Histological and ultrastructural degenerative findings in the gluteus medius tendon after hip arthroplasty.

BACKGROUND: Despite gluteus medius (GMED) tendinosis being relatively common, its presence in association with hip osteoarthritis (OA) or total hip arthroplasty (THA) is not well studied. It was hypothesized that more tendon degeneration would be found in patients with OA of the hip and in those that had undergone THA than that in a control group. METHODS: One hundred patients were included between 2016 and 2019 and were included into 4 groups; the patients were undergoing revision surgery in two groups and primary THA in the other two groups; 22 patients had previously undergone primary THA through a direct lateral approach (involving sectioning of the GMED tendon), 24 patients had previously undergone primary THA through a posterior approach (leaving the GMED tendon intact), 29 patients had primary hip OA, and 25 patients who suffered a femoral neck fracture served as controls. Biopsies from the GMED tendon were obtained at the time of the primary THA or the hip revision surgery. The tendon biopsies were examined ultrastructurally and histologically. RESULTS: Ultrastructurally, the direct lateral and posterior revision groups had statistically significantly more collagen fibrils with smaller diameters compared with the fracture and primary THA groups. Moreover, the direct lateral revision group had more collagen fibrils with smaller diameters compared with the posterior revision group. Histologically, the direct lateral revision group had a higher total degeneration score (TDS) compared with the primary hip OA group. CONCLUSIONS: The GMED tendon shows more ultrastructural degeneration in patients who undergo hip revision arthroplasty than in patients with primary OA of the hip and control patients, who had suffered a femoral neck fracture. Furthermore, patients who had previously undergone primary THA through a direct lateral approach revealed more histological GMED tendon degeneration than patients who suffer primary hip OA.

No significant histological or ultrastructural tendinosis changes in the hamstring tendon in patients with mild to moderate osteoarthritis of the knee?

PURPOSE: To investigate the periarticular degenerative changes of the knee joint in association with osteoarthritis (OA). More tendinosis was expected to be found in the semitendinosus tendon in patients with knee OA than in patients without knee OA. METHODS: Samples from 41 patients were included between January 2016 and October 2017. Twenty-one patients median age 53 (33-63) years with mild to moderate OA underwent high tibial osteotomy (HTO) and 20 patients median age 38 (31-57) years without OA underwent anterior cruciate ligament reconstruction (ACLR). Biopsies from the semitendinosus tendon were obtained at the time of surgery and examined histologically, morphologically and ultrastructurally using light and electron microscope. RESULTS: The histological evaluation of the semitendinosus tendon revealed the presence of more hemosiderin in the ACLR group. No significant morphological or ultrastructural differences were shown between patients in the HTO and ACLR group. CONCLUSION: Patients with mild and moderate medial compartment knee OA displayed no more degenerative changes in their semitendinosus tendon than patients without OA, as seen in both the light and the electron microscope. LEVEL OF EVIDENCE: III.

Radiofrequency Microtenotomy or Physical Therapy for Achilles Tendinopathy: Results of a Randomized Clinical Trial.

