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Oliva F, Marsilio E, Migliorini F, Maffulli N. Chronic quadriceps tendon rupture: quadriceps tendon reconstruction using ipsilateral semitendinosus tendon graft. J Orthop Surg Res 2023; 18:355. [PMID: 37173685 PMCID: PMC10176907 DOI: 10.1186/s13018-023-03822-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Ruptures of the quadriceps tendon (QTRs) are uncommon. If the rupture is not diagnosed, chronic ruptures may develop. Re-ruptures of the quadriceps tendon are rare. Surgery is challenging because of tendon retraction, atrophy and poor quality of the remaining tissue. Multiple surgical techniques have been described. We propose a novel technique in which the quadriceps tendon is reconstructed using the ipsilateral semitendinosus tendon.
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Affiliation(s)
- Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
| | - Emanuela Marsilio
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
| | - Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, E1 4DG, England
- School of Pharmacy and Biotechnology, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England
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Morphofunctional reorganization of plantar aponeurosis in experimental modeling of fasciopathy by synthetic analogue of prostaglandin E1. ACTA BIOMEDICA SCIENTIFICA 2022. [DOI: 10.29413/abs.2022-7.3.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Foundation. Chronic plantar fasciopathic pain syndrome is a pathology that significantly affects the quality of life of patients of all age categories. Insufficient knowledge of the etiological and pathogenetic factors in the development of fasciopathies explains the multiplicity, and sometimes inconsistency, of conservative and surgical treatment regimens. The choice of the optimal variant of therapeutic or surgical intervention may be associated with experimental modeling of fasciopathies and the study of the dynamics of the pathological process.The aim. To study the morphological changes in structures identical to the human plantar aponeurosis in experimental modeling of fasciopathy in animals.Research methods. The material for the study was fragments of the tendonaponeurotic complex of the foot of laboratory animals (control group: animals with the introduction of physiological sodium chloride solution (n = 12); main group: animals with the introduction of alprostadil (n = 12)). The methods of light microscopy (staining with alcian and toluidine blue, according to Van Gieson, Weigert – Van Gieson and Picro-Mallory) and morphometry were used.Results and discussion. As a result of the study, it was found that the four-fold administration of alprostadil had a significant effect on the structure of the dense fibrous connective tissue of the plantar foot of laboratory animals. The mechanisms of damage (edema, microhemorrhages, infiltration by lymphocytes, plasmocytes and leukocytes, dystrophy by the type of mucoid and fibrinoid swelling, delamination and rupture of collagen fibers), adaptation and regeneration (the appearance of a large number of activated fibrocytes, fibroblasts, microvessels, neoplasm of collagen fibers) were activated. All this together led to spatial focal histotopographic changes, consisting in an increase in the cellular composition of connective tissue structures against the background of a noticeable violation of their spatial orientation.Conclusion. Modeling of fasciopathy using alprostadil was accompanied by the appearance of mosaic reversible and irreversible heteromorphic and heterochronous changes in all connective tissue aponeurotic structures. Such histotopographic changes should be considered as one of the reasons for the clinical manifestations of plantar fasciopathies, causing functional insufficiency and explaining the clinical recurrent nature of the pathological process.
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Lulińska-Kuklik E, Rahim M, Domańska-Senderowska D, Ficek K, Michałowska-Sawczyn M, Moska W, Kaczmarczyk M, Brzeziański M, Brzeziańska-Lasota E, Cięszczyk P, September AV. Interactions between COL5A1 Gene and Risk of the Anterior Cruciate Ligament Rupture. J Hum Kinet 2018; 62:65-71. [PMID: 29922378 PMCID: PMC6006531 DOI: 10.1515/hukin-2017-0177] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Collagen alpha-1(V) chain, encoded by the COL5A1 gene, plays a crucial role in abundant fibrillar collagens supporting many tissues in the body containing type I collagen and appears to regulate the association between heterotypic fibers composed of both type I and type V collagen occurring among others in muscles, tendons and ligaments. Taking this fact into consideration we decided to examine the association between COL5A1 rs12722 and rs13946 polymorphisms, individually and as inferred haplotypes, with anterior cruciate ligament rupture risk (ACLR) in professional soccer players. A total of 134 male professional soccer players with surgically diagnosed primary anterior cruciate ligament ruptures and 211 apparently healthy male professional soccer players, who were without any self-reported history of ligament or tendon injury, were included in the study. Both the cases and the healthy controls were recruited from the same soccer teams, of a similar age category, and had a comparable level of exposure to anterior cruciate ligament injury. Genomic DNA was extracted from oral epithelial cells using GenElute Mammalian Genomic DNA MiniprepKit. All samples were genotyped for the rs12722 and rs13946 polymorphisms using a Rotor-Gene realtime polymerase chain reaction. Statistically significant differences in the genotype frequencies for the COL5A1 rs13946 polymorphisms in dominant modes of inheritance occurred (p = 0.039). Statistically significant differences were documented only in the dominant model under the representation tendency of the C-C haplotype in the ACLR group compared to controls (p = 0.038). Our results suggest that variation in the COL5A1 gene may be one of the non-modifiable factors associated with the ACL injury in professional soccer players. The C-C rs12722-rs13946 haplotype provides a protective effect against the ACL tear.
