Capsular closure after hip arthroscopy: our experience

BACKGROUND AND AIM OF THE WORK: In the last decade, arthroscopic treatment of hip diseases has significantly spread and evolved and currently it represents the gold standard for the treatment of femoral- acetabular impingement. In the recent years, the function of the joint capsule (and therefore the results of an arthroscopic capsulotomy) has been hugely developed, opening a heated debate. The Literature is still torn about the need for a capsular suture, but more recent studies are more oriented in its execution at the end of the surgical procedure. According to these recent studies, the joint capsule performs an essential function of primary stability, and its closure is therefore necessary to restore the native anatomy and physiology. Nevertheless, capsular management remains a controversial topic. This is a retrospective study with the aim of assessing the influence of capsular suture on the patient's functional outcome in a cohort of patients with femoral-acetabular impingement arthroscopically treated. HYPOTHESIS: Our hypothesis is that an adequate capsular suture positively influences the patient's functional outcome. METHODS AND RESULTS: 50 patients treated with hip arthroscopy for femoral-acetabular impingement have been retrospectively enrolled at the Orthopaedic Clinic of Academic Hospital of Udine during a period of two-years (2017-2018); collected data have been analysed and compared with a retrospective model. Patients have been divided into two equivalent groups, 25 treated with capsular suture, 25 without performing the suture. Patient's post-operative functional outcome has been analysed using the modified Harris Hip Score (mHHS), the Non-Arthritic Hip Score (NAHS) and the Hip Outcome Score-Sport Scale (HOS-SS). The functional outcome in patients where capsular sutures were performed was better than in non-sutured patients, in all three analysed scales. CONCLUSIONS: Capsular suture with a single side-to-side stitch at the end of the procedure can positively influence the patient's functional outcome

Subchondroplasty in the treatment of bone marrow lesions of the knee: Preliminary experience on first 15 patients

Purpose The aim of this prospective study was to assess the effectiveness in terms of pain relief and functional improvement of the Subchondroplasty procedure in the treatment of osteoarthritis-related bone marrow lesions (BMLs) of the knee. Methods The study included first 15 consecutive patients undergone to Subchon-droplasty procedure for the treatment of chronic degenerative BMLs in which previous conservative treatment have failed. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, Knee Injury and Osteoarthritis Outcome Scores (KOOS), and visual analog scale (VAS) pain scores were obtained preoperatively and at 1, 6, and 12 months of follow-up. Results WOMAC scores significantly improved from 39.7 \ub1 20.2 before surgery to 26.8 \ub1 16.1 at the 1-month follow-up (p = 0.045). A further significant improvement to 15.5 \ub1 12.7 (p = 0.02) and to 8.6 \ub1 3.1 (p <0.01) was obtained both at 6-month and at 1-year follow-up. KOOS scores improved significantly from 47.5 \ub1 16.6 before surgery to 65.4 \ub1 14.9 at 1 month (p = 0.013) and to 80.4 \ub1 15.1 at 6-month follow-up (p = 0.01). A further improvement to 85.6 \ub1 15.1 was recorded 1 year postoperatively, although nonsignificant. VAS score showed a significant improvement from 55.8 \ub1 20.5 preoperatively to 36.2 \ub1 16.9 at 1 month (p = 0.008) and to 18.2 \ub1 17.3 at 6-month follow-up (p = 0.005). This further improved to 12.8 \ub1 17.9 at 1-year follow-up, although not significantly. Conclusion Subchondroplasty procedure represents a safe and valid surgical option in the treatment of osteoarthritis-related BMLs of the knee, providing an improvement in terms of pain relief and functional recovery. Longer studies are required to evaluate how long these improvements may last. Level of Evidence Therapeutic case-series, Level IV study

Histological analysis of ACL reconstruction failures due to synthetic-ACL (LARS) ruptures

INTRODUCTION: Anterior Cruciate Ligament (ACL) reconstruction is an established surgical procedure. Synthetic ligaments represent an option for ACL reconstruction. Their popularity declined for the raising concerns due to re-ruptures, knee synovitis and early arthritis related to I and II generation artificial ligaments. The introduction of a III generation synthetic ligament (Ligament Advanced Reinforcement System-LARS) permitted renewed interest in the adoption of this kind of graft. Main purpose of our study was to describe the histological findings on samples obtained from a consecutive series of ACL revision surgeries due to LARS ACL reconstruction failures. Secondary aim was to determine the reason for LARS rupture. METHODS: In a period between 2016 and 2018 eleven patients underwent ACL revision surgery due to LARS ACL reconstruction failure. At the time of the arthroscopic procedure, samples of synovial membrane and remnants of the torn LARS were sent to the Pathological-Anatomy Institute of our Hospital for a histological analysis. RESULTS: Histological analysis of the synovial tissues confirmed the arthroscopic evidence of synovitis mainly characterized by chronic inflammation with predominance of multinucleated giant cells. The adoption of polarized light microscopy revealed the presence of brightly bi-refractive material (LARS wear particles) in the synovial tissue; at higher magnification wear debris were detected inside the cytoplasma of multi nucleated cells. The histological analysis of the removed LARS revealed a surrounding typical foreign body reaction with poor signs of fibrovascular ingrowth of the synthetic ligament. CONCLUSIONS: Our findings could not clearly advocate a unique mechanism of LARS-ACL reconstruction failure: biologic issues (poor tissue ingrowth) and mechanical issues (fibers properties and tunnel position) probably concur in a multi factorial manner. ACL reconstruction using artificial ligaments can not be considered a simple surgery. Artificial augments require some expertise and could therefore achieve better results if used by skilled sport surgeons other than trainees or low volume surgeons. The Authors believe that ACL reconstruction with synthetic devices still have restricted indications for selected patients (e.g. elderly patients who require a fast recovery, professional athlete, autologous tendons not available and/or refusing donor tendons). Our study arises additional suspicion on the unresponsiveness of synthetic fibers and claim some concern in the implantation of synthetic devices