BACKGROUND: Achilles tendinopathy is a painful disorder, and various treatment options are available. Bipolar radiofrequency microtenotomy (RFM) has shown promising results in treating tendinosis. PURPOSE/HYPOTHESIS: The purpose was to compare the results between treatment with bipolar RFM and physical therapy (PT) for patients with midportion Achilles tendinopathy. It was hypothesized that RFM would be equivalent or superior to PT. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 38 patients with midportion Achilles tendinopathy were evaluated for 2 years. The patients were randomized to receive either RFM or PT. There were 20 patients in the RFM group and 18 patients in the PT group. Clinical outcomes were assessed using the visual analog scale (VAS) for pain and the Foot and Ankle Outcome Score (FAOS). The degree of tendinosis was evaluated with magnetic resonance imaging (MRI) of the affected ankle performed before intervention and 2 years after intervention. RESULTS: In both groups, the VAS scores at the 2-year follow-up were significantly improved compared with preintervention: from 7.2 ± 1.5 to 1.0 ± 1.4 for the RFM group and from 5.9 ± 1.3 to 3.1 ± 1.8 for the PT group (P < .01 for both). Compared with the PT group, the RFM group had significantly better VAS scores at both the 1- and 2-year follow-ups (P < .01 for both) and better scores on 4 of the 5 FAOS subscales at the 2-year follow-up (P < .01 for all). MRI revealed an improvement in the tendinosis score in both groups, without any significant difference between the groups. CONCLUSION: In this randomized study, the clinical assessments revealed significant improvements in the VAS, FAOS, and tendinosis score as seen on MRI 2 years after intervention with either RFM or PT in patients with midportion Achilles tendinopathy. The improvement was significantly better in the RFM group with regard to VAS and FAOS, but not in the MRI appearance. REGISTRATION: NCT03274557 (ClinicalTrials.gov identifier).

Radiofrequency microtenotomy: a promising method for treatment of rotator cuff tendinopathy.

PURPOSE: Subacromial pain syndrome is a common disorder. Arthroscopic subacromial decompression is currently the preferred treatment method. Bipolar radiofrequency microtenotomy has shown promising results in treating tendinosis. In this study, the authors compare the results after arthroscopic acromioplasty with bipolar radiofrequency microtenotomy for patients with subacromial pain syndrome. METHODS: A total of 27 patients, with subacromial pain syndrome, were followed for 2 years. There were 14 patients in the arthroscopic acromioplasty group and 13 patients in the radiofrequency microtenotomy group. Clinical outcome data included pain reported using a visual analog scale, Constant score, and strength. Magnetic resonance imaging of the affected shoulder was performed before and 2 years after intervention for an evaluation of the tendinosis grade. RESULTS: All patients attended the final follow-up 2 years after intervention. No significant differences were found at baseline between the groups. Pain measured by the visual analog scale revealed a significant reduction in both groups at 12 weeks, 6 months and 2 years compared with baseline. There was no significant difference between the groups in terms of visual analog scale, Constant score, or strength. The magnetic resonance imaging revealed a significant improvement in the tendinosis score in both groups, without any significant difference between the groups. CONCLUSION: In this prospective randomized study, the clinical assessments revealed a significant improvement in terms of the visual analog scale, strength, Constant score, and tendinosis score 2 years after intervention with either arthroscopic acromioplasty or radiofrequency microtenotomy in patients with subacromial pain syndrome. However, no significant differences were found between the groups. This study reveals that there are surgical options other than acromioplasty in patients with SAPS. LEVEL OF EVIDENCE: II.

More tendon degeneration in patients with shoulder osteoarthritis.

PURPOSE: Tendon disorders are a major problem in the general population. It is known that rotator cuff tendinopathy contributes to osteoarthritis (OA) of the shoulder. The aim of the study was to analyse the presence of tendinopathy in patients with shoulder OA and an intact rotator cuff, using a multimodal approach. METHODS: Thirteen consecutive patients median age 67 (52-84) years, with OA of the shoulder, and 13 consecutive control patients, with a fracture of the proximal humerus, median age 70 (51-84) years, underwent an open biopsy procedure from the biceps and subscapularis tendon in conjunction with shoulder arthroplasty. In addition to a macroscopic evaluation, the samples underwent histologic, morphologic and ultrastructural analyses in light and transmission electron microscopy. RESULTS: Macroscopic degeneration was found in 15 of 26 specimen in the OA group but in seven of 25 in the control group (p = 0.048). The histologic analysis revealed a non-significant difference for the total degeneration score (TDS) between the study groups. The morphologic evaluation of the samples revealed that the OA group had significantly more samples with non-homogeneous extracellular matrix (ECM), (p = 0.048). Ultrastructurally, the OA group revealed a significantly larger fibril diameter in the biceps tendon (p < 0.0001) but not in the subscapularis tendon compared with the control group. CONCLUSION: A significantly worse macroscopic appearance and significantly more morphologically inhomogeneous ECM, indicating more tendon degeneration, were found in the OA group compared with the control group. This indicates that it could be beneficial to treat the tendinosis in an early stage to decrease symptoms from the OA. STUDY DESIGN: Level of evidence, III.