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Affiliation(s)
- Ewelina Lulińska-Kuklik
- Faculty of Tourism and Recreation, Gdansk University of Physical Education and Sport, Gdansk, Poland
| | - Masouda Rahim
- Division of Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Daria Domańska-Senderowska
- Department of Molecular Bases of Medicine, 1st Chair of Internal Diseases, Medical University of Lodz, Lodz, Poland
| | - Krzysztof Ficek
- Faculty of Physiotherapy, The Jerzy Kukuczka Academy of Physical Education in Katowice, Katowice, Poland.,Galen-Orthopaedics, Bierun, Poland
| | | | - Waldemar Moska
- Faculty of Tourism and Recreation, Gdansk University of Physical Education and Sport, Gdansk, Poland
| | - Mariusz Kaczmarczyk
- Faculty of Tourism and Recreation, Gdansk University of Physical Education and Sport, Gdansk, Poland.,Pomeranian Medical University, Department of Clinical and Molecular Biochemistry, Szczecin, Poland
| | - Michał Brzeziański
- Department of Molecular Bases of Medicine, 1st Chair of Internal Diseases, Medical University of Lodz, Lodz, Poland
| | - Ewa Brzeziańska-Lasota
- Department of Molecular Bases of Medicine, 1st Chair of Internal Diseases, Medical University of Lodz, Lodz, Poland
| | - Paweł Cięszczyk
- Faculty of Physical Education, Gdansk University of Physical Education and Sport, Gdansk, Poland
| | - Alison V September
- Division of Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Vaughn NH, Stepanyan H, Gallo RA, Dhawan A. Genetic Factors in Tendon Injury: A Systematic Review of the Literature. Orthop J Sports Med 2017; 5:2325967117724416. [PMID: 28856171 PMCID: PMC5571768 DOI: 10.1177/2325967117724416] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Tendon injury such as tendinopathy or rupture is common and has multiple etiologies, including both intrinsic and extrinsic factors. The genetic influence on susceptibility to tendon injury is not well understood. PURPOSE To analyze the published literature regarding genetic factors associated with tendon injury. STUDY DESIGN Systematic review; Level of evidence, 3. METHODS A systematic review of published literature was performed in concordance with the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) guidelines to identify current evidence for genetic predisposition to tendon injury. PubMed, Ovid, and ScienceDirect databases were searched. Studies were included for review if they specifically addressed genetic factors and tendon injuries in humans. Reviews, animal studies, or studies evaluating the influence of posttranscription factors and modifications (eg, proteins) were excluded. RESULTS Overall, 460 studies were available for initial review. After application of inclusion and exclusion criteria, 11 articles were ultimately included for qualitative synthesis. Upon screening of references of these 11 articles, an additional 15 studies were included in the final review, for a total of 26 studies. The genetic factors with the strongest evidence of association with tendon injury were those involving type V collagen A1, tenascin-C, matrix metalloproteinase-3, and estrogen-related receptor beta. CONCLUSION The published literature is limited to relatively homogenous populations, with only level 3 and level 4 data. Additional research is needed to make further conclusions about the genetic factors involved in tendon injury.
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Affiliation(s)
- Natalie H. Vaughn
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Hayk Stepanyan
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Robert A. Gallo
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Stępień-Słodkowska M, Ficek K, Kaczmarczyk M, Maciejewska-Karłowska A, Sawczuk M, Leońska-Duniec A, Stępiński M, Ziętek P, Król P, Chudecka M, Cięszczyk P. The Variants Within the COL5A1 Gene are Associated with Reduced Risk of Anterior Cruciate Ligament Injury in Skiers. J Hum Kinet 2015; 45:103-11. [PMID: 25964814 PMCID: PMC4415823 DOI: 10.1515/hukin-2015-0011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The purpose of this study was to examine the association of the BstUI RFLP C/T (rs 12722) and DpnII RFLP C/T (rs 13946) COL5A1 polymorphisms, individually and as haplotypes, with anterior cruciate ligament ruptures in recreational skiers. Subjects were 138 male recreational skiers with surgically diagnosed primary anterior cruciate ligament ruptures. The control group consisted of 183 apparently healthy male recreational skiers, who were without any self-reported history of ligament or tendon injury. DNA was extracted from buccal cells donated by the subjects and genotyping was carried out using real-time PCR. The genotype distributions for both polymorphisms met Hardy-Weinberg expectations in both groups. There were no significant differences in genotype distribution of allele frequencies of COL5A1 BstUI RFLP C/T and COL5A1 DpnII RFLP C/T polymorphisms between the ACL rupture and control groups. The T-T (BstUI RFLP T, DpnII RFLP T) haplotype was the most common (55.6%). The haplotype T-C was not present in any of the subjects. There was an underrepresentation tendency of the C-T haplotype in the study group compared to controls under recessive mode of inheritance. Higher frequency of the COL5A1 BstUI RFLP C/T and COL5A1DpnII RFLP C/T polymorphisms haplotype is associated with reduced risk of anterior cruciate ligament injury in a group of apparently healthy male recreational skiers.