All-suture anchors in arthroscopic acetabular labral repair: our experience

BACKGROUND: Over the past years, the role of the acetabular labrum in hip joint biomechanics and its relations with joint health has been of particular interest. There is a good clinical improvement of patients in whom the acetabular labrum is preserved during arthroscopic hip surgery. The purpose of this study is to report the results of arthroscopic repair of labral tears at a medium term follow up. MATERIALS AND METHODS: We performed a retrospective review of all cases that underwent hip arthroscopy at our Institution from January 2013 until December 2018. There were 24 patients, 13 males and 11 females, and their mean age at the time of surgery was 29, 42 years (range, 19 to 43 years). All patients were treated by the same surgeon with an extracapsular OUT-IN approach. Suture was performed using a non-absorbable suture anchor all-suture. Clinical assessment was performed at December 2019 using a modified Harris hip score (mHHS), hip outcomes score activities of daily living (HOS ADL), hip outcomes score activities of sport scale (HOS SS). All patients with acetabular labrum injury had femoro-acetabular impingement. RESULTS: The mean overall values in the preoperative period were 67.21 \ub1 10.31 for mHHS, 70.04 \ub1 12.11 for HOS-ADL and 60.06 \ub1 14.58 for HOS -SS. The results obtained in the re-evaluations of patients in December 2019 with a mean follow-up of 38, 3 months (minimum 1 year) are on average 82.17 \ub1 11.36 for mHHS, 83.00 \ub1 12.80 for HOS-ADL and 76.09 \ub1 18.52 for HOS-SS. CONCLUSIONS: The progress of knowledge and the advancement of diagnostic and therapeutic skills has led to a greater awareness of the importance of treating acetabular labrum tears. Arthroscopic treatment with suture appear to be a good option for these patients and we had encouraging results in our center

Total knee revision arthroplasty: comparison between tibial tubercle osteotomy and quadriceps snip approach. Complication rate

BACKGROUND AND AIM OF THE WORK: The total knee arthroplasty (TKA) revision is not a second time of primary implant surgery but is a very complex issue for orthopedic surgeon. When local conditions make necessary a greater visualization, medial para-patellar access with quadriceps snip (QS) or the osteotomy of the tibial tuberosity (TTO) can be the solutions. This work aims to compare the quadriceps snip and the detachment of the tibial tubercle, focusing on possible complications. MATERIALS AND METHODS: At our institution, between January 2017 and February 2019 52 TKA revision for periprosthetic joint infection (PJI) or aseptic mobilization were performed. In 43 cases an extensive surgical approach was required: for patients with range of movement (ROM) 60\ub0 a QS was performed. Clinical and radiological follow-up was available for all the 43 cases. RESULTS: The data about clinical outcome in our study show that both groups have a positive trend in KSS score over time with similar ROM results. Two partial avulsions of patellar tendon during revision surgery were reported. Clinical outcome in both groups has shown good results at the end of follow-up with no post-operative incidence of complications. CONCLUSION: We can assert that both QS and TTO are good approach for TKA revision. Future studies will be needed to understand if preparatory ROM is a good way to decide which surgical approach to use.(www.actabiomedica.it)

efficacy of botulinum toxin type a treatment of functional impairment of degenerative hip joint preliminary results

