Efficacia del trattamento con concentrati piastrinici (P.R.P.) nelle lesioni condrali e tendinopatie

Purpose: Recent knowledge regarding tissue biology highlights a complex regulation of growth factors in reaction to tissue damage. Platelet Rich Plasma (P.R.P.), containing a natural pool of growth factors, can be obtained in a simple and minimally invasive way and be applied to the lesion site. The aim of this study is to explore this novel approach to treat cartilage degenerative lesions of the knee and tendon chronic lesions( patellar tendon, and achilles tendon). In this study we evaluated if the treatment with PRP injections can reduce pain and increase function in cases of patellar tendinosis (Jumper’s Knee), in chronic achilles tendinopathy and in patients with cartilage injuries of the knee. Materials and Methods: 40 patients with cartilage lesion of the knee, 28 male and 12 female with mean age 47 y. (min 18- max 52 years), were treated and prospectively evaluated at a minimum 6 months follow-up; in the same way, 12 patients with achilles tendon lesion (8 male and 4 female) with mean age 44,5 y. (min 32-max 58 years) and 10 patients with “Jumper’s Knee” (8 male and 2 female) with mean age 23,2 y. (min 18-max 37 years), were evaluated at 6 months follow up. The procedure involved 3 multiple injections , performed every two weeks. All patients were clinically evaluated at the end of the treatment and at 6 months follow up. IKDC, SF36, EQ-VAS, scores were used for clinical evaluation and patient satisfaction and functional status were also recorded. Results: Statistical analysis showed a significant improvement in the SF36 questionnaire in all parameters evaluated at the end of the therapy and 6 months follow-up in both group(tendinopathies and chondral lesions), and in the EQ VAS and IKDC score (paired T-test, p<0.0005) from basal evaluation to the end of the therapy, and a further improvement was present at 6 months follow-up. Whereas a higher improvement of the sport activity level was achieved in the “Jumper’s Knee” group. No complications related to the injections or severe adverse events were observed during the treatment and follow up period. Conclusion: PRP inhibits excess inflammation, apoptosis, and metalloproteinase activity. These interactive pathways may result in the restoration of tendon or cartilage, which can with stand loading with work or sports activity, thereby diminishing pain. PRP may also modulate the microvascular environment or alter efferent or afferent neural receptors. The clinical results are encouraging, indicating that PRP injections may have the potential to increase the tendon and cartilage healing capacity in cases with chronic tendinosis and chondropathy of the knee.

Identifizierung und Charakterisierung glialer Gene im embryonalen zentralen Nervensystem von Drosophila melanogaster

Im embryonalen Nervensystem von Drosophila wird gliales Schicksal durch den Transkriptionsfaktor gcm induziert. Es konnte gezeigt werden, daß die ektopische Expression von gcm im Nervensystem einen Überschuß an Gliazellen generiert, während Funktionsverlustmutanten von gcm nahezu keine Gliazellen mehr besitzen. Im Gegensatz zu der beschriebenen Funktion von gcm als binäres Schaltergen zwischen neuronalem und glialem Schicksal, gibt es nur wenig Hinweise auf Mechanismen zur weiteren Spezifizierung und Differenzierung der verschiedenen glialen Subtypen und den daran beteiligten Genen. Die vorliegende Arbeit beschreibt die auf Microarray-Experimenten basierende Genom-weite Suche nach neuen gcm-abhängigen glialen Genen. Diese Analyse vergleicht die ektopische Expression von gcm im gesamten Nervensystem und zum ersten Mal die gcm Funktionsverlustmutante mit dem Wildtyp. Beide Ansätze wurden als Zeitverlaufsexperimente durchgeführt, die den Zeitraum der Gliogenese in Drosophila umfassen. Im Vorfeld durchgeführte Kontrollexperimente ermöglichten die Bestimmung des methodischen und genetischen Hintergrundrauschens, die eine Reduktion von "falsch positiven" Genen ermöglichte und die Sensitivität der Microarray-Auswertung erhöhte. Durch manuelle Filterschritte wurde der Schwerpunkt der Daten-Interpretation eher auf biologische Aspekte als auf eine rein statistische Auswertung gelegt und dies brachte deutlich Vorteile in der Auswahl der potentiellen Zielgene. Insbesondere die Analyse der temporalen Expressionsprofile, der Vergleich der antagonistischen Ansätze sowie eine ausführliche Recherche der vorhandenen Datenbanken im Hinblick auf bekannte Expression und Funktion der differentiell regulierten Gene, ermöglichten die Identifizierung von etwa 400 potentiellen Zielgenen. Für mehr als 30% dieser Gene konnte Expression in den gcm-abhängigen Gliazellen, hämatopoetischen Zellen oder den "tendon cells" nachgewiesen werden. Hierunter befinden sich mehr als 50 Gene, deren Abhängigkeit von gcm bisher nicht bekannt war. Eine zelluläre Analyse ausgewählter Kandidatengene auf Einzelzellebene, ihre Abhängigkeit von gcm sowie eine regulatorische Analyse in verschiedenen mutanten Hintergründen bekannter glialer Gene, geben Einblick in die verschiedenen Mechanismen glialer Regulation. An einigen Beispielen wird eine mögliche Funktion der aus dieser Analyse hervorgegangen Gene in den bekannten Kontext glialer Differenzierung und Funktion für Drosophila diskutiert.

