clinical outcomes and the complications related to arthroscopic superior capsular reconstruction (SCR) with acellular porcine dermal xenograft for the treatment of irreparable massive rotator cuff tears. METHODS: A prospective observational study of patients treated with arthroscopic SCR for irreparable massive rotator cuff tears in the period from 2016 to 2017 was performed. Range of motion and Shoulder Pain and Disability Index (SPADI) scores were assessed preoperatively, at 6 months postoperatively, and at 12 months postoperatively. RESULTS: A total of 20 shoulders in 19 patients, with an average age of 60 years, were included in the study. Twelve patients met the criterion for the minimal clinically important difference in the SPADI score. The mean SPADI score showed significant improvement from 51.3% to 10.4% at 1-year follow-up. Active abduction improved from 65.4° to 149.3° and active forward flexion improved from 68.6° to 151.4° at 1-year follow-up. The procedure had a 30% complication rate, including a 15% rate of immunologic rejection of the xenograft. Five patients underwent revision procedures, including arthroscopic debridement and removal of xenograft residuals, implantation of a balloon spacer, and revision SCR with a fascia lata autograft. CONCLUSIONS: Arthroscopic SCR with an acellular porcine dermal xenograft led to a successful outcome in 60% of cases. The procedure showed a quite high complication rate; the most severe cases were related to acute immunologic rejection of the xenograft. LEVEL OF EVIDENCE: Level IV, case series.

Behavior of Human Articular Chondrocytes During In Vivo Culture in Closed, Permeable Chambers.

The exact contribution of transplanted chondrocytes for cartilage tissue repair prior expansion in monolayer culures remains undetermined. At our laboratory, we have created a new permeable chamber to study the chondrogenesis of dedifferentiated cells implanted ectopically in a closed and controlled environment. The behavior of chondrocytes has been studied in settings frequently used in clinical approaches during transplantation, namely injection of autologous chondrocyte cells in suspension (ACI), cells soaked in collagen membranes (MACI), and cells applied in a polymer gel (fibrin). As controls, we have tested the redifferentiation of chondrocytes in cell aggregates, and we have checked the proper functionality of chambers both in vitro and in vivo. After retrieval, firmed tissue-like shapes were recovered only from chambers containing cells seeded in membranes. Histomorphological, immunohistochemical, and ultrastructural analyses revealed synthesis of fibrous-like tissue, characterized by low-density collagen fibers, low collagen type II, abundant collagen type I, and low amounts of proteoglycans. Additionally, neither the collagen membranes nor the fibrin gel was reabsorbed by cells. In summary, our results show that the newly developed permeable chambers function correctly, allowing proper cell feeding and preventing cell leakage or host cell invasion. Additionally, our results suggest that, under these circumstances, chondrocytes are not able to orchestrate formation of hyaline cartilage and have little capacity to degrade artificial membranes or carrier gels such as fibrin. These are interesting observations that should be considered for understanding what role the transplanted chondrocytes play during restoration of articular cartilage after implantation.

Comparative Analyses of the Secretome from Dedifferentiated and Redifferentiated Adult Articular Chondrocytes.

OBJECTIVE: The main goal of this study was to compare the secretion products derived from human articular chondrocytes established in either long-term monolayer cultures or in scaffold-free 3-dimensional (3-D) cultures. METHODS: Stable isotope labeling of amino acids in cell culture (SILAC) was applied to investigate quantitatively the differences between proteins secreted from dedifferentiated and redifferentiated chondrocytes. Proteins in cell supernatants were resolved by 1-D gel electrophoresis and analyzed by mass spectrometry. The results from the proteomic analyses were validated by immunoblotting. Additionally, antibody arrays were used to screen culture supernatants for 79 different morphogens. RESULTS: Quantitative SILAC showed that some relevant growth factors such as CTGF or GAS6 were elevated in monolayers, along with proteins characteristic of a dedifferentiated phenotype such as collagen type I and tenascin. In spheroids, data showed overexpression of some cartilage-specific proteins such as aggrecan, together with important matrix regulators such as chitinase-3-like protein and stromelysin-1. Antibody arrays revealed that chondrocytes in monolayer secrete higher levels of leukocyte-activating agents such as MCP-1 and GRO, whereas the spheroid configuration favors the production of cell morphogens such as MCSF and VEGF. CONCLUSION: Our results show that some classic dedifferentiation and redifferentiation markers are differentially expressed in 2-D or 3-D culture configurations. Other cell/matrix regulatory molecules are also found to be differentially expressed by chondrocytes in 2-D and 3-D conditions by SILAC and antibody arrays. Our data bring new information for understanding the biology of chondrocytes in general and the process of cartilage tissue reconstruction in particular.

The secretory profiles of cultured human articular chondrocytes and mesenchymal stem cells: implications for autologous cell transplantation strategies.

This study was undertaken to compare the phenotype of human articular chondrocytes (ACs) and bone marrow-derived mesenchymal stem cells (MSCs) after cell expansion by studying the spectrum of proteins secreted by cells into the culture medium. ACs and MSCs were expanded in monolayer cultures for some weeks, as done in standard cell transplantation procedures. Initially, the expression of cartilage signature genes was compared by real-time PCR. Metabolic labeling of proteins (SILAC) in combination with mass spectrometry (LC/MS-MS) was applied to investigate differences in released proteins. In addition, multiplex assays were carried out to quantify the amounts of several matrix metalloproteases (MMPs) and their natural inhibitors (TIMPs). Expanded chondrocytes showed a slightly higher expression of cartilage-specific genes than MSCs, whereas the overall spectra of released proteins were very similar for the two cell types. In qualitative terms MSCs seemed to secrete similar number of extracellular matrix proteins (43% vs. 45% of total proteins found) and catabolic agents (9% vs. 10%), and higher number of anabolic agents (12 % vs. 7%) compared to ACs. Some matrix-regulatory agents such as serpins, BMP-1, and galectins were detected only in MSC supernatants. Quantitative analyses of MMPs and TIMPs revealed significantly higher levels of MMP-1, MMP-2, MMP-3, and MMP-7 in the medium of ACs. Our data show that after the expansion phase, both ACs and MSCs express a dedifferentiated phenotype, resembling each other. ACs hold a phenotype closer to native cartilage at the gene expression level, whereas MSCs show a more anabolic profile by looking at the released proteins pattern. Our data together with the inherent capability of MSCs to maintain their differentiation potential for longer cultivation periods would favor the use of these cells for cartilage reconstruction.