Correction to: More tendon degeneration in patients with shoulder osteoarthritis.

Unfortunately, the given name and the family name of the authors were incorrectly identified in the original article. The author names are corrected here by this correction paper. The original article has been corrected.

More histologic and ultrastructural degenerative signs in the subscapularis tendon and the joint capsule in male patients with shoulder impingement.

PURPOSE: The purpose of the present study was to analyze biopsy samples from the subscapularis tendon and from the joint capsule from male patients with shoulder impingement syndrome (SAIS) and compare them with samples from male patients with post-traumatic recurrent shoulder instability. The hypothesis of the study was that patients with SAIS would have more histologic and ultrastructural degenerative changes in their subscapularis tendon and joint capsule than patients with post-traumatic recurrent shoulder instability. METHODS: Male patients scheduled for surgery, with either subacromial decompression or Bankart reconstruction, were included. Four biopsies from each patient were obtained from the capsule and four from the subscapularis tendon during arthroscopic surgery. The histologic characteristics and the presence of glycosaminoglycans were assessed using the light microscope, and the ultrastructure was assessed using a transmission electron microscope. RESULTS: Eight patients, median age 53 (45-74) years (p < 0.0001), were included in the impingement group, and 12 patients, median age 27 (22-48) years, were included in the instability group. The histologic assessment revealed significantly higher cellularity and total degeneration score in the capsule (p = 0.016 and p = 0.014 respectively) in patients with subacromial impingement compared with the instability patients. The corresponding finding was not made for the subscapularis tendon. The ultrastructural evaluation revealed that the instability patients had more fibrils with a large diameter (indicating less degeneration) in both the subscapularis tendon and the capsule compared with the impingement patients (p < 0.0001). CONCLUSION: Male patients with subacromial impingement have more histologic and ultrastructural degenerative changes in their shoulder compared with patients with post-traumatic recurrent shoulder instability. CLINICAL RELEVANCE: It appears that in patients with subacromial impingement, the whole shoulder joint is affected and not only the subacromial space. It is the opinion of the authors that intra-articular therapeutic injections could be tried more often in these patients. LEVEL OF EVIDENCE: III.

Medium-Term Results After Treatment of Recalcitrant Lateral Epicondylitis: A Prospective, Randomized Study Comparing Open Release and Radiofrequency Microtenotomy.

BACKGROUND: Recalcitrant lateral epicondylitis (elbow extensor-origin tendinosis) is a common cause of elbow pain with many treatment options. In the present study, the medium-term results after open release and radiofrequency microtenotomy are reported. HYPOTHESIS: Microtenotomy would provide long-term pain relief that was as good as the open release method. STUDY DESIGN: Prospective, randomized trial. METHODS: Twenty-four patients randomized to either open release or microtenotomy were assessed after 5 to 7 years. Clinical examination and dynamic infrared thermography (DIRT) of both elbows were performed preoperatively and at the medium-term follow-up. Magnetic resonance imaging (MRI) of both elbows was performed at the medium-term follow-up. RESULTS: Significant pain reduction was found using a visual analog scale (VAS) at the medium-term follow-up in both groups compared with the preoperative assessment (P < .005). The Mayo Elbow Performance Score (MEPS) increased significantly in both groups (P < .01). The improvement in grip strength was not significant in either group. There was no significant difference between the groups in terms of VAS, strength, and the MEPS. On the DIRT examinations, there were significantly fewer hot spots at the medium-term follow-up than preoperatively (P = .0067, both study groups together). The MRI examinations revealed grade II changes in the operated elbow in 1 patient in each group at the medium-term follow-up, while all the other MRI examinations revealed a normal tendon. CONCLUSION: In this prospective, randomized trial with a medium-term follow-up, the results were similar after surgical release and microtenotomy in patients with recalcitrant lateral epicondylitis. The hypothesis was thus verified.