Neuronal differentiation and epithelial integrity: the role of Drosophila Short stop

The nervous system is the most complex organ in animals and the ordered interconnection of neurons is an essential prerequisite for normal behaviour. Neuronal connectivity requires controlled neuronal growth and differentiation. Neuronal growth essentially depends on the actin and microtubule cytoskeleton, and it has become increasingly clear, that crosslinking of these cytoskeletal fractions is a crucial regulatory process. The Drosophila Spectraplakin family member Short stop (Shot) is such a crosslinker and is crucial for several aspects of neuronal growth. Shot comprises various domains: An actin binding domain, a plakin-like domain, a rod domain, calcium responsive EF-hand motifs, a microtubule binding Gas2 domain, a GSR motif and a C-terminal EB1aff domain. Amongst other phenotypes, shot mutant animals exhibit severely reduced dendrites and neuromuscular junctions, the subcellular compartmentalisation of the transmembrane protein Fasciclin2 is affected, but it is also crucially required in other tissues, for example for the integrity of tendon cells, specialised epidermal cells which anchor muscles to the body wall. Despite these striking phenotypes, Shot function is little understood, and especially we do not understand how it can carry out functions as diverse as those described above. To bridge this gap, I capitalised on the genetic possibilities of the model system Drosophila melanogaster and carried out a structure-function analysis in different neurodevelopmental contexts and in tendon cells. To this end, I used targeted gene expression of existing and newly generated Shot deletion constructs in Drosophila embryos and larvae, analyses of different shot mutant alleles, and transfection of Shot constructs into S2 cells or cultured fibroblasts. My analyses reveal that a part of the Shot C-terminus is not essential in the nervous system but in tendon cells where it stabilises microtubules. The precise molecular mechanism underlying this activity is not yet elucidated but, based on the findings presented here, I have developed three alternative testable hypothesis. Thus, either binding of the microtubule plus-end tracking molecule EB1 through an EB1aff domain, microtubulebundling through a GSR rich motif or a combination of both may explain a context-specific requirement of the Shot C-terminus for tendon cell integrity. Furthermore, I find that the calcium binding EF-hand motif in Shot is exclusively required for a subset of neuronal functions of Shot but not in the epidermal tendon cells. These findings pave the way for complementary studies studying the impact of [Ca2+] on Shot function. Besides these differential requirements of Shot domains I find, that most Shot domains are required in the nervous system and tendon cells alike. Thus the microtubule Gas2 domain shows no context specific requirements and is equally essential in all analysed cellular contexts. Furthermore, I could demonstrate a partial requirement of the large spectrin-repeat rod domain of Shot in neuronal and epidermal contexts. I demonstrate that this domain is partially required in processes involving growth and/or tissue stability but dispensable for cellular processes where no mechanical stress resistance is required. In addition, I demonstrate that the CH1 domain a part of the N-terminal actin binding domain of Shot is only partially required for all analysed contexts. Thus, I conclude that Shot domains are functioning different in various cellular environments. In addition my study lays the base for future projects, such as the elucidation of Shot function in growth cones. Given the high degree of conservation between Shot and its mammalian orthologues MACF1/ACF7 and BPAG1, I believe that the findings presented in this study will contribute to the general understanding of spectraplakins across species borders.

Valutazione dell'efficacia di iniezioni peritendinee di acido ialuronico nel tendine rotuleo di ratto disallenato

