Nanothermometry-Enabled Intelligent Laser Tissue Soldering.

While often life-saving, surgical resectioning of diseased tissues puts patients at risk for post-operative complications. Sutures and staples are well-accepted and routinely used to reconnect tissues, however, their mechanical mismatch with biological soft tissue and invasiveness contribute to wound healing complications, infections, and post-operative fluid leakage. In principle, laser tissue soldering offers an attractive, minimally-invasive alternative for seamless soft tissue fusion. However, despite encouraging experimental observations, including accelerated healing and lowered infection risk, critical issues related to temperature monitoring and control during soldering and associated complications have prevented their clinical exploitation to date. Here, intelligent laser tissue soldering (iSoldering) with integrated nanothermometry is introduced as a promising yet unexplored approach to overcome the critical shortcomings of laser tissue soldering. It demonstrates that adding thermoplasmonic and nanothermometry nanoparticles to proteinaceous solders enables heat confinement and non-invasive temperature monitoring and control, offering a route to high-performance, leak-tight tissue sealing even at deep tissue sites. The resulting tissue seals exhibit excellent mechanical properties and resistance to chemically-aggressive digestive fluids, including gastrointestinal juice. The iSolder can be readily cut and shaped by surgeons to optimally fit the tissue defect and can even be applied using infrared light from a medically approved light source, hence fulfilling key prerequisites for application in the operating theatre. Overall, iSoldering enables reproducible and well-controlled high-performance tissue sealing, offering new prospects for its clinical exploitation in diverse fields ranging from cardiovascular to visceral and plastic surgery.

Women and men in orthopaedics.

PURPOSE: To compare and discuss the gender disparities in the Orthopaedic specialty. METHODS: We reviewed the literature to find the rates of women applying for an orthopaedic residency, fellowship, and academic career program, to understand the causes of the disparities in women in orthopaedics, and how this relates to orthopaedic surgical practice. RESULTS: The idea that men and women are different and have different working styles and skills and the belief that males are more dominant and more status-worthy than females leads to gender barriers and stereotypes that restrict women from entering male-dominated specialties. It is important to mention that equivalent barriers restrict men from pursuing female-dominated specialties such as Gynecology. Economic disparities and gender stereotypes that divide medical specialties into masculine and feminine, creating a gender gap in health care are major concerns. However, the number of women in the health sector is expected to increase due to the growing amount of female students that are expected to soon graduate. A leadership gender gap also exists; although women consist of 70% of the health care workforce they occupy only 25% of leadership positions. CONCLUSION: The existence of gender-based disparities in healthcare is multifactorial. The explanation behind the existence of a so-called gender gap lies in organizational and individual factors. Early development and family relations, the decision between work and life balance, personal choices and interests, as well as working conditions, absence of role models and mentorship and institutional policies make gender disparities even more evident.

Minimally Invasive Versus Open Repair for Acute Achilles Tendon Rupture: Meta-Analysis Showing Reduced Complications, with Similar Outcomes, After Minimally Invasive Surgery.

BACKGROUND: There is no consensus on the optimal technique for repairing an acute Achilles tendon rupture. The purpose of this meta-analysis was to compare the complications, subjective outcomes, and functional results between minimally invasive surgery and open repair of an Achilles tendon rupture. METHODS: A systematic literature search of MEDLINE/PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EBSCOhost, and ClinicalTrials.gov was performed. Eligible studies were randomized controlled trials (RCTs) comparing minimally invasive surgery and open repair of acute Achilles tendon ruptures. A meta-analysis was performed, while bias and the quality of the evidence were rated according to the Cochrane Database questionnaire and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. The meta-analysis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. RESULTS: Eight studies, with 182 patients treated with minimally invasive surgery and 176 treated with open repair, were included. The meta-analysis showed a significantly decreased risk ratio (RR) of 0.21 (95% confidence interval [CI] = 0.10 to 0.40, p = 0.00001) for overall complications and 0.15 (95% CI = 0.05 to 0.46, p = 0.0009) for wound infection after minimally invasive surgery. Patients treated with minimally invasive surgery were more likely to report good or excellent subjective results (RR = 1.18, 95% CI = 1.04 to 1.33, p = 0.009). No differences between groups were found with respect to reruptures, sural nerve injury, return to preinjury activity level, time to return to work, or ankle range of motion. The overall quality of evidence was generally low because of a substantial risk of bias, heterogeneity, indirectness of outcome reporting, and evaluation of a limited number of patients. CONCLUSIONS: There was a significantly decreased risk of postoperative complications, especially wound infection, when acute Achilles tendon rupture was treated with minimally invasive surgery compared with open surgery. Patients treated with minimally invasive surgery were significantly more likely to report a good or excellent subjective outcome. Current evidence is associated with high heterogeneity and a considerable risk of bias. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The Anterolateral Ligament Does Exist: An Anatomic Description.