Retro-trochanteric sciatica-like pain: current concept.

The aim of this manuscript is to review the current knowledge in terms of retro-trochanteric pain syndrome, make recommendations for diagnosis and differential diagnosis and offer suggestions for treatment options. The terminology in the literature is confusing and these symptoms can be referred to as 'greater trochanteric pain syndrome', 'trochanteric bursitis' and 'trochanteritis', among other denominations. The authors focus on a special type of sciatica, i.e. retro-trochanteric pain radiating down to the lower extremity. The impact of different radiographic assessments is discussed. The authors recommend excluding pathology in the spine and pelvic area before following their suggested treatment algorithm for sciatica-like retro-trochanteric pain.

Human articular chondrocytes express ChemR23 and chemerin; ChemR23 promotes inflammatory signalling upon binding the ligand chemerin(21-157).

INTRODUCTION: Chemerin is a chemotactic peptide which directs leukocytes expressing the chemokine-like receptor ChemR23 towards sites of inflammation. ChemR23 is a G protein-coupled receptor which binds several different ligands, and it is also expressed by other cell types such as adipocytes. In addition to chemotaxis, recent reports suggest that ChemR23 is capable of mediating either inflammatory or anti-inflammatory effects, depending on the type of ligand it binds. In the present study, we aimed to clarify whether human chondrocytes express ChemR23 and chemerin, and whether chemerin/ChemR23 signalling could affect secretion of inflammatory mediators. METHODS: Tissue sections were taken from human knee joints and labelled with antibodies towards chemerin and ChemR23. Chondrocytes from cartilage tissue were isolated, cultured and assessed for chemerin and ChemR23 expression by PCR and immunolabelling. Receptor activation and intracellular signalling were studied by assessment of phosphorylated mitogen activated protein kinases (MAPKs) and phosphorylated Akt after stimulating cells with recombinant chemerin(21-157). Biological effects of chemerin(21-157) were investigated by measuring secretion of pro-inflammatory cytokines and metalloproteases in cell supernatants. RESULTS: Both serially cultured human articular chondrocytes and resident cells in native cartilage expressed chemerin and ChemR23. Stimulating cells with chemerin(21-157) resulted in phosphorylation of p44/p42 MAPKs (ERK 1/2) and Akt (Ser 473). Also, significantly enhanced levels of the pro-inflammatory cytokines interleukin-6 (IL-6), interleukin-8 (IL-8), tumour necrosis factor alpha (TNF-α), interleukin-1 beta (IL-1ß), and the matrix metalloproteases MMP-1, MMP-2, MMP-3, MMP-8 and MMP-13 were detected. CONCLUSIONS: These results demonstrate that human chondrocytes express both the receptor ChemR23 and the ligand chemerin. Chemerin(21-157) stimulation engaged signal-transduction pathways that further promoted inflammatory signalling in chondrocytes, as judged by an enhanced secretion of cytokines and metalloproteases. Taken together, the previously reported chemotaxis and the present findings suggest that the receptor and its ligand may play pivotal roles in joint inflammation.

Surgical release of the internal obturator tendon for the treatment of retro-trochanteric pain syndrome: a prospective randomized study, with long-term follow-up.

Twelve patients with clinical signs of retro-trochanteric pain syndrome were randomized to either operative treatment or a control group. Six patients were operated on with sectioning of the tendon to the internal obturator near its insertion to the trochanter major. There was no significant pain decrease in either group at 6 months. However, at 8 years, the decrease in pain was significant in the surgical group (P < 0.03) but not in the control group. Three patients in the surgical group who needed pain medication with opioids preoperatively managed without such drugs at 8 years. Two patients in the surgical group were working half time at the 8 year follow-up. Before the start of the study the patients had been out of work for 3 and 10 years, respectively. At inclusion 4/12 patients had minor degenerative changes at the L3-L5 level as seen on computerized tomography or magnetic resonance imaging. At 8 years, the corresponding change was found in 7/9 patients (P = 0.025). In conclusion, at 8 years after surgical release of the internal obturator muscle, the patients had a significant decrease in pain compared with the finding at inclusion. The corresponding was not found in the control group.