Introduzione L’attività fisica moderata seguita da improvvisa interruzione può influenzare le caratteristiche biologiche del tendine. Lo scopo del lavoro è stato quello di valutare l’attività cellulare, le caratteristiche istologiche, istomorfometriche e microstrutturali del tendine patellare e della sua entesi in condizioni di non allenamento (sedentarietà), allenamento ed improvviso arresto dell’attività fisica. E’ stato ipotizzato che un’iniezione peri-tendinea di acido ialuronico nelle settimane successive all’improvviso arresto dell’attività fisica potesse mantenere l’integrità strutturale e biologica del tendine patellare. Materiali e Metodi 24 ratti Sprague Dawley maschi di 8 settimane sono stati suddivisi in tre gruppi, allenati per 10 settimane, fino a 60-80% VO2max. I ratti sono stati suddivisi in tre gruppi: Non Allenati (6), Allenati (6), Disallenati (12). A 6 dei 12 ratti del gruppo Detrained, è stata praticata un’infiltrazione peri-tendinea a nel tendine patellare destro di 300 μl di acido ialuronico, mentre nei rimanenti 6, è stata praticata l’infiltrazione con soluzione fisiologica. I tendini rotulei espiantati sono stati valutati con coltura cellulare, valutazione biologica molecolare, valutazioni morfologiche microstrutturali, proliferazione, conta ed attività cellulare. Risultati I risultati in vitro hanno evidenziato vitalità e conta cellulare simili fra i Gruppi Trained e Detrained-HA con un incremento significativo del metabolismo cellulare rispetto agli altri Gruppi. La cellularità ha mostrato valori maggiori nei Gruppi Non Allenati e Detrained-NaCl ove si è osservata una biosintesi del collagene III superiore ai Gruppi Trained e Detrained-HA. Contrariamente, la produzione di collagene I e II presentava valori maggiori nei Gruppi Trained e Detrained-HA suggerendo una superiore efficienza tessutale e metabolica di questi ultimi. Conclusioni Questi risultati confermano che l’allenamento ed il suo improvviso arresto hanno effetti sulla struttura tendinea patellare di ratto e che l’iniezione peritendinea di acido ialuronico nel periodo di inattività ha effetti significativi su metabolismo cellulare e sul tendine rispetto al trattamento con soluzione fisiologica.

Sviluppo e caratterizzazione di scaffold elettrofilati per la ricostruzione del tessuto tendineo.

Gli obbiettivi di questo lavoro di tesi risultano i seguenti: 1) Progettare e caratterizzare una tipologia di bundle bioriassorbibile attraverso la tecnica dell’elettrofilatura, composto da una miscela di acido poli-(L)lattico (PLLA) e collagene, che cerchi di mimare le proprietà meccaniche dei fascicoli di collagene tendineo umano ed equino; 2) Individuare una metodologia di assemblaggio multiscala dei bundle che permetta la creazione di uno scaffold in grado di mimare la struttura gerarchica di un tendine completo; 3) Applicare la filosofia traslazionale alla progettazione dello scaffold al fine di poter applicare tale tecnologia sia nell’ambito della medicina umana che in quella veterinaria, lavorando nel senso della medicina unica.

Examination of FGFRL1 as a candidate gene for diaphragmatic defects at chromosome 4p16.3 shows that Fgfrl1 null mice have reduced expression of Tpm3, sarcomere genes and Lrtm1 in the diaphragm

Fgfrl1 (also known as Fgfr5; OMIM 605830) homozygous null mice have thin, amuscular diaphragms and die at birth because of diaphragm hypoplasia. FGFRL1 is located at 4p16.3, and this chromosome region can be deleted in patients with congenital diaphragmatic hernia (CDH). We examined FGFRL1 as a candidate gene for the diaphragmatic defects associated with 4p16.3 deletions and re-sequenced this gene in 54 patients with CDH. We confirmed six known coding single nucleotide polymorphisms (SNPs): c.209G > A (p.Pro20Pro), c.977G > A (p.Pro276Pro), c.1040T > C (p.Asp297Asp), c.1234C > A (p.Pro362Gln), c.1420G > T (p.Arg424Leu), and c.1540C > T (p.Pro464Leu), but we did not identify any gene mutations. We genotyped additional CDH patients for four of these six SNPs, including the three non-synonymous SNPs, to make a total of 200 chromosomes, and found that the allele frequency for the four SNPs, did not differ significantly between patients and normal controls (p > or = 0.05). We then used Affymetrix Genechip Mouse Gene 1.0 ST arrays and found eight genes with significantly reduced expression levels in the diaphragms of Fgfrl1 homozygous null mice when compared with wildtype mice-Tpm3, Fgfrl1 (p = 0.004), Myl2, Lrtm1, Myh4, Myl3, Myh7 and Hephl1. Lrtm1 is closely related to Slit3, a protein associated with herniation of the central tendon of the diaphragm in mice. The Slit proteins are known to regulate axon branching and cell migration, and inhibition of Slit3 reduces cell motility and decreases the expression of Rac and Cdc42, two genes that are essential for myoblast fusion. Further studies to determine if Lrtm1 has a similar function to Slit3 and if reduced Fgfrl1 expression can cause diaphragm hypoplasia through a mechanism involving decreased myoblast motility and/or myoblast fusion, seem indicated.

