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Soler R, Rodas G, Rius-Tarruella J, Alomar X, Balius R, Ruíz-Cotorro Á, Masci L, Maffulli N, Orozco L. Safety and Efficacy of Bone Marrow-Derived Mesenchymal Stem Cells for Chronic Patellar Tendinopathy (With Gap >3 mm) in Patients: 12-Month Follow-up Results of a Phase 1/2 Clinical Trial. Orthop J Sports Med 2023; 11:23259671231184400. [PMID: 37711505 PMCID: PMC10498712 DOI: 10.1177/23259671231184400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/05/2023] [Indexed: 09/16/2023] Open
Abstract
Background In a previous study, the authors found that at 6 months after treatment with a 20 × 106 dose of bone marrow-derived mesenchymal stem cells (BM-MSCs), patients showed improved tendon structure and regeneration of the gap area when compared with treatment using leukocyte-poor platelet-rich plasma (Lp-PRP). The Lp-PRP group (n = 10), which had not seen tendon regeneration at the 6-month follow-up, was subsequently offered treatment with BM-MSCs to see if structural changes would occur. In addition, the 12-month follow-up outcomes of the original BM-MSC group (n = 10) were evaluated. Purpose To evaluate the outcomes of all patients (n = 20) at 12 months after BM-MSC treatment and observe if the Lp-PRP pretreated group experienced any type of advantage. Study Design Cohort study; Level of evidence, 2. Methods Both the BM-MSC and original Lp-PRP groups were assessed at 12 months after BM-MSC treatment with clinical examination, the visual analog scale (VAS) for pain during daily activities and sports activities, the Victorian Institute of Sport Assessment-Patella score for patellar tendinopathy, dynamometry, and magnetic resonance imaging (MRI). Differences between the 2 groups were compared with the Student t test. Results The 10 patients originally treated with BM-MSCs continued to show improvement in tendon structure in their MRI scans (P < .0001), as well as in the clinical assessment of their pain by means of scales (P < .05). Ten patients who were originally treated with Lp-PRP and then with BM-MSCs exhibited an improvement in tendon structure in their MRI scans, as well as a clinical pain improvement, but this was not significant on the VAS for sports (P = .139). Thus, applying Lp-PRP before BM-MScs did not yield any type of advantage. Conclusion The 12-month follow-up outcomes after both groups of patients (n = 20) received BM-MSC treatment indicated that biological treatment was safe, there were no adverse effects, and the participants showed a highly statistically significant clinical improvement (P < .0002), as well as an improvement in tendon structure on MRI (P < .0001). Preinjection of Lp-PRP yielded no advantages.
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Affiliation(s)
- Robert Soler
- Institut de Teràpia Regenerativa Tissular (ITRT), Centro Médico Teknon Hospital, Barcelona, Spain
| | - Gil Rodas
- Medical Department FC Barcelona, Barcelona, Spain
- Sports Medicine Unit, Clínic Hospital and Sant Joan de Déu Hospital, Barcelona, Spain
| | - Joan Rius-Tarruella
- Institut de Teràpia Regenerativa Tissular (ITRT), Centro Médico Teknon Hospital, Barcelona, Spain
| | - Xavier Alomar
- Diagnóstico por la Imagen, Clínica Creu Blanca, Barcelona, Spain
| | - Ramon Balius
- Consell Català de l’Esport, Generalitat de Catalunya, Barcelona, Spain
| | - Ángel Ruíz-Cotorro
- Servicios Médicos de la Real Federación Española de Tenis (RFET), Barcelona, Spain
- Director de la Clínica Tenis Teknon, Centro Médico Teknon, Barcelona, Spain
| | - Lorenzo Masci
- Institute of Sports Exercise and Health (ISEH), London, UK
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine, Surgery and Dentistry, Salerno, Italy
- Center of Sports and Exercise Medicine, Queen Mary University of London, London, UK
- School of Pharmacy and Bioengineering, Keele University School of Medicine, Staffordshire, UK
| | - Lluís Orozco
- Institut de Teràpia Regenerativa Tissular (ITRT), Centro Médico Teknon Hospital, Barcelona, Spain
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Tarantino D, Mottola R, Resta G, Gnasso R, Palermi S, Corrado B, Sirico F, Ruosi C, Aicale R. Achilles Tendinopathy Pathogenesis and Management: A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6681. [PMID: 37681821 PMCID: PMC10487940 DOI: 10.3390/ijerph20176681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/09/2023] [Accepted: 08/25/2023] [Indexed: 09/09/2023]
Abstract
The Achilles tendon is the thickest and strongest tendon of the human body, and it is frequently injured during sports activity. The incidence of Achilles tendon pathologies has increased over recent decades, especially in the last few years, because of increased sports participation among the general population and due to the diffusion of competitive sports at a high level. Tendinopathies are common in athletes and in middle-aged overweight patients. The term "tendinopathy" refers to a condition characterised clinically by pain and swelling, with functional limitations of tendon and nearby structures, and consequently to chronic failure of healing response process. Tendinopathies can produce marked morbidity, and at present, scientifically validated management modalities are limited. Despite the constantly increasing interest and number of studies about Achilles tendinopathy (AT), there is still not a consensual point of view on which is the best treatment, and its management is still controversial. AT can be treated conservatively primarily, with acceptable results and clinical outcomes. When this approach fails, surgery should be considered. Several surgical procedures have been described for both conditions with a relatively high rate of success with few complications and the decision for treatment in patients with AT should be tailored on patient's needs and level of activity. The aim of this article is to give insights about the pathogenesis and most used and recent treatment options for AT.
