It’s time to change perspective! New diagnostic tools for lateral elbow pain

Purpose: The presence of intra-articular findings that may complement the extra-articular pathology in lateral epicondilytis has been suggested, and a role for minor instability of the elbow as part of the causative process of this disease has been postulated. This study was designed to describe two new clinical tests, aimed at detecting intra-articular pathology in patients affected by recalcitrant lateral epicondylitis and investigate their diagnostic performance. Methods: Ten patients suffering of atraumatic lateral elbow pain unresponsive to conservative treatment were considered in this study. Two clinical tests were developed and administrated prior to arthroscopy: Supination and Antero-Lateral pain Test (SALT); Posterior Elbow Pain by Palpation-Extension\uc2\ua0of the Radiocapitellar joint (PEPPER). Sensitivity, specificity, predictive values and accuracy of SALT and PEPPER as diagnostic tests for seven intra-articular findings were calculated. Results: In 90% of the patients, at least one test was positive. All patients with signs of lateral ligamentous patholaxity or intra-articular abnormal findings had a positive response to at least one of the two tests. SALT proved to have a high sensitivity but a low specificity and is accurate in detecting the presence of intra-articular abnormal findings, especially synovitis. PEPPER test was sensible, specific and accurate in the detection of radial head chondropathy. Conclusions: Two new diagnostic tests (SALT and PEPPER) were specifically designed to evoke pain from intra-articular structures. These tests could be a valid support in the diagnostic algorithm of recalcitrant lateral elbow pain. Positive findings may be indicative of a minor instability of the lateral elbow condition. Level of evidence: Diagnostic study, development of diagnostic criteria on basis of consecutive patients, level II

La protesi di spalla negli esiti traumatici

Le fratture di omero prossimale esitano frequentemente in sequele che richiedono, nei casi gravi, un intervento di protesizzazione dell\u2019articolazione gleno-omerale. Lo scopo del nostro studio \ue8 analizzare i risultati clinici e funzionali dell\u2019utilizzo della protesi di spalla negli esiti traumatici. Abbiamo eseguito una revisione della letteratura dal 2005 al 2015 e abbiamo identificato 20 lavori che dimostrano come le protesi di spalla siano in grado di migliorare il dolore e la mobilit\ue0 nei pazienti con esiti di fratture dell\u2019omero prossimale ma con risultati inferiori rispetto a quelli ottenuti nel trattamento delle fratture in acuto o nell\u2019artrosi primaria. Nelle sequele di frattura infatti, l\u2019impianto di una protesi \ue8 spesso una procedura complessa con tassi di complicanze elevati. Se in passato erano tradizionalmente utilizzate le emiartroprotesi, recentemente le protesi totali anatomiche e inverse hanno mostrato risultati migliori anche nelle casiste con follow-up a medio-lungo termine.The treatment of fracture sequelae of proximal humerus is still a challenge. Shoulder arthroplasty improves pain and Range Of Motion (ROM) but the results are inferior to the outcomes currently obtained in primary osteoarthritis or acute trauma. Anatomical and reverse total shoulder prosthesis are becoming increasingly popular because of better results than hemiarthroplasty

Revision reverse shoulder arthroplasty in failed shoulder arthroplasties for rotator cuff deficiency

PURPOSE: the aim of this systematic literature review is to report clinical outcomes of reverse shoulder arthroplasty (RSA) used as a revision surgery following failure of the primary implant due to rotator cuff insufficiency. METHODS: a systematic review was performed using the following key words: revision, shoulder, rotator cuff deficiency, outcome assessment, treatment outcome, complications. Studies eligible for inclusion in the review were clinical trials investigating patients in whom a primary shoulder arthroplasty implant with an incompetent rotator cuff was replaced with a reverse shoulder prosthesis. RESULTS: nine articles were identified and further reviewed. The results refer to a total of 226 shoulders that were treated with RSA as revision surgery. The patients in the studies had a mean age ranging from 64 to 72 years and the longest follow-up was 3.8 years. Improvements in function and reduction of pain were shown by many studies, but the mean Constant score ranged from 44.2 to 56. High complication rates (of up to 62%) were recorded, and a mean reoperation rate of 27.5%. CONCLUSIONS: RSA as revision surgery for patients with rotator cuff deficiency is a valid option, and often the only solution available, but it should be limited to elderly patients with poor function and severe pain. LEVEL OF EVIDENCE: level IV, systematic review of level I-IV studies