The debate around the existence, anatomy, and role of the so-called anterolateral ligament of the knee represents one of the main sources of recent controversy among orthopedic surgeons. In the modern era of sports medicine, several content experts have contributed to the understanding of the anatomy of the anterolateral aspect of the knee. This article analyzes the historical, phylogenetic, anatomic, arthroscopic, and radiological evidence regarding the anterolateral ligament. The existence of the anterolateral ligament as a distinct ligamentous structure and its exact anatomic features are still matters of controversy and ongoing study.

Mechanisms and situations of anterior cruciate ligament injuries in professional male soccer players: a YouTube-based video analysis.

BACKGROUND: Soccer is considered the most popular sport in the world concerning both audience and athlete participation, and the incidence of ACL injury in this sport is high. The understanding of injury situations and mechanisms could be useful as substratum for preventive actions. PURPOSE: To conduct a video analysis evaluating the situations and mechanisms of ACL injury in a homogeneous population of professional male soccer players, through a search entirely performed on the YouTube.com Web site focusing on the most recent years. METHODS: A video analysis was conducted obtaining videos of ACL injury in professional male soccer players from the Web site YouTube. Details regarding injured players, events and situations were obtained. The mechanism of injury was defined on the basis of the action, duel type, contact or non-contact injury, and on the hip, knee and foot position. RESULTS: Thirty-four videos were analyzed, mostly from the 2014-2015 season. Injuries occurred mostly in the first 9 min of the match (26%), in the penalty area (32%) or near the side-lines (44%), and in non-rainy conditions (97%). Non-contact injuries occurred in 44% of cases, while indirect injuries occurred in 65%, mostly during pressing, dribbling or tackling. The most recurrent mechanism was with an abducted and flexed hip, with knee at first degrees of flexion and under valgus stress. CONCLUSIONS: Through a YouTube-based video analysis, it was possible to delineate recurrent temporal, spatial and mechanical characteristics of ACL injury in male professional soccer players. LEVEL OF EVIDENCE: Level IV, case series.

Tendon Extracellular Matrix Alterations in Ullrich Congenital Muscular Dystrophy.

Collagen VI (COLVI) is a non-fibrillar collagen expressed in skeletal muscle and most connective tissues. Mutations in COLVI genes cause two major clinical forms, Bethlem myopathy and Ullrich congenital muscular dystrophy (UCMD). In addition to congenital muscle weakness, patients affected by COLVI myopathies show axial and proximal joint contractures and distal joint hypermobility, which suggest the involvement of the tendon function. We examined a peroneal tendon biopsy and tenocyte culture of a 15-year-old patient affected by UCMD with compound heterozygous COL6A2 mutations. In patient's tendon biopsy, we found striking morphological alterations of tendon fibrils, consisting in irregular profiles and reduced mean diameter. The organization of the pericellular matrix of tenocytes, the primary site of collagen fibril assembly, was severely affected, as determined by immunoelectron microscopy, which showed an abnormal accumulation of COLVI and altered distribution of collagen I (COLI) and fibronectin (FBN). In patient's tenocyte culture, COLVI web formation and cell surface association were severely impaired; large aggregates of COLVI, which matched with COLI labeling, were frequently detected in the extracellular matrix. In addition, metalloproteinase MMP-2, an extracellular matrix-regulating enzyme, was increased in the conditioned medium of patient's tenocytes, as determined by gelatin zymography and western blot. Altogether, these data indicate that COLVI deficiency may influence the organization of UCMD tendon matrix, resulting in dysfunctional fibrillogenesis. The alterations of tendon matrix may contribute to the complex pathogenesis of COLVI related myopathies.

Variants in KIF1A gene in dominant and sporadic forms of hereditary spastic paraparesis.

