The influence of suprapectoral arthroscopic biceps tenodesis for isolated biceps lesions on elbow flexion force and clinical outcomes.

PURPOSE: To prospectively evaluate elbow flexion force, cosmetic and clinical outcome of all-arthroscopic suprapectoral biceps tenodesis for isolated biceps lesions. METHODS: Tenodesis was performed using a 6.25-mm absorbable interference screw for intraosseous fixation. Seventeen out of 24 patients (70.8 %, median age 49.0 ± 10.1 years; 10 = male) could be included for 24 months follow-up. Elbow flexion strength in 10° and 90° elbow flexion, the upward-directed force of the upper arm in the O'Brien position, objective evaluation of a Popeye-sign deformity and validated clinical scores (CMS, SST, ASES) were assessed preoperatively, 3, 6, 12 and 24 months postoperatively. RESULTS: Elbow flexion strength in 90° improved significantly from 12 months onwards (P = 0.001) without significant difference to the contralateral arm from 3 months postoperatively (n.s.). At 24 months, an average increase of 46.4 % (median 37.7 %) from preoperative could be seen. The dominant arm was affected in 70.6 %. All scores showed a significant improvement 3 months postoperatively: SST (P = 0.003), ASES (P = 0.006) and total CMS (P < 0.001). Three patients (17.6 %) developed a distalization of the maximum biceps circumference of more than 20 % compared to preoperative. CONCLUSIONS: All-arthroscopic proximal suprapectoral intraosseous single-limb biceps tenodesis for the treatment of isolated biceps lesions provides good-to-excellent clinical results with significant improvement of elbow flexion strength and clinical scores and no significant difference to the unaffected contralateral arm. LEVEL OF EVIDENCE: IV.

Arthroscopically assisted retrograde drilling of the humeral head with a guiding device.

This manuscript describes the successful treatment of a steroid-induced avascular necrosis of the humeral head using arthroscopically assisted retrograde drilling of a stage II lesion using a guiding device. At the final follow-up 19 month post-operatively, the patient presented pain-free without functional limitations although the osteonecrosis had not been fully healed.

Opioids as an alternative to amide-type local anaesthetics for intra-articular application.

PURPOSE: Recently, the safety profile of local anaesthetics in intra-articular use became into focus of investigation. Opioid drugs have a different mode of action and may be a safe and potent alternative for intra-articular application. The purpose of this in vitro study is to provide evidence for significant chondrotoxicity of amide-type local anaesthetics even after short-term application on human chondrocytes and to demonstrate the absence of such negative effects for opioids [morphine, morphine-6-glucuronide (M6G)]. METHOD: Visually intact cartilage explants of human, mainly osteoarthritic joints (n = 9), were harvested and cultivated in monolayer for expansion and transferred into alginate bead. The beads were incubated for increasing incubation times (15 min, 1 and 4 h) in decreasing concentrations (full, ½, » for 15 min) of bupivacaine, ropivacaine, morphine, M6G or saline control. Adenosine triphosphate content of 798 beads was measured 3 days post-incubation to assess cell viability. RESULTS: A clear ranking of cytotoxic potency: bupivacaine > ropivacaine > morphine = M6G = saline was observed. Results reveal a dose- and time-dependent manner of cytotoxic effects on human chondrocytes for bupivacaine and ropivacaine but not for opioids. Cell viability after exposure to morphine and M6G was comparable to exposure to saline. CONCLUSION: The results confirm dose- and time-dependent cytotoxic effects on human chondrocytes for amide-type local anaesthetics. This study confirms the safety of morphine and M6G in terms of an absence of cytotoxic effects after intra-articular application, making them safe potential alternatives in clinical practice.

Joint failure after steroid therapy in tuberculous encephalitis.

We report a case of multifocal avascular osteonecrosis (AVN) following steroid administration in a case of tuberculous encephalitis in a young patient. The risk of joint-related AVN as a side effect of adjunctive steroid therapy should be taken into consideration when evaluating the dosage and treatment duration in tuberculous encephalitis.

Physiology and pathophysiology of nitrosative and oxidative stress in osteoarthritic joint destruction.

Osteoarthritis (OA) is one of the most common chronic diseases, with increasing importance due to increased life expectancy. On a cellular level, the pathophysiology of joint function impairment and ultimate destruction associated with OA remains poorly understood. Free radicals are highly reactive molecules involved in both normal intracellular signal transduction and degenerative cellular processes. An imbalance between the free radical burden and cellular scavenging mechanisms, defined as oxidative stress, has been identified as a relevant factor in OA pathogenesis. This literature review elucidates the involvement of nitrosative and oxidative stress in cellular ageing in joints, cell senescence, and apoptosis. Free radical exposure is known to promote cellular senescence and apoptosis, and the involvement of radical oxygen species (ROS) in inflammation, fibrosis control, and pain nociception has been proven. A relatively novel approach to OA pathophysiology considers the joint to be a dynamic system consisting of 3, continuously interacting compartments, cartilage, synovial tissue, and subchondral bone. Current knowledge concerning free radical involvement in paracrine signalling in OA is reviewed. The interrelationship between oxidative imbalances and OA pathophysiology may provide a novel approach to the comprehension, and therefore modification, of OA disease progression and symptom control.