Clinical outcome of latissimus dorsi tendon transfer and partial cuff repair in irreparable postero-superior rotator cuff tear

Background and purpose Irreparable rotator cuff tears are a common cause of pain in adult population, requiring in many cases a surgical treatment. Possible alternatives are debridement, partial repair, muscle transfers and joint replacement. We evaluated two groups of patients with irreparable rotator cuff tear treated surgically: one group received an arthroscopic-assisted latissimus dorsi tendon transfer (LDTT), and the other an arthroscopic rotator cuff partial repair. Aim of our study was to compare clinical results and quality of life in two groups of patients with massive irreparable rotator cuff tear: one receiving an arthroscopic LDTT and the other receiving an arthroscopic rotator cuff partial repair. Methods Forty patients were assigned to two groups: 20 patients to group TT treated with LDTT and 20 patients to group PR treated with a partial repair. The average follow-up duration was 2.8 years (1\u20135, SD 3). Pre- and postoperative modified UCLA shoulder score, ROM, measurement of the strength and the rotator cuff quality of life (RC-QOL) were used to asses the outcome. Results LDTT showed significative improvements when compared to partial repair in UCLA score results, strength and RC-QOL questionnaire. No differences were found between the groups in pain relief. Conclusion Both techniques are effective in reducing patients\u2019 symptoms. We believe that in younger, high-demanding patients with no or mild osteoarthritis, the LDTT represents a valid treatment option with better modified UCLA score improvement and strength at our follow-up

Single platelet-rich plasma injection for early stage of Osteoarthritis of the knee

Purpose \u2003The purpose of this study was to determine the safety efficacy and outcomes of platelet-rich plasma (PRP) intra-articular injections for early stages of knee osteoarthritis (OA). Methods \u2003Twenty-five patients affected by grade I and II knee primary OA according to the Kellgren-Lawrence scale received a single intra-articular PRP injection. Patients were prospectively evaluated for 6 months. Visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Knee injury and Osteoarthritis Outcome Score (KOOS) scoring scales were used to evaluate clinical outcomes. Wilcoxon signed rank test was used to evaluate significance of improvement of WOMAC, KOOS, and VAS scores. Results \u2003Twenty-one patients completed 6-months follow-up. The median WOMAC score improved from 29.1 points (range: 17.4-60.4; standard deviation [SD]\u2009=\u200913.0) at baseline to 42.41 (range: 24.3-71.2; SD\u2009=\u200912.5) at final follow-up. Improvements in median KOOS and VAS score have been also found, from 37.49 points and 64.2 mm before injection to 59.71 points and 42.8 mm, respectively. All these improvements were statistically significant ( p \u2009<\u20090.05). No adverse reactions have been observed. Conclusion \u2003Treating knee OA with PRP injection is safe. A single dose of PRP seems to be effective in managing pain and improving quality of life in patients with low-grade knee OA. Level of Evidence \u2003Level IV, therapeutic case series

Total Joint Arthroplasty in Patients with Inflammatory Rheumatic Diseases

Since its introduction, total joint arthroplasty (TJA) has improved the quality of life of patients with degenerative joint disorders. In the last decades, a number of conventional and biological disease-modifying antirheumatic drugs have become available for the treatment of patients with inflammatory rheumatic diseases (IRD), leading to a reduction in the need to undergo TJA. However, TJA is still frequently performed in IRD patients. Both rheumatologists and orthopedics should be aware that patients with IRD have a peculiar perioperative risk profile due to disease-related, patient-related, and surgery-related risk factors. On the basis of current evidence, TJA is a safe procedure for IRD patients as long as an accurate risk stratification and a multidisciplinary approach are applied. We here describe the current strategies for an appropriate surgical management of osteoarthritis in IRD patients and the fascinating opening perspectives that surgeons and clinicians may expect in the future