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Affiliation(s)
- Domiziano Tarantino
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Rosita Mottola
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Giuseppina Resta
- Department of Orthopaedic and Trauma Surgery, Casa di Cura di Bernardini, 74121 Taranto, Italy;
| | - Rossana Gnasso
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Stefano Palermi
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Bruno Corrado
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Felice Sirico
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Carlo Ruosi
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (R.M.); (R.G.); (S.P.); (B.C.); (F.S.); (C.R.)
| | - Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy;
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Aletto C, Aicale R, Oliva F, Maffulli N. Hand Flexor Tendon Repair: From Biology to Surgery and Rehabilitation. Hand Clin 2023; 39:215-225. [PMID: 37080653 DOI: 10.1016/j.hcl.2022.12.001] [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] [Indexed: 04/22/2023]
Abstract
Tendon biology and anatomy are crucial to manage hand flexor tendon injuries, not only for surgical treatment but also for rehabilitation; surgeon and physical therapist have to choose zone by zone the best way to manage and restore the normal function of hand flexor tendons.
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Affiliation(s)
- Cristian Aletto
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi 84084, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno 84131, Italy.
| | - Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi 84084, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno 84131, Italy
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi 84084, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno 84131, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Baronissi 84084, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Salerno 84131, Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England; Keele University, Faculty of Medicine, School of Pharmacy and Bioengineering, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, UK
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Why Use Adipose-Derived Mesenchymal Stem Cells in Tendinopathic Patients: A Systematic Review. Pharmaceutics 2022; 14:pharmaceutics14061151. [PMID: 35745724 PMCID: PMC9230128 DOI: 10.3390/pharmaceutics14061151] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/18/2022] [Accepted: 05/26/2022] [Indexed: 01/27/2023] Open
Abstract
The aim of the present systematic review was to provide a clear overview of the clinical current research progress in the use of adipose-derived mesenchymal stem cells (ASCs) as an effective therapeutic option for the management of tendinopathies, pathologies clinically characterized by persistent mechanical pain and structural alteration of the tendons. The review was carried out using three databases (Scopus, ISI Web of Science and PubMed) and analyzed records from 2013 to 2021. Only English-language papers describing the isolation and manipulation of adipose tissue as source of ASCs and presenting ASCs as treatment for clinical tendinopathies were included. Overall, seven clinical studies met the inclusion criteria and met the minimum quality inclusion threshold. Data extraction and quality assessment were performed by groups of three reviewers. The available evidence showed the efficacy and safety of ASCs treatment for tendinopathies, although it lacked a clear description of the biomolecular mechanisms underlying the beneficial properties of ASCs.
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Maffulli N, Oliva F, Maffulli GD, Migliorini F. Failed Surgery for Patellar Tendinopathy in Athletes: Midterm Results of Further Surgical Management. Orthop J Sports Med 2021; 9:2325967121994550. [PMID: 33855096 PMCID: PMC8013696 DOI: 10.1177/2325967121994550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 11/19/2020] [Indexed: 11/22/2022] Open
Abstract
Background: Tendon injuries are commonly seen in sports medicine practice. Many elite players involved in high-impact activities develop patellar tendinopathy (PT) symptoms. Of them, a small percentage will develop refractory PT and need to undergo surgery. In some of these patients, surgery does not resolve these symptoms. Purpose: To report the clinical results in a cohort of athletes who underwent further surgery after failure of primary surgery for PT. Study Design: Case series; Level of evidence, 4. Methods: A total of 22 athletes who had undergone revision surgery for failed surgical management of PT were enrolled in the present study. Symptom severity was assessed through the Victorian Institute of Sport Assessment Scale for Patellar Tendinopathy (VISA-P) upon admission and at the final follow-up. Time to return to training, time to return to competition, and complications were also recorded. Results: The mean age of the athletes was 25.4 years, and the mean symptom duration from the index intervention was 15.3 months. At a mean follow-up of 30.0 ± 4.9 months, the VISA-P score improved 27.8 points (P < .0001). The patients returned to training within a mean of 9.2 months. Fifteen patients (68.2%) returned to competition within a mean of 11.6 months. Of these 15 patients, a further 2 had decreased their performance, and 2 more had abandoned sports participation by the final follow-up. The overall rate of complications was 18.2%. One patient (4.5%) had a further revision procedure. Conclusion: Revision surgery was feasible and effective in patients in whom PT symptoms persisted after previous surgery for PT, achieving a statistically significant and clinically relevant improvement of the VISA-P score as well as an acceptable rate of return to sport at a follow-up of 30 months.