KIF1A gene encodes the kinesin 1a protein, an axonal motor protein working in cargo transport along neurites. Variants in KIF1A were identified in different forms of neurodegenerative diseases with dominant and recessive inheritance. Homozygous recessive mutations were found in the hereditary sensory and autonomic neuropathy type 2, HSAN2 and in a recessive subtype of hereditary spastic paraparesis, SPG30. De novo heterozygous dominant variants were found both in a dominant form of SPG30 (AD-SPG30) with one single family reported and in patients with different forms of progressive neurodegenerative diseases. We report the results of a genetic screening of 192 HSP patients, with the identification of four heterozygous variants in KIF1A in four cases, two of whom with family history for the disease. Three of the four variants fall within the motor domain, a frequent target for variants related to the AD-SPG30 subtype. The fourth variant falls downstream the motor domain in a region lacking any functional domain. The KIF1A-related patients show clinical pictures overlapping the known AD-SPG30 phenotype including pure and complicated forms with few differences. Of note, one of the families, originating from the Sicily island, carries the same variant p.S69L detected in the first AD-SPG30 family of Finnish origin reported; differently from the first one, the latter family shows a wide intra-familial phenotype variability. Overall, these data reveal a very low frequency of the AD-SPG30 subtype while confirming the presence of amino acid residues in the motor domain representing preferential targets for mutations, thereby supporting their functional relevance in kinesin 1a activity.

Knee arthrodesis with a press-fit modular intramedullary nail without bone-on-bone fusion after an infected revision TKA.

INTRODUCTION: Knee arthrodesis can be an effective treatment after an infected revision Total Knee Arthroplasty (TKA). The main hypothesis of this study is that a two-stage arthrodesis of the knee using a press-fit, modular intramedullary nail and antibiotic loaded cement, to fill the residual gap between the bone surfaces, prevents an excessive limb shortening, providing satisfactory clinical and functional results even without direct bone-on-bone fusion. MATERIAL AND METHODS: The study included 22 patients who underwent knee arthrodesis between 2004 and 2009 because of recurrent infection following revision-TKA (R-TKA). Clinical and functional evaluations were performed using the Visual Analogue Scale (VAS) and the Lequesne Algofunctional Score. A postoperative clinical and radiographical evaluation of the residual limb-length discrepancy was conducted by three independent observers. RESULTS: VAS and LAS results showed a significant improvement with respect to the preoperative condition. The mean leg length discrepancy was less than 1cm. There were three recurrent infections that needed further surgical treatment. DISCUSSION: This study demonstrated that reinfection after Revision of total knee Arthroplasty can be effectively treated with arthrodesis using a modular intramedullary nail, along with an antibiotic loaded cement spacer and that satisfactory results can be obtained without direct bone-on-bone fusion.

Osteochondral tissue engineering approaches for articular cartilage and subchondral bone regeneration.

PURPOSE: Osteochondral defects (i.e., defects which affect both the articular cartilage and underlying subchondral bone) are often associated with mechanical instability of the joint and therefore with the risk of inducing osteoarthritic degenerative changes. This review addresses the current surgical treatments and most promising tissue engineering approaches for articular cartilage and subchondral bone regeneration. METHODS: The capability to repair osteochondral or bone defects remains a challenging goal for surgeons and researchers. So far, most clinical approaches have been shown to have limited capacity to treat severe lesions. Current surgical repair strategies vary according to the nature and size of the lesion and the preference of the operating surgeon. Tissue engineering has emerged as a promising alternative strategy that essentially develops viable substitutes capable of repairing or regenerating the functions of damaged tissue. RESULTS: An overview of novel and most promising osteochondroconductive scaffolds, osteochondroinductive signals, osteochondrogenic precursor cells, and scaffold fixation approaches are presented addressing advantages, drawbacks, and future prospectives for osteochondral regenerative medicine. CONCLUSION: Tissue engineering has emerged as an excellent approach for the repair and regeneration of damaged tissue, with the potential to circumvent all the limitations of autologous and allogeneic tissue repair. LEVEL OF EVIDENCE: Systematic review, Level III.

Meniscal allograft transplantation without bone plugs: a 3-year minimum follow-up study.