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Affiliation(s)
| | - Krzysztof Ficek
- University of Szczecin, Department of Physical Culture and Health Promotion, Szczecin, Poland
| | - Mariusz Kaczmarczyk
- Gdansk University of Physical Education and Sport, Faculty of Tourism and Recreation, Gdansk, Poland
| | | | - Marek Sawczuk
- University of Szczecin, Department of Physical Culture and Health Promotion, Szczecin, Poland
| | - Agata Leońska-Duniec
- University of Szczecin, Department of Physical Culture and Health Promotion, Szczecin, Poland. ; Gdansk University of Physical Education and Sport, Faculty of Tourism and Recreation, Gdansk, Poland
| | - Miłosz Stępiński
- University of Szczecin, Department of Physical Culture and Health Promotion, Szczecin, Poland
| | - Paweł Ziętek
- Medical University at Szczecin, Department of Orthopedics and Traumatology of Pomeranian Medical, Szczecin, Poland
| | - Paweł Król
- University of Rzeszow, Department of Physical Culture, Rzeszow, Poland
| | - Monika Chudecka
- University of Szczecin, Department of Physical Culture and Health Promotion, Szczecin, Poland
| | - Paweł Cięszczyk
- University of Szczecin, Department of Physical Culture and Health Promotion, Szczecin, Poland. ; Gdansk University of Physical Education and Sport, Faculty of Tourism and Recreation, Gdansk, Poland
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Pruna R, Artells R, Ribas J, Montoro B, Cos F, Muñoz C, Rodas G, Maffulli N. Single nucleotide polymorphisms associated with non-contact soft tissue injuries in elite professional soccer players: influence on degree of injury and recovery time. BMC Musculoskelet Disord 2013; 14:221. [PMID: 23890452 PMCID: PMC3726514 DOI: 10.1186/1471-2474-14-221] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 07/03/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The biological mechanisms involved in non-contact musculoskeletal soft tissue injuries (NCMSTI) are poorly understood. Genetic risk factors may be associated with susceptibility to injuries, and may exert marked influence on recovery times. METHODS Data on type and degree of injury and recovery time were collected in 73 male professional soccer players (43 White, 11 Black Africans and 19 Hispanics) who suffered total of 242 injuries (203 muscle, 24 ligament, and 15 tendon injuries). One single nucleotide polymorphism (SNPs) in the following genes were analyzed: Elastin (ELN); Titin (TTN); SRY-related HMG-box (SOX15); Insulin-like growth factor 2 (IGF2); Chemokine, CC motif, ligand 2 (CCL2); Collagen type 1 alpha 1(COL1A1); Collagen type 5 alpha 1 (COL5A1), and Tenascin C (TNC). RESULTS There was evidence of a statistically significant association between the degree of injury and the IGF2 genotype (P = 0.034). In addition, there was evidence of a statistically significant association between the degree of muscle injury and CCL2 (P = 0.026) Finally, there was evidence of a statistically significant association between ELN and degree of injury (p = 0.009) and recovery time (P = 0.043). There was no evidence of a statistically significant association between any of the genes studied and degree of injury or recovery time for tendon injuries. CONCLUSION SNPs in the IGF2, CCL2, and ELN genes may be associated to the degree and recovery time of NCMSTI.
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High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon. Phys Ther Sport 2012; 14:163-7. [PMID: 23131435 DOI: 10.1016/j.ptsp.2012.07.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 04/19/2012] [Accepted: 07/02/2012] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Several substances are routinely injected in and around tendons. The present study evaluated the long term effects of high volume image guided injection (HVIGI) of normal saline, local anaesthetic and aprotinin in athletic patients with resistant tendinopathy of the main body of the Achilles tendon. DESIGN Case series. METHODS The study included a series of 94 athletes (69 men and 25 women; average age 37.5 years, range 22-63) with ultrasound confirmed tendinopathy of the main body of the Achilles tendon. All the patients had not improved after at least three months of conservative management. Patients were injected with 10 mL of 0.5% Bupivacaine Hydrochloride, 25 mg aprotinin, and up to 40 mL of injectable normal saline. We prospectively administered the Victorian Institute of Sport Assessment-Achilles tendon (VISA-A) to assess the short- and long-term pain and functional improvement. RESULTS At baseline (n = 94), the VISA-A score was 41.7 ± 23.2 (range 11-60), and had improved to 74.6 ± 21.4 (range 71-100) by 12 months (n = 87) (p = 0.003), with no significant difference between sexes. CONCLUSION HVIGI with aprotinin significantly reduces pain and improves function in patients with chronic Achilles tendinopathy in the short- and long-term follow up.