Kinematic improvement following Botulinum Toxin-A injection in upper-limb spasticity due to stroke

Background Focal spasticity is a significant motor disorder following stroke, and Botulinum Toxin Type-A (BoNT-A) is a useful treatment for this. The authors evaluated kinematic modifications induced by spasticity, and whether or not there is any improvement following injection of BoNT-A. Methods Eight patients with stroke with upper-limb spasticity, showing a flexor pattern, were evaluated using kinematics before and after focal treatment with BoNT-A. A group of sex- and age-matched normal volunteers acted as a control group. Results Repeated-measures ANOVA showed that patients with stroke performed more slowly than the control group. Following treatment with BoNT-A, there was a significant improvement in kinematics in patients with stroke, while in the control group, performance remained unchanged. Conclusions Focal treatment of spasticity with BoNT-A leads to an adaptive change in the upper limb of patients with spastic stroke.

Magnetic resonance imaging in traumatic posterior hip dislocation

The objective was to report the ability of a magnetic resonance image to document the integrity of the obturator externus tendon after posterior hip dislocation as a potential predictor for preserved femoral head vascularity.

Ankle joint pressure changes in a pes cavovarus model after lateralizing calcaneal osteotomies

Tendon transfers and calcaneal osteotomies are commonly used to treat symptoms related to medial ankle arthrosis in fixed pes cavovarus. However, the relative effect of these osteotomies in terms of lateralizing the ground contact point of the hindfoot and redistributing ankle joint contact stresses are unknown.

Polyneuropathies--short and sweet

Complaints of sensory loss and (painful) tingling in a stocking distribution are not uncommon in primary care. These symptoms are especially troublesome while getting asleep. Characteristically, ankle tendon reflexes and vibration perception are diminished. These are the hallmarks of distal-symmetric sensory polyneuropathy (PNP), with diabetes mellitus being the most common cause in our patient population. PNP presents itself only after years of suboptimal glycemic control in diabetes type 1. In patients with type 2, symptoms of PNP can precede formal diagnosis of diabetes! In this mini-review we present an algorithm for diagnosis and management of PNP's in general practice.

Leukocyte- and Platelet-Rich Fibrin (L-PRF) for Long-Term Delivery of Growth Factor in Rotator Cuff Repair: Review, Preliminary Results and Future Directions

Surgical repair of the rotator cuff repair is one of the most common procedures in orthopedic surgery. Despite it being the focus of much research, the physiological tendon-bone insertion is not recreated following repair and there is an anatomic non-healing rate of up to 94%. During the healing phase, several growth factors are upregulated that induce cellular proliferation and matrix deposition. Subsequently, this provisional matrix is replaced by the definitive matrix. Leukocyte- and platelet-rich fibrin (L-PRF) contain growth factors and has a stable dense fibrin matrix. Therefore, use of LPRF in rotator cuff repair is theoretically attractive. The aim of the present study was to determine 1) the optimal protocol to achieve the highest leukocyte content; 2) whether L-PRF releases growth factors in a sustained manner over 28 days; 3) whether standard/gelatinous or dry/compressed matrix preparation methods result in higher growth factor concentrations. 1) The standard L-PRF centrifugation protocol with 400 x g showed the highest concentration of platelets and leukocytes. 2) The L-PRF clots cultured in medium showed a continuous slow release with an increase in the absolute release of growth factors TGF-β1, VEGF and MPO in the first 7 days, and for IGF1, PDGF-AB and platelet activity (PF4=CXCL4) in the first 8 hours, followed by a decrease to close to zero at 28 days. Significantly higher levels of growth factor were expressed relative to the control values of normal blood at each culture time point. 3) Except for MPO and the TGFβ-1, there was always a tendency towards higher release of growth factors (i.e., CXCL4, IGF-1, PDGF-AB, and VEGF) in the standard/gelatinous- compared to the dry/compressed group. L-PRF in its optimal standard/gelatinous-type matrix can store and deliver locally specific healing growth factors for up to 28 days and may be a useful adjunct in rotator cuff repair.

Hand and Wrist Surgery

Despite improved medical treatment of rheumatoid arthritis, carpal tunnel compression, caput ulnae syndrome and palmar and dorsal tenosynovitis with potential tendon rupture represent urgent surgical indications. While diagnostic and therapeutic synovectomy may guide medical treatment, it should be performed before joint instability and destructive arthritis are established. Swan-neck and Boutonniere deformities as well as ulnar or radial drift of metacarpophalangeal (MCP) joints or the wrist can only be corrected when the involved joints are supple and intact. In the presence of destructive arthritis, partial and total wrist fusion, arthroplasties of the MCP joints and arthrodeses of the distal interphalangeal joints are recommended.

Biologically based strategies to augment rotator cuff tears

Lesions of the rotator cuff (RC) are among the most frequent tendon injuries. In spite of the developments in both open and arthroscopic surgery, RC repair still very often fails. In order to reduce