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Affiliation(s)
- Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy
- Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, UK
- School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke on Trent, UK
- Nicola Maffulli, MD, MS, PhD, Department of Musculoskeletal Disorders, Faculty of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi (SA), Italy ()
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy
| | | | - Filippo Migliorini
- Department of Orthopaedics, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
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Percutaneous ultrasonic tenotomy effectively debrides tendons of the extensor mechanism of the knee: A technical note. Knee 2020; 27:649-655. [PMID: 32563419 DOI: 10.1016/j.knee.2020.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 03/12/2020] [Accepted: 04/10/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Percutaneous ultrasonic tenotomy (PUT) is a minimally-invasive method of treating patellar tendinosis, but its immediate effect on tendon structure has never been studied. Given the crucial nature of the extensor mechanism of the knee, it is important to understand the procedure's effect on tendon structure prior to clinical implementation. The aim of this study was to analyze the tendon structure of the extensor mechanism of the knee after PUT in a cadaveric model. METHODS Four fresh-frozen cadaveric specimens (two patellar and two quadriceps tendons) underwent PUT. The tendons were then sectioned and stained with hematoxilin & eosin (H&E). The sections were analyzed for a clear area of debridement. The area of debridement was calculated as an average of three measurements. RESULTS All four tendons demonstrated a clear area of debridement limited to the treatment area without damaging any surrounding tissue. The area of debridement for the patellar and quadriceps tendons treated was 2.89 mm2, 1.5 mm2, 2.98 mm2 and 7.29 mm2, respectively. CONCLUSIONS Percutaneous ultrasonic tenotomy effectively debrided the treatment area in all tendons without damaging surrounding tissue. Further work is needed to report clinical outcomes, assess the risk of post-procedure tendon rupture and define return-to-sport progression.
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Steinmann S, Pfeifer CG, Brochhausen C, Docheva D. Spectrum of Tendon Pathologies: Triggers, Trails and End-State. Int J Mol Sci 2020; 21:ijms21030844. [PMID: 32013018 PMCID: PMC7037288 DOI: 10.3390/ijms21030844] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/18/2020] [Accepted: 01/24/2020] [Indexed: 12/31/2022] Open
Abstract
The biggest compartment of the musculoskeletal system is the tendons and ligaments. In particular, tendons are dense tissues connecting muscle to bone that are critical for the integrity, function and locomotion of this system. Due to the increasing age of our society and the overall rise in engagement in extreme and overuse sports, there is a growing prevalence of tendinopathies. Despite the recent advances in tendon research and due to difficult early diagnosis, a multitude of risk factors and vague understanding of the underlying biological mechanisms involved in the progression of tendon injuries, the toolbox of treatment strategies remains limited and non-satisfactory. This review is designed to summarize the current knowledge of triggers, trails and end state of tendinopathies.
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Affiliation(s)
- Sara Steinmann
- Experimental Trauma Surgery, Department of Trauma Surgery, University Medical Center Regensburg, Am Biopark 9, 93053 Regensburg, Germany; (S.S.); (C.G.P.)
| | - Christian G. Pfeifer
- Experimental Trauma Surgery, Department of Trauma Surgery, University Medical Center Regensburg, Am Biopark 9, 93053 Regensburg, Germany; (S.S.); (C.G.P.)
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Christoph Brochhausen
- Institute of Pathology, University Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany;
| | - Denitsa Docheva
- Experimental Trauma Surgery, Department of Trauma Surgery, University Medical Center Regensburg, Am Biopark 9, 93053 Regensburg, Germany; (S.S.); (C.G.P.)
- Department of Medical Biology, Medical University-Plovdiv, 15A Vassil Aprilov Blvd., 4002 Plovdiv, Bulgaria
- Correspondence: ; Tel.: +49 941 943-1605
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Kaplan K, Olivencia O, Dreger M, Hanney WJ, Kolber MJ. Achilles Tendinopathy: An Evidence-Based Overview for the Sports Medicine Professional. Strength Cond J 2019. [DOI: 10.1519/ssc.0000000000000485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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