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Maffulli N, Del Buono A, Spiezia F, Longo UG, Denaro V. Light microscopic histology of quadriceps tendon ruptures. INTERNATIONAL ORTHOPAEDICS 2012; 36:2367-71. [PMID: 22878910 PMCID: PMC3479299 DOI: 10.1007/s00264-012-1637-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 07/25/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess histological changes and possible differences in the quadriceps of patients undergoing open repair of the tendon after spontaneous rupture, and subjects with no history of tendon pathology. MATERIALS Biopsies were harvested from the quadriceps tendon of 46 patients (34 men, 12 women) who had reported unilateral atraumatic quadriceps tendon rupture and had undergone surgical repair of the tendon. Samples were also harvested from both the tendons in 11 (N = 11 × 2) patients, nine males and two females, dying from cardiovascular disorders. For each tendon, three slides were randomly selected and examined under light microscopy, and assessed using a semiquantitative grading scale (range 0-21) which considers fibre structure, fibre arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, and hyalinisation. RESULTS The pathological sum-score averaged 19.2 ± 3.7 in ruptured tendons and 5.6 ± 2.0 in controls, and all variables considered were significantly different between the two groups, showing an association between tendon abnormalities and rupture (0.05 < P < 0.001). CONCLUSION This study confirms that the presence of histological degenerative changes in torn quadriceps tendons increases the risk of rupture.
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Affiliation(s)
- Nicola Maffulli
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England, UK.
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Longo UG, Loppini M, Berton A, Marinozzi A, Maffulli N, Denaro V. The FIFA 11+ program is effective in preventing injuries in elite male basketball players: a cluster randomized controlled trial. Am J Sports Med 2012; 40:996-1005. [PMID: 22415208 DOI: 10.1177/0363546512438761] [Citation(s) in RCA: 138] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recently, structured training programs for sports injury prevention ("The 11" and "The 11+") have been validated in soccer. The FIFA 11+ program has not been evaluated in basketball. HYPOTHESIS The FIFA 11+ program is effective in reducing the rates of injury in male basketball players. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS The authors randomized 11 teams of the same club. Seven teams were allocated to the intervention group (80 players; mean [SD] age 13.5 [2.3] years), and 4 teams were allocated to the control group (41 players; mean [SD] age 15.2 [4.6] years). The authors conducted an injury surveillance program during a 9-month season. The primary outcome was any injury to the athletes. The secondary outcome was any injury to the lower extremity (foot, ankle, lower leg, knee, thigh, groin, and hip). They included an analysis of the type of exposure (match or training), injury location in the body, and type of injury (acute or overuse). RESULTS During the 9-month season, 23 (19%) of the 121 players included in the study sustained a total of 31 injuries (14 in the intervention group and 17 in the control group). In the intervention group, injury rates per 1000 athlete-exposures were lower than those in the control group, with statistical significance, for overall injuries (0.95 vs 2.16; P = .0004), training injuries (0.14 vs 0.76; P = .007), lower extremity injuries (0.68 vs 1.4; P = .022), acute injuries (0.61 vs 1.91; P < .0001), and severe injuries (0 vs 0.51; P = .004). The intervention group also had statistically significant lower injury rates for trunk (0.07 vs 0.51; P = .013), leg (0 vs 0.38; P = .007), and hip and groin (0 vs 0.25; P = .023) compared with the control group. There was no statistically significant difference in match injuries, knee injuries, ankle injuries, and overuse injuries between 2 groups. The most frequent acute injury diagnoses were ligament sprains (0.41 and 0.38 in the intervention and control groups, respectively; P < .006) and contractures (0.76 and 0.07 in the control and intervention groups, respectively; P < .003). CONCLUSION The FIFA 11+ warm-up program is effective in reducing the rates of injuries in elite male basketball players.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Trauma and Orthopaedic Surgery, UniversityCampus Bio-Medico of Rome, Italy
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Galasso O, Iaccino E, Gallelli L, Perrotta I, Conforti F, Donato G, Gasparini G. Collagen type V polymorphism in spontaneous quadriceps tendon ruptures. Orthopedics 2012; 35:e580-4. [PMID: 22495864 DOI: 10.3928/01477447-20120327-31] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Spontaneous simultaneous bilateral quadriceps tendon rupture is associated with multiple medical conditions and pharmacological treatments; however, identifying prior risk factors is impossible in most cases. Achilles tendon and anterior cruciate ligament ruptures are associated with collagen, type V, alpha 1 (COL5A1) polymorphism. This genetic variant may be implicated quadriceps tendon rupture. The COL5A1 encodes the protein for pro-α1 chains of the low-abundance heterotrimeric type V collagen. In most noncartilaginous tissues, type V collagen is a quantitatively minor component of type I collagen that has been implicated in the regulation of the size and configuration of type I collagen fibrils. The functional significance of COL5A1 polymorphism in relation to type V collagen expression or activity has not been determined.This article describes a patient with COL5A1 polymorphism and spontaneous simultaneous quadriceps tendon rupture. However, genetic and histologic studies performed on blood and tendon tissues and 3 consecutive sex- and age-matched controls showed a statistically significant reduction in collagen type V expression and an alteration in collagen structure in the tendon. These findings might explain the pathomechanisms of spontaneous tendon ruptures associated with COL5A1 polymorphism.