BACKGROUND: Meniscal allograft transplantation is a viable option for subtotally meniscectomized and totally meniscectomized symptomatic patients and potentially results in pain relief and increased function. HYPOTHESIS: The use of a single tibial tunnel arthroscopic technique without bone plugs will reduce symptoms (pain) and improve knee function at a minimum 3-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty-two meniscal transplantations (16 medial, 16 lateral; 23 men, 9 women) were prospectively evaluated at a minimum of 36 months (mean, 40.4 ± 6.90 months; range, 36-66 months) after surgery. The average age at the time of surgery was 35.6 ± 10.3 years (range, 15-55 years). The transplantation was performed using an arthroscopic bone plug-free technique with a single tibial tunnel plus "all-inside" meniscal sutures. The anterior meniscal horn was sutured to the capsule. Follow-up included a visual analog scale (VAS) score for knee pain and subjective and objective International Knee Documentation Committee (IKDC), Lysholm, Tegner, and SF-36 scores. All patients underwent radiographic and magnetic resonance imaging (MRI) evaluation of the involved knee before the surgery and at the final follow-up. The MRI outcomes were evaluated with the modified Yulish score. RESULTS: Regarding clinical evaluation, there was a significant improvement in scores at follow-up compared with preoperatively: the VAS score decreased from 70.6 ± 21.7 to 25.2 ± 22.7 (P < .0001), the SF-36 physical component score increased from 37.31 ± 7.2 to 49.69 ± 8.3 (P < .0001), the SF-36 mental component score increased from 49.69 ± 10.8 to 53.53 ± 7.5 (P = .0032), the Tegner activity score increased from 3 (range, 3-5) to 5 (range, 3-6) (P < .0121), the Lysholm score increased from 59.78 ± 18.25 to 84.84 ± 14.4 (P < .0001), the subjective IKDC score increased from 47.44 ± 20.60 to 77.20 ± 15.57 (P < .0001), and the objective IKDC score changed from 1 A, 21 B, 6 C, and 4 D to 22 A, 9 B, and 1 C (P < .0001). No significant difference was found in this study between patients who received medial allografts and patients who received lateral allografts. There was no significant difference between outcomes of patients with isolated and combined procedures. The MRI findings showed 69% extruded allografts (8 medial and 14 lateral). In detail, we found 50% of the medial allografts and 87% of the lateral allografts extruded. No significant difference in clinical outcomes and modified Yulish score was found between patients with extruded allografts and with in situ allografts. The MRI results also showed a significant decrease of the modified Yulish score from baseline to 3-year minimum follow-up (P < .0001 for femur and P < .0001 for tibia). Only one patient underwent arthroscopic selective meniscectomy because of a medial posterior horn retear of the graft. One patient developed lack of flexion and underwent an arthroscopic arthrolysis. These 2 patients did not draw benefit from allografting and therefore were considered failures. In all remaining cases (94%), meniscal allograft transplantation was able to reduce symptoms (pain measured by VAS) and improve knee function (as measured by IKDC and Lysholm scores). CONCLUSION: This study found that a single tibial tunnel arthroscopic technique without bone plugs for meniscal allograft transplantation significantly reduced pain and improved knee function in 94% of patients at a minimum 3-year follow-up.

Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons: a review.

The purposes of this paper are to summarize the concepts relating to the use of a combined intra-articular and extra-articular reconstructive procedure in the arthroscopic treatment of a torn ACL and to review several operative techniques utilizing gracilis and semitendinosus tendons that are currently in use to treat this instability. The highly satisfactory results obtained over the time show that a combination of intra- and extra-articular procedures for ACL reconstruction is a valid surgical option.

Platelet-rich plasma: new clinical application: a pilot study for treatment of jumper's knee.

This study describes a simple, low-cost, minimally invasive way to apply PRP growth factors to chronic patellar tendinosis; 20 male athletes with a mean history of 20.7 months of pain received treatment, and outcomes were prospectively evaluated at 6 months follow-up. No severe adverse events were observed, and statistically significant improvements in all scores were recorded. The results suggest that this method may be safely used for the treatment of jumper's knee, by aiding the regeneration of tissue which otherwise has low healing potential.

Histological and ultrastructural evaluation of Leeds-Keio ligament 20 years after implant: a case report.

We were capable of undertaking a histological and ultrastructural evaluation of an intact Leeds-Keio ligament implanted 20 years ago to assess the neoligamentization process inside this artificial ligament. The histological evaluation disclosed a collagen fibrils orientation very close to the structure of a normal anterior cruciate ligament (ACL) where the collagen fibres are multidirectional [Strocchi et al. in J Anat 180(3):515-519, 1992]. On the other hand we found an unimodal distribution of collagen fibrils in the reconstructed ACL. This suggests that even at long-term follow-up stress exerts a variable influence. The multidirectional arrangement of collagen fibres resembles a normal ACL, but the unimodal distribution of fibrils is quite different from those seen in normal tendon and ligaments which tend to have a bimodal peak [Decker et al. in J Submicrosc Cytol Pathol 23:9-21, 1991; Strocchi et al. in J Anat 180(3):515-519, 1992]. Studies based on biopsy suffer from the potential weakness that the specimen may not have been representative of the entire prosthesis. Further long-term studies, possibly with the entire prosthesis and not only a biopsy, would highlight the behaviour and remodelling of this artificial ligament in greater detail and could be important for the development of future generations of artificial ligaments or tissue engineering ACL reconstruction.