Oxidative stress in secondary osteoarthritis: from cartilage destruction to clinical presentation?

Due to an increasing life expectance, osteoarthritis (OA) is one of the most common chronic diseases. Although strong efforts have been made to regenerate degenerated joint cartilage, OA is a progressive and irreversible disease up to date. Among other factors the dysbalance between free radical burden and cellular scavenging mechanisms defined as oxidative stress is a relevant part of OA pathogenesis. Here, only little data are available about the mediation and interaction between different joint compartments. The article provides a review of the current literature regarding the influence of oxidative stress on cellular aging, senescence and apoptosis in different joint compartments (cartilage, synovial tissue and subchondral bone). Free radical exposure is known to promote cellular senescence and apoptosis. Radical oxygen species (ROS) involvement in inflammation, fibrosis control and pain nociception has been proven. The data from literature indicates a link between free radical burden and OA pathogenesis mediating local tissue reactions between the joint compartments. Hence, oxidative stress is likely not only to promote cartilage destruction but also to be involved in inflammative transformation, promoting the transition from clinically silent cartilage destruction to apparent OA. ROS induced by exogenous factors such as overload, trauma, local intraarticular lesion and consecutive synovial inflammation cause cartilage degradation. In the affected joint, free radicals mediate disease progression. The interrelationship between oxidative stress and OA etiology might provide a novel approach to the comprehension and therefore modification of disease progression and symptom control.

Surgical and nonsurgical treatment of total rupture of the pectoralis major muscle in athletes: update and critical appraisal.

The complete rupture of the pectoralis major tendon is an uncommon injury but has become increasingly common among athletes in recent years. This may be due to a higher number of individuals taking part in high-impact sports and weightlifting as well as the use of anabolic substances, which can make muscles and tendons vulnerable to injury. In recent literature, there are only few recommendations to rely on conservative treatment alone, but there are a number of reports and case series recommending early surgical intervention. Comparing the results of the two treatment regimens, there is clear evidence for a superior outcome after surgical repair with better cosmesis, better functional results, regaining of muscle power, and return to sports compared with the conservative treatment. In summary, anatomic surgical repair is the treatment of choice for complete acute ruptures of the pectoralis major tendon or muscle in athletes.

Effects of the beta3-adrenergic agonist BRL 37344 on endothelial nitric oxide synthase phosphorylation and force of contraction in human failing myocardium.

BACKGROUND: In nonfailing myocardium, beta(3)-adrenergic signaling causes a decrease in contractility via endothelial nitric oxide synthase (eNOS) activation and nitric oxide (NO) release. This study investigates the hypothesis that beta(3)-adrenergic signaling undergoes alterations in failing myocardium. METHODS: We compared eNOS- and beta(3)-adrenoceptor expression using Western blot analysis in human nonfailing myocardium versus failing myocardium. With the use of immunohistochemistry, we investigated the distribution of the beta(3)-adrenoceptor protein and eNOS translocation and phosphorylation under basal conditions. beta(3)-adrenergic, eNOS activation, and inotropy were measured in failing myocardium using BRL37344 (BRL, a beta(3)-adrenoceptor agonist). RESULTS: beta(3)-adrenoceptor expression was increased in failing myocardium. Under basal conditions, Akt- and eNOS(Ser1177) phosphorylation were reduced in failing myocardium. During stimulation with BRL in failing myocardium, a further dephosphorylation of eNOS(Ser1177) and Akt was observed, whereas eNOS(Ser114) phosphorylation was increased. These results suggest a deactivation of eNOS via beta(3)-adrenergic stimulation. Nevertheless, BRL decreased contractility in failing myocardium, but this effect was not observed in the presence of the NO blocker L-NMA. In failing myocardium, the beta(3)-adrenoceptor was predominantly expressed in endothelial cells. In the cardiomyocytes, the beta(3)-adrenoceptor was mainly located at the intercalated disks. CONCLUSION: In failing cardiomyocytes, beta(3)-adrenergic stimulation seems to deactivate rather than activate eNOS. At the same time, beta(3)-adrenergic stimulation induced a NO-dependent negative inotropic effect. Because beta(3)-adrenoceptors are expressed mainly in the endothelium in failing myocardium, our observations suggest a paracrine-negative inotropic effect via NO liberation from the cardiac endothelial cells.

Increased Ca2+ sensitivity and protein expression of SERCA 2a in situations of chronic beta3-adrenoceptor deficiency.