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Affiliation(s)
- Olimpio Galasso
- Department of Orthopaedic and Trauma Surgery, University Magna Græcia of Catanzaro, School of Medicine, Catanzaro, Italy.
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Abstract
Young patients with degenerative shoulder disease are a therapeutic challenge. To try to delay a shoulder arthroplasty, biological interpositional arthroplasty has been proposed to provide a biologically active bearing surface that could eventually results in the formation of fibrocartilage, fibrous tissue, or hyaline cartilage. Anterior capsule, autogenous fascia lata, Achilles tendon allograft, lateral meniscus allograft, human dermis, and porcine small intestine submucosa have been used as interposition material, either alone or in combination with a hemiarthroplasty or humeral resurfacing procedure. Some investigators have reported favorable long-term results, although others have found this procedure unreliable. Several variables are unknown at present, such as the best biological resurfacing device, healing potential, possible antigenic responses, optimal fixation technique or position, aftercare restrictions. Further prospective studies with long follow-up are necessary to provide data that will help to define the role of biological glenoid resurfacing in young patients with glenohumeral arthritis.
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Animal models for translational research on shoulder pathologies: from bench to bedside. Sports Med Arthrosc Rev 2011; 19:184-93. [PMID: 21822100 DOI: 10.1097/jsa.0b013e318205470e] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Several animal models have been used for in vivo and in vitro shoulder research. In vitro models, consisting of cadaveric specimens, are useful in providing basic understanding of the functioning of the shoulder and for biomechanical experiments. In vivo models provide the means to model living phenomena, such as tendon healing process, tendinopathy, instability, and adaptive responses to surgery. However, intrinsic differences among different species make translation to human shoulder pathologies difficult. Most of the animals used in experimental settings are quadrupeds, using the forelimbs for weight-bearing during locomotion, with no or minimal overhead activity. The various animal models already used to study shoulder pathologies are presented in this article. However, there is a lack of validation for these animal models, which provides challenge to the further research in this field.
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Abstract
The pathogenesis of rotator cuff tears is multifactorial. Tendon abnormalities of the rotator cuff include alteration of collagen fiber structure, tenocytes, cellularity, and vascularity. Ruptured tendons show marked collagen degeneration and disordered arrangement of collagen fibers. Fibroblast population decreases as the size of the tear in the rotator cuff increases. The larger fibroblast population seen in the smaller tears is also actively proliferating and is part of an active reparative process. Inflammatory cell infiltrate correlates inversely to rotator cuff tear size in the torn supraspinatus tendon samples, with larger tears showing a marked reduction in all cell types. As tear size increase, there is also a progressive decrease in the number of blood vessels. Whether rotator cuff tear heals spontaneously is an important pathologic and clinical question. Histologic changes indicative of repair and inflammation lead to consider biological options in addition to biomechanical treatment of the rotator cuff tears.
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Abstract
Rotator cuff tears are common, and lead to shoulder pain and functional impairment. Despite their frequency and related disability, etiology and pathogenesis are still debated. Multiple factors contribute to tears of the rotator cuff. Extrinsic factors are anatomic variables, such as acromial morphologic characteristics, os acromiale, and acromial spurs that compress the rotator cuff by bony impingement or direct pressure from the surrounding soft tissue. Intrinsic factors arise from the tendon itself, because of tensile overload, aging, microvascular supply, traumatisms, or degeneration. Little information is available from a cellular and molecular point of view. We reviewed the biological factors involved in the pathogenesis of rotator cuff tears. Understanding the mechanism of rotator cuff pathology would facilitate the rationale for therapeutic interventions, by guiding the design, selection, and implementation of treatment strategies such as biologic modulation and preventive measures.
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Biological strategies to enhance healing of the avascular area of the meniscus. Stem Cells Int 2011; 2012:528359. [PMID: 22220179 PMCID: PMC3246301 DOI: 10.1155/2012/528359] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 11/01/2011] [Indexed: 12/15/2022] Open
Abstract
Meniscal injuries in the vascularized peripheral part of the meniscus have a better healing potential than tears in the central avascular zone because meniscal healing principally depends on its vascular supply. Several biological strategies have been proposed to enhance healing of the avascular area of the meniscus: abrasion therapy, fibrin clot, organ culture, cell therapy, and applications of growth factors. However, data are too heterogeneous to achieve definitive conclusions on the use of these techniques for routine management of meniscal lesions. Although most preclinical and clinical studies are very promising, they are still at an experimental stage. More prospective randomised controlled trials are needed to compare the different techniques for clinical results, applicability, and cost-effectiveness.