Differences in the secretome of cartilage explants and cultured chondrocytes unveiled by SILAC technology.

The main goal of our study was to analyze and compare the profiles of secreted proteins from adult human articular chondrocytes in monolayers, and cartilage explants in culture, using a de novo protein labeling approach. Stable isotope labeling of proteins in culture was used to differentiate between chondrocyte-derived proteins and other preexisting matrix-derived components, or proteins coming from serum or synovial fluids. Proteins in culture supernatants were resolved by one-dimensional SDS-PAGE electrophoresis, and analyzed in tandem with LC/MS-MS (liquid chromatography/double mass spectrometry). Results from stable isotope labeling with amino acids in cell culture (SILAC) were validated by specific immunoblotting of four relevant proteins identified in the secretion media. After 8-10 days of culture, over 90% of proteins secreted during monolayer growth contained (13)C(6)-Arg and (13)C(6)-Lys. Nonlabeled proteins corresponded mostly to plasma-associated proteins, indicating background contamination of medium with serum remnants. The majority of the secreted proteins in 2D cultures were extracellular matrix components and matrix regulators, along with some inflammatory agents and metabolic enzymes. In explants, only 25%-30% of proteins were labeled with heavy amino acids, corresponding to matrix regulators and carrier molecules. Nonlabeled proteins corresponded primarily to structural matrix components. In qualitative terms, all labeled proteins coming from cartilage explants were also found in chondrocytes supernatants. In summary, our results show differences in the labeling pattern of proteins found in supernatants from explants and monolayers. Most proteins found in the media of explants were subproducts of matrix turnover rather than newly synthesized. To our knowledge, this study is the first one so far applying SILAC technology in the context of cartilage and chondrocytes physiology.

Displaced stress fracture of the femoral neck in young active adults.

Stress fractures of the femoral neck in healthy individuals are rare and most prevalent among long-distance runners and military recruits. Women seem to be at higher risk of developing stress fractures because of possible eating disorders and, thereby, following amenorrhoea and osteoporosis. The majority of fractures of the femoral neck are undisplaced. However, they might progress into displaced fractures with avascular necrosis of the femoral head and following development of osteoarthritis as a probable consequence even when treated properly. Early diagnosis with MRI or radionuclide scanning in patients with a history of pain in the groin region during training might be crucial in detecting the fractures at early stages; thereby preventing possible complications following surgical treatment of displaced fractures. The authors present a report of two young adults who developed displaced fractures of the femoral neck and were treated with closed reduction and internal fixation.

Gluteal compartment syndrome after lumbar laminectomy.

Gluteal compartment syndrome may, in its severe form, have serious consequences. It may result in severe rhabdomyolysis, and if left untreated it can result in acute renal collapse, multiorgan failure and even death. The present report concerns a patient who developed a gluteal compartment syndrome after lumbar surgery. The syndrome was complicated by acute renal failure with high concentrations of serum creatinine kinase, myoglobin, and potassium, requiring acute haemodialysis before surgical release. The operation revealed increased intracompartmental pressure with weak or absent reaction of muscles to electric stimulation. To prevent the development of gluteal compartment syndrome during operative procedures, it is important to avoid harmful pressure to the gluteal regions on the operating table. It is also important to optimise muscle circulation by adequate hydration therapy and avoidance of nephrotoxic stimuli. If gluteal compartment syndrome develops, immediate diagnosis and surgical decompression are mandatory .

[Endoscopic treatment of vesicoureteral reflux in children]. / Endoskopisk behandling av vesikoureteral refluks hos barn.

BACKGROUND: At Rikshospitalet, Norway, vesicoureteral reflux (VUR) in children has been treated with subureteric teflon (polytetrafluoroethylen) injection (STING) since 1994. After a biological injection substance became commercially available, we changed to Deflux (dextranomer/hyaluronic acid) in 2000. The aim of this study was to assess whether the VUR results following use of the new injection substance are comparable to those for the previously used substance. MATERIAL AND METHODS: 202 ureters with VUR grade II-V in 132 patients (91 girls) were treated for the first time with subureteric injections of teflon (n = 77) or Deflux (n = 125) during the 5-year period November 1998-2003. The charts were retrospectively reviewed. RESULTS: 201 ureters (131 patients) were followed up with urinary tract ultrasound and voiding cystogram 1-34 months after the last injection. After the first teflon injection 43% of the ureters had no reflux and an additional 9% were improved. After the first Deflux injection 48 % of the ureters had no reflux and 10% were improved. After 1-3 injections 78% (teflon 71%, Deflux 81%) were without or had reduced VUR. Three ureters showed terminal stenosis after the first Deflux injection. Statistically, the results were independent of VUR grade, injection substance and surgeon experience, and similar for duplex and single ureters. INTERPRETATION: Endoscopic treatment of VUR in children is safe and simple. The results after Deflux and teflon were similar. Urinary tract ultrasound and voiding cystogram should be used for follow-up of all patients some months after injection.