Repair versus shaving of partial-thickness articular-sided tears of the upper subscapularis tendon : a prospective randomized controlled trial

Purpose: The purpose of this study was to evaluate whether treating partial-thickness articular-sided tears of the upper subscapularis (ssC) tendon with a dedicated suture anchor would result in an internal rotation strength improvement compared with simple shaving of the ssC tendon and footprint. Methods: Twenty-six patients with a limited ssC tendon tear (equal or inferior to the most superior centimeter) in association with a posterosuperior cuff lesion were prospectively randomized to two treatments: repair with a dedicated suture anchor versus shaving of the tendon and footprint. the patients also underwent long head of the biceps (LHB) treatment and posterosuperior cuff tear repair. in each patient the following parameters were measured both preoperatively and at a minimum follow-up of 2.5 years: strength in internal rotation in the bear-hug testing position (using a digital tensiometer), DAsH score and Constant scores. MRi assessment of tendon healing was performed at the final follow-up. Results: Twenty of the 26 patients (76%) were reviewed after a mean follow-up time of 42 months: 11 patients had undergone ssC tendon repair and nine simple shaving. At final follow-up no significant differences were found between the repaired and shaving group in strength in internal rotation (9.5 \ub1 3.8 kg versus 10.3\ub15.4 kg; p=0.7). the DAsH score and Constant score also failed to show significant differences between the two groups. Furthermore, no significant difference in ssC tendon healing rate was observed on MRi evaluation. Conclusions: Partial-thickness articular-sided tear of the upper ssC tendon in association with a posterosuperior rotator cuff repair and LHB treatment, when limited to the superior centimeter of the ssC tendon, shows a comparable performance in terms of strength in internal rotation either after simple shaving or a tendon-to-bone repair. Level of evidence: Level II, prospective comparative study

Regenerative Medicine in Rotator Cuff Injuries

Rotator cuff injuries are a common source of shoulder pathology and result in an important decrease in quality of patient life. Given the frequency of these injuries, as well as the relatively poor result of surgical intervention, it is not surprising that new and innovative strategies like tissue engineering have become more appealing. Tissue-engineering strategies involve the use of cells and/or bioactive factors to promote tendon regeneration via natural processes. The ability of numerous growth factors to affect tendon healing has been extensively analyzed in vitro and in animal models, showing promising results. Platelet-rich plasma (PRP) is a whole blood fraction which contains several growth factors. Controlled clinical studies using different autologous PRP formulations have provided controversial results. However, favourable structural healing rates have been observed for surgical repair of small and medium rotator cuff tears. Cell-based approaches have also been suggested to enhance tendon healing. Bone marrow is a well known source of mesenchymal stem cells (MSCs). Recently, ex vivo human studies have isolated and cultured distinct populations of MSCs from rotator cuff tendons, long head of the biceps tendon, subacromial bursa, and glenohumeral synovia. Stem cells therapies represent a novel frontier in the management of rotator cuff disease that required further basic and clinical research

Dynamic contact area ratio in shoulder instability: an innovative diagnostic technique measuring interplay of bony lesions

Purpose: The hypothesis of this study is that Dynamic Contact Area Ratio of the humerus and glenoid, measured with CT scans, is significantly reduced in patients with anterior shoulder instability compared to the Dynamic Contact Area Ratio in a control group of people without shoulder instability. Methods: Preoperative CT scans of patients who underwent surgery for anterior shoulder instability were collected. Additionally, the radiologic database was searched for control subjects. Using a validated software tool (Articulis) the CT scans were converted into 3-dimensional models and the amount the joint contact surface during simulated motion was calculated. Results: CT scans of 18 patients and 21 controls were available. The mean Dynamic Contact Area Ratio of patients was 25.2 \ub1 6.7 compared to 30.1 \ub1 5.1 in healthy subjects (p = 0.014). Conclusion: Dynamic Contact Area Ratio was significantly lower in patients with anterior shoulder instability compared to controls, confirming the hypothesis of the study. The findings of this study indicate that calculating the Dynamic Contact Area Ratio based on CT scan images may help surgeons in diagnosing anterior shoulder instability. Level of evidence: III