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Scaffolds in tendon tissue engineering. Stem Cells Int 2011; 2012:517165. [PMID: 22190961 PMCID: PMC3236365 DOI: 10.1155/2012/517165] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 10/18/2011] [Indexed: 02/06/2023] Open
Abstract
Tissue engineering techniques using novel scaffold materials offer potential alternatives for managing tendon disorders. Tissue engineering strategies to improve tendon repair healing include the use of scaffolds, growth factors, cell seeding, or a combination of these approaches. Scaffolds have been the most common strategy investigated to date. Available scaffolds for tendon repair include both biological scaffolds, obtained from mammalian tissues, and synthetic scaffolds, manufactured from chemical compounds. Preliminary studies support the idea that scaffolds can provide an alternative for tendon augmentation with an enormous therapeutic potential. However, available data are lacking to allow definitive conclusion on the use of scaffolds for tendon augmentation. We review the current basic science and clinical understanding in the field of scaffolds and tissue engineering for tendon repair.
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Longo UG, Loppini M, Berton A, Spiezia F, Maffulli N, Denaro V. Tissue engineered strategies for skeletal muscle injury. Stem Cells Int 2011; 2012:175038. [PMID: 25098362 PMCID: PMC3216349 DOI: 10.1155/2012/175038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 09/15/2011] [Indexed: 12/13/2022] Open
Abstract
Skeletal muscle injuries are common in athletes, occurring with direct and indirect mechanisms and marked residual effects, such as severe long-term pain and physical disability. Current therapy consists of conservative management including RICE protocol (rest, ice, compression and elevation), nonsteroidal anti-inflammatory drugs, and intramuscular corticosteroids. However, current management of muscle injuries often does not provide optimal restoration to preinjury status. New biological therapies, such as injection of platelet-rich plasma and stem-cell-based therapy, are appealing. Although some studies support PRP application in muscle-injury management, reasons for concern persist, and further research is required for a standardized and safe use of PRP in clinical practice. The role of stem cells needs to be confirmed, as studies are still limited and inconsistent. Further research is needed to identify mechanisms involved in muscle regeneration and in survival, proliferation, and differentiation of stem cells.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, Trigoria, 00128 Rome, Italy
- Centro Integrato di Ricerca (CIR) Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - Mattia Loppini
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, Trigoria, 00128 Rome, Italy
- Centro Integrato di Ricerca (CIR) Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - Alessandra Berton
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, Trigoria, 00128 Rome, Italy
- Centro Integrato di Ricerca (CIR) Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - Filippo Spiezia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, Trigoria, 00128 Rome, Italy
- Centro Integrato di Ricerca (CIR) Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128, Rome, Italy
| | - Nicola Maffulli
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, Trigoria, 00128 Rome, Italy
- Centro Integrato di Ricerca (CIR) Campus Bio-Medico University, Via Alvaro del Portillo 21, 00128, Rome, Italy
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Longo UG, Petrillo S, Franceschetti E, Maffulli N, Denaro V. Growth factors and anticatabolic substances for prevention and management of intervertebral disc degeneration. Stem Cells Int 2011; 2012:897183. [PMID: 25098367 PMCID: PMC3216373 DOI: 10.1155/2012/897183] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 09/12/2011] [Indexed: 12/17/2022] Open
Abstract
Intervertebral disc (IVD) degeneration is frequent, appearing from the second decade of life and progressing with age. Conservative management often fails, and patients with IVD degeneration may need surgical intervention. Several treatment strategies have been proposed, although only surgical discectomy and arthrodesis have been proved to be predictably effective. Biological strategies aim to prevent and manage IVD degeneration, improving the function and anabolic and reparative capabilities of the nucleus pulposus and annulus fibrosus cells and inhibiting matrix degradation. At present, clinical applications are still in their infancy. Further studies are required to clarify the role of growth factors and anticatabolic substances for prevention and management of intervertebral disc degeneration.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico, University of Rome, Via Álvaro del Portillo 200, 00128 Rome, Italy
- Centro Integrato di Ricerca (CIR), Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Stefano Petrillo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico, University of Rome, Via Álvaro del Portillo 200, 00128 Rome, Italy
- Centro Integrato di Ricerca (CIR), Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Edoardo Franceschetti
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico, University of Rome, Via Álvaro del Portillo 200, 00128 Rome, Italy
- Centro Integrato di Ricerca (CIR), Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Nicola Maffulli
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico, University of Rome, Via Álvaro del Portillo 200, 00128 Rome, Italy
- Centro Integrato di Ricerca (CIR), Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128 Rome, Italy
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Advances in meniscal tissue engineering. Stem Cells Int 2011; 2012:420346. [PMID: 25098366 PMCID: PMC3205710 DOI: 10.1155/2012/420346] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 08/26/2011] [Indexed: 01/08/2023] Open
Abstract
Meniscal tears are the most common knee injuries and have a poor ability of healing. In the last few decades, several techniques have been increasingly used to optimize meniscal healing. Current research efforts of tissue engineering try to combine cell-based therapy, growth factors, gene therapy, and reabsorbable scaffolds to promote healing of meniscal defects. Preliminary studies did not allow to draw definitive conclusions on the use of these techniques for routine management of meniscal lesions. We performed a review of the available literature on current techniques of tissue engineering for the management of meniscal tears.