A 5-year prospective study of non-surgical treatment of retro-trochanteric pain.

Diffuse retro-trochanteric pain occasionally radiating to the lower extremity could be caused by the piriformis or internal obturator muscle syndromes. Thirteen patients, with retro-trochanteric pain were included in the study. All patients suffered from a diffuse, but intense and often radiating hip pain. The median duration of the symptoms was 8 (1-20) years. The patients were treated by a specific supervised stretching programme with special emphasis on the internal obturator muscle. The duration of the stretching programme was 4 weeks. At inclusion, the median pain on the visual analogue scale (VAS) was 6.0 (3-7). The VAS for pain decreased to 4.0 (0-7) (p = 0.01) at 12 weeks. Five years after treatment, the VAS for pain was still significantly lower than at inclusion, 4.0 (0-7) (p = 0.018). A significant reduction in the number of positive Freiberg's tests and in the number of patients limping was also observed, both at 3 months and at 5 years after treatment. It appears that a supervised stretching programme renders significant short and long term decrease in symptom for patients with retro-trochanteric pain.

Radiofrequency microtenotomy: a promising method for treatment of recalcitrant lateral epicondylitis.

BACKGROUND: Recalcitrant lateral epicondylitis (elbow tendinosis) is a common cause of elbow pain. There are many forms of treatment, none being superior. HYPOTHESIS: The main hypothesis tested in this study is that radiofrequency microtenotomy offers better results than the extensor tendon release and repair operation for elbow tendinosis, especially earlier recovery. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Twenty-four patients were randomized into 2 treatment groups, extensor tendon release and repair, and microtenotomy. Dynamic infrared thermography (DIRT) was employed as an objective method to verify the diagnosis as well as to document the outcome 3 months after the surgical procedure. RESULTS: Visual analog scale pain scores in the microtenotomy but not in the release group decreased significantly after 3 weeks. There was no statistically significant difference in pain scores between the 2 groups at 3, 6, and 12 weeks, and at 10 to 18 months. At 12 weeks, grip strength had improved significantly in the microtenotomy but not in the release group. The functional score was significantly increased in both groups. The DIRT group showed significant differences in epicondyle skin temperature between diseased and normal elbows both pre- and postoperatively. Abnormal DIRT images correlated well with elevated pain scores. CONCLUSIONS: Radiofrequency microtenotomy provides a promising alternative to the release operation for elbow tendinosis. Dynamic infrared thermography provides a reliable, noninvasive, objective method for the diagnosis of elbow tendinosis, as well as for evaluation of the outcome following treatment.

The internal obturator muscle may cause sciatic pain.

Six patients suspected to have piriformis syndrome were operated in the hip region in an attempt to relieve pressure on the sciatic nerve. The piriformis muscle and tendon as well as their relationship to the sciatic nerve were found to be normal. However, the internal obturator muscle was found to be very tense, slightly hyperaemic and pressing the sciatic nerve. During Lasegue's testing on the operating table the internal obturator and not the piriformis muscle impinged on the nerve at an early stage in the hip flexion movement. A sectioning of the tendon to the internal obturator muscle near its insertion at the trochanter was performed. Median pain score was found to be reduced from the preoperative value (8.5) to that at 6 weeks (3.5) (P<0.05) and 3 (3.5) (P<0.05) and 6 months (5.5) (N.S.) postoperatively. No significant reduction of pain was found in a control group of six patients followed during the same period. Three patients who needed opioids preoperatively managed without such drugs 6 months after the operation. Two patients in the operated group were at work 50 and 100% after having been out of work for 3 and 10 years, respectively.