This study investigated the influence of chronic beta(3)-adrenoceptor deficiency on myocardial function. Therefore, we investigated Ca(2+)-regulatory proteins, SERCA 2a activity, and myofibrillar and mitochondrial function in hearts of wild-type (WT, n=7) and beta(3)-adrenoceptor knockout mice (beta(3)-KNO, n=7). Morphometric heart analysis showed no difference between WT and beta(3)-KNO. No alterations were observed for the protein expression of the ryanodine receptor or phospholamban. However, in beta(3)-KNO mice, protein expression of SERCA 2a and phospholamban phosphorylation were significantly increased. These changes were accompanied by an increased SERCA 2a activity in beta(3)-KNO. Alterations in phospholamban phosphorylation were independent of alterations in beta(1)/beta(2)-adrenoceptor distribution and protein expression of G proteins in beta(3)-KNO. Measurement of myofibrillar Ca(2+) sensitivity showed no difference in the Ca(2+)/force relation for WT and beta(3)-KNO. The same seems to hold true for mitochondrial function since the protein expressions of cytochrome c, uncoupling protein 3 and cytochrome c oxidase subunit IV were similar in WT and beta(3)-KNO. The conclusion is that depression of beta(3)-adrenergic stimulation may modulate the protein expression of SERCA 2a and phospholamban phosphorylation, thereby improving sarcoplasmic reticulum Ca(2+) uptake. Thus, beta(3)-adrenergic depression may be a therapeutic aim in situations of impaired SERCA 2a activity, e.g. for the treatment of heart failure.

Beta3-adrenergic eNOS stimulation in left ventricular murine myocardium.

This study investigates mechanisms underlying beta3-adrenergic activation of the endothelial nitric oxide synthase (eNOS) in myocardial tissue of wild-type (WT) and beta3-adrenoceptor knockout (beta3-KNO) mice, in the absence and presence of BRL 37344 (BRL), the preferential beta3-adrenoceptor selective agonist. Nitric oxide (NO)-liberation was measured after the application of BRL (10 micromol/L), using fluorescence dye diaminofluorescein (DAF), in left ventricular cardiac preparations. Phosphorylation of eNOSSer1177, eNOSThr495, eNOSSer114, and eNOS translocation, and alterations of 8-isoprostaglandin F2alpha (a parameter for reactive oxygen radical generation), after application of BRL (10 micromol/L), were studied using immunohistochemical stainings in isolated, electrically stimulated (1 Hz) right atrial (RA) and left ventricular (LV) myocardium. An increased NO release after BRL application (10 micromol/L) was observed in the RA and LV myocardial tissue of WT mice, but not in beta3-KNO mice. This NO liberation in WT mice was paralleled by an increased eNOSSer1177, but not eNOSThr495, phosphorylation. A cytosolic eNOS translocation was observed after the application of BRL (10 micromol/L) only in the RA myocardial tissue of WT mice. A BRL (10 micromol/L)-dependent increase in eNOSSer114 phosphorylation was observed only in the LV myocardial tissue of WT mice; this was paralleled by an increase in 8-isoprostaglandin F2alpha. In murine myocardium, 3 beta3-adrenoceptor-dependent activation pathways for eNOS exist (i.e., a translocation and phosphorylation of eNOSSer1177 and eNOSSer114). These pathways are used in a regional-dependent manner. beta3-adrenergic oxygen-derived free radical production might be important in situations of enhanced beta3-adrenoceptor activation, as has been described in human heart failure.

Mechanisms of beta 3-adrenoceptor-induced eNOS activation in right atrial and left ventricular human myocardium.

beta-Adrenoceptors are important modulators of cardiac function. The present study investigated beta(3)-adrenergic eNOS activation in human myocardium. We measured nitric oxide (NO) liberation (diaminofluorescence) and signal transduction (immunohistochemistry, phosphorylation of eNOS(Ser1177), eNOS(Thr495), eNOS(Ser114), Akt/protein kinase B (Akt/PKB), and eNOS translocation) in human right atrial (RA, aortocoronary-bypass OP) and left ventricular nonfailing (LV, rejected donor hearts) myocardium after application of BRL 37344 (BRL), a preferential beta(3)-adrenoceptor agonist. In both RA and LV, BRL (10 microl) induced a liberation of NO. An eNOS activation via translocation was only observed in RA after application of BRL (10 microM). Yet, the NO liberation in both LV and RA was accompanied by phosphorylation of eNOS(Ser1177) and Akt/PKB. BRL-induced eNOS phosphorylation was abolished by LY292004, a blocker of PI-3 kinase. eNOS-Ser(114) phosphorylation was unchanged in RA, but decreased in LV after beta(3)-adrenergic stimulation. BRL did not alter phosphorylation of eNOS(Thr495). In conclusion, receptor-dependent eNOS activation is differentially regulated in the human heart. In the left ventricle, eNOS activation via phosphorylation seems to be of major importance, whereas in human atrial myocardium eNOS translocation is the predominant mechanism induced by beta(3)-adrenergic activation.