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Bilateral consecutive rupture of the quadriceps tendon in a man with BstUI polymorphism of the COL5A1 gene. Knee Surg Sports Traumatol Arthrosc 2011; 19:1403; author reply 1404-5. [PMID: 21328072 DOI: 10.1007/s00167-011-1408-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 01/17/2011] [Indexed: 10/18/2022]
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Marked pathological changes proximal and distal to the site of rupture in acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2011; 19:680-7. [PMID: 20563556 DOI: 10.1007/s00167-010-1193-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2009] [Accepted: 05/31/2010] [Indexed: 12/16/2022]
Abstract
A laboratory study was performed to evaluate the histopathological features of the macroscopically intact portion of the Achilles tendon in patients undergoing surgery for an acute rupture of the Achilles tendon. Tendon samples were harvested from 29 individuals (21 men, 8 women; mean age: 46 ± 12) who underwent repair of an Achilles tendon tear tear, and from 11 male patients who died of cardiovascular events (mean age: 61). Three pieces of tendon were harvested: at the rupture site, 4 cm proximal to the site of rupture, 1 cm proximal to the insertion of the Achilles tendon on the calcaneum. Slides were assessed using a semiquantitative grading scale assessing fiber structure and arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, and hyalinization. Intra-observer reliability of the subscore readings was calculated. The pathological features were significantly more pronounced in the samples taken from the site of rupture than in the samples taken proximally and distal to it (0.008 < P < 0.01). There were no significant differences in the mean pathologic sum-scores in the samples taken proximally and distal to the site of rupture. Unruptured Achilles tendons, even at an advanced age, and ruptured Achilles tendons are clearly part of two distinct populations, with the latter demonstrating histopathological evidence of failed healing response even in areas macroscopically normal.
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Longo UG, Rittweger J, Garau G, Radonic B, Gutwasser C, Gilliver SF, Kusy K, Zieliński J, Felsenberg D, Maffulli N. Patellar tendinopathy in master track and field athletes: influence of impact profile, weight, height, age and gender. Knee Surg Sports Traumatol Arthrosc 2011; 19:508-12. [PMID: 21057939 DOI: 10.1007/s00167-010-1314-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 10/21/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE Patellar tendinopathy causes significant morbidity in professional and recreational athletes. Despite the relevance of the problem, its causative factors remain poorly understood. The purpose of this cross-sectional study is to evaluate the influence of age, gender, weight, height and impact profile on developing patellar tendinopathy in master track and field athletes. METHODS During the European Veterans Athletics Championships in Poznań in July 2006, 174 athletes (103 men and 71 women; mean age: 53.8 (SD 11.4) years, range 35-82 years) were evaluated with the VISA-P questionnaire. A fully trained orthopaedic surgeon made a diagnosis of patellar tendinopathy according to clinical criteria. RESULTS There was no effect of gender upon the presence of patellar tendinopathy (n.s.). No significant track and field specialty effect upon the frequency of patellar tendinopathy was found on the VISA-P questionnaire scores. There was no effect of track and field specialty on the VISA-P score. No evidence of a statistically significant association was found between age and VISA-P score (n.s.). There was no statistically significant difference in either prevalence of patellar tendinopathy or VISA-P score between high-impact and low-impact athletes (n.s.). CONCLUSION In master track and field athletes, impact profile, weight, height, age and gender did not exert any influence on developing patellar tendinopathy.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Longoni, 83, 00155, Rome, Italy
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Maffulli N, Longo UG, Loppini M, Denaro V. Current treatment options for tendinopathy. Expert Opin Pharmacother 2011; 11:2177-86. [PMID: 20569088 DOI: 10.1517/14656566.2010.495715] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Tendon disorders are frequent and are responsible for much morbidity, both in sport and the workplace. Although several therapeutic options are routinely used, very few well-conducted randomised prospective, placebo, controlled trials have been performed to assist in choosing the best evidence-based management. AREAS COVERED IN THIS REVIEW We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases over the years 1966 - 2010 to review the best evidence-based options for the management of patients with tendinopathy. WHAT THE READER WILL GAIN The reader will obtain information on the available medical and surgical therapies used to manage tendinopathy-related symptoms. The effectiveness of therapies, the length of management and the adverse effects are examined. TAKE-HOME MESSAGE Management of tendinopathy is often anecdotic and lacking well-researched scientific evidence. Teaching patients to control the symptoms may be more beneficial than leading them to believe that tendinopathy is fully curable.
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Affiliation(s)
- Nicola Maffulli
- Queen Mary University of London, Mile End Hospital, Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, 275 Bancroft Road, London E1 4 DG, UK.
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Longo UG, Lamberti A, Maffulli N, Denaro V. Tissue engineered biological augmentation for tendon healing: a systematic review. Br Med Bull 2011; 98:31-59. [PMID: 20851817 DOI: 10.1093/bmb/ldq030] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Tendon injuries give rise to significant morbidity. In the last few decades, several techniques have been increasingly used to optimize tendon healing. SOURCES OF DATA We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of the commercial names of each scaffold and the keywords 'tendon', 'rotator cuff', 'supraspinatus tendon', 'Achilles tendon', 'growth factors', 'cytokines', 'gene therapy', 'tissue engineering', 'mesenchymal' and 'stem cells' over the years 1966-2009. All articles relevant to the subject were retrieved, and their bibliographies were hand searched for further references in the context to tissue-engineered biological augmentation for tendon healing. AREAS OF AGREEMENT Several new techniques are available for tissue-engineered biological augmentation for tendon healing, growth factors, gene therapy and mesenchimal stem cells. AREAS OF CONTROVERSY Data are lacking to allow definitive conclusions on the use of these techniques for routine management of tendon ailments. GROWING POINTS The emerging field of tissue engineering holds the promise to use new techniques for tendon augmentation and repair. Preliminary studies support the idea that these techniques can provide an alternative for tendon augmentation with great therapeutic potential. AREAS TIMELY FOR DEVELOPING RESEARCH The optimization strategies discussed in this article are currently at an early stage of development. Although these emerging technologies may develop into substantial clinical treatment options, their full impact needs to be critically evaluated in a scientific fashion.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Biomedico University, Trigoria, Rome, Italy
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Abstract
Injuries can counter the beneficial aspects related to sports activities if an athlete is unable to continue to participate because of residual effects of injury. We provide an updated synthesis of existing clinical evidence of long-term follow-up outcome of sports injuries. A systematic computerized literature search was conducted on following databases were accessed: PubMed, Medline, Cochrane, CINAHL and Embase databases. At a young age, injury to the physis can result in limb deformities and leg-length discrepancy. Weight-bearing joints including the hip, knee and ankle are at risk of developing osteoarthritis (OA) in former athletes, after injury or in the presence of malalignment, especially in association with high impact sport. Knee injury is a risk factor for OA. Ankle ligament injuries in athletes result in incomplete recovery (up to 40% at 6 months), and OA in the long term (latency period more than 25 years). Spine pathologies are associated more commonly with certain sports (e.g. wrestling, heavy-weight lifting, gymnastics, tennis, soccer). Evolution in arthroscopy allows more accurate assessment of hip, ankle, shoulder, elbow and wrist intra-articular post-traumatic pathologies, and possibly more successful management. Few well-conducted studies are available to establish the long-term follow-up of former athletes. To assess whether benefits from sports participation outweigh the risks, future research should involve questionnaires regarding the health-related quality of life in former athletes, to be compared with the general population.
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Affiliation(s)
- Nicola Maffulli
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, UK.
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Posthumus M, September A, Schwellnus MP, Collins M. Identification of genetic risk factors underlying complex multifactorial phenotypes. Knee Surg Sports Traumatol Arthrosc 2010; 18:1810-1; author reply 812-3. [PMID: 20872134 DOI: 10.1007/s00167-010-1275-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Accepted: 04/01/2010] [Indexed: 11/26/2022]
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Maffulli N, Longo UG, Loppini M, Spiezia F, Denaro V. New options in the management of tendinopathy. Open Access J Sports Med 2010; 1:29-37. [PMID: 24198540 PMCID: PMC3781852 DOI: 10.2147/oajsm.s7751] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Tendon injuries can be acute or chronic, and caused by intrinsic or extrinsic factors, either alone or in combination. Tendinopathies are a common cause of disability in occupational medicine and account for a substantial proportion of overuse injuries in sports. Tendinopathy is essentially a failed healing response, with haphazard proliferation of tenocytes, abnormalities in tenocytes, with disruption of collagen fibres and subsequent increase in noncollagenous matrix. The scientific evidence base for managing tendinopathies is limited. What may appear clinically as an "acute tendinopathy" is actually a well advanced failure of a chronic healing response in which there is neither histologic nor biochemical evidence of inflammation. In this review we report the new options for the management of tendinopathy, including eccentric exercises, extracorporeal shockwave therapy, injections (intratendinous injections of corticosteroids, aprotinin, polidocanol platelet-rich plasma, autologous blood injection, high-volume injections) and surgery. Open surgery aims to excise fibrotic adhesions, remove areas of failed healing and make multiple longitudinal incisions in the tendon to detect intratendinous lesions, and to restore vascularity and possibly stimulate the remaining viable cells to initiate cell matrix response and healing. New surgical techniques aim to disrupt the abnormal neoinnervation to interfere with the pain sensation caused by tendinopathy. These procedures are intrinsically different from the classical ones in present use, because they do not attempt to address directly the pathologic lesion, but act only to denervate them. They include endoscopy, electrocoagulation, and minimally invasive stripping. Further randomized controlled trials are necessary to clarify better the best therapeutic options for the management of tendinopathy.
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Affiliation(s)
- Nicola Maffulli
- Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Mile end Hospital, London, England
| | - Umile Giuseppe Longo
- Department of Orthopedic and Trauma Surgery, Campus Biomedico University, Rome, Italy
| | - Mattia Loppini
- Department of Orthopedic and Trauma Surgery, Campus Biomedico University, Rome, Italy
| | - Filippo Spiezia
- Department of Orthopedic and Trauma Surgery, Campus Biomedico University, Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopedic and Trauma Surgery, Campus Biomedico University, Rome, Italy
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