Objective: the aim of this study was to investigate the effect of botulinum toxin type a injection into the adductor muscles in reducing pain and improving joint mobility and quality of life in patients affected by hip osteoarthritis. Methods: a total of 39 outpatients, mean age 68 years (age range 41–82 years), were evaluated using the harris hip Score to test hip function, a visual analogue scale to measure pain intensity and the Short Form 36 (SF-36) questionnaire to assess patient well-being and quality of life at baseline, 2, 4 and 12 weeks after treatment with botulinum toxin type a. a total of 400 u of botulinum toxin type a (Dysport) was injected into the adductor longus muscle and the adductor magnus muscle. Results: The Harris Hip Score increased significantly after 2, 4 and 12 weeks (df 3, χ 2 = 45.1; p < 0.0001). A significant decrease in pain intensity was detected at all the follow-up visits, after 2, 4 and 12 weeks (df 3; χ 2 = 27.8; p < 0.001). the SF-36 score was significantly higher 4 and 12 weeks after treatment. At each evaluation visit a significant correlation was detected between decreased pain and improved hip mobility. Conclusion: Botulinum toxin type a induced a reduction in pain, indicating that this might be an innovative, less invasive treatment in patients affected by severe hip osteoarthritis, with remarkable effects on the clinical management of this disease

Efficacy of botulinum toxin type A treatment of functional impairment of degenerative hip joint: Preliminary results

Objective: the aim of this study was to investigate the effect of botulinum toxin type a injection into the adductor muscles in reducing pain and improving joint mobility and quality of life in patients affected by hip osteoarthritis. Methods: a total of 39 outpatients, mean age 68 years (age range 41–82 years), were evaluated using the harris hip Score to test hip function, a visual analogue scale to measure pain intensity and the Short Form 36 (SF-36) questionnaire to assess patient well-being and quality of life at baseline, 2, 4 and 12 weeks after treatment with botulinum toxin type a. a total of 400 u of botulinum toxin type a (Dysport) was injected into the adductor longus muscle and the adductor magnus muscle. Results: The Harris Hip Score increased significantly after 2, 4 and 12 weeks (df 3, χ 2 = 45.1; p < 0.0001). A significant decrease in pain intensity was detected at all the follow-up visits, after 2, 4 and 12 weeks (df 3; χ 2 = 27.8; p < 0.001). the SF-36 score was significantly higher 4 and 12 weeks after treatment. At each evaluation visit a significant correlation was detected between decreased pain and improved hip mobility. Conclusion: Botulinum toxin type a induced a reduction in pain, indicating that this might be an innovative, less invasive treatment in patients affected by severe hip osteoarthritis, with remarkable effects on the clinical management of this disease

The Exposure to Osteoarthritic Synovial Fluid Enhances the Immunomodulatory Profile of Adipose Mesenchymal Stem Cell Secretome

Objective. Several clinical studies have proposed the infusion of adipose mesenchymal stem cells (AMSCs) as an alternative therapy for joint diseases with inflammatory components, such as osteoarthritis. Indeed, AMSCs are able to stimulate tissue repair through a paracrine activity and the interaction with the inflammatory microenvironment seems to have a critical role. Design. To reproduce the inflammatory microenvironment, AMSCs were exposed to osteoarthritic synovial fluid (SF) for 48 h and the effect of their secretome on differentiation of monocytes (M0) into macrophages M1-like and mature dendritic cells (mDCs) was evaluated. Furthermore, the effect of the secretome of AMSCs exposed to SF was evaluated on the T cell population in terms of T cell proliferation and expansion of T regulatory cells (T reg). Results. Our data show that the exposure of AMSCs to SF activates cells and promotes the release of immunosuppressive factors, which induce macrophage polarization of M0 into the M2-like phenotype and inhibit differentiation of monocytes into mature dendritic cells (mDCs). Only the secretome of exposed AMSCs was able to inhibit T cell proliferation and promote T reg expansion. Conclusions. Our results suggest that the microenvironment plays a fundamental role for the development of anti-inflammatory and immunomodulatory properties of AMSCs

Short-term efficacy and safety of betamethasone valerate 2.25 mg medicated plaster in patients with chronic lateral epicondylitis: Results of a randomised, double blind, placebo-controlled study

Background. This placebo-controlled, double-blind study evaluated the short-term effects of betamethasone valerate (BMV) 2.25mg medicated plaster in patients with chronic lateral elbow tendinopathy (LET). Methods. Adult outpatients with LET and on-movement pain intensity ≥50 mm at a 0-100mm visual analogue scale (VAS) were randomised to receive BMV (N=101) or placebo (N=98), 12 hours/day for 4 weeks. Pain decrease from baseline to Day 28 was the primary endpoint. Other endpoints were: patient-rated tennis elbow evaluation (PRTEE), use of rescue paracetamol, tolerability at the application site. Results. Decrease in mean pain VAS from baseline to Day 28 was significantly higher with BMV vs. placebo: the difference between groups (intent-to-treat) was-8.57 mm (95% CI:-16.19 to-0.95 mm; p=0.028). Higher pain decreases in the BMV group over placebo were reported weekly during each control visit and daily in patients’ measurements on diaries. Treatment with BMV also led to higher decreases vs. placebo in PRTEE total, pain and functional disability score. Use of paracetamol was minimal. BMV plaster was well tolerated for general and local adverse events. Conclusions. BMV 2.25mg plaster was superior to placebo and well tolerated in patients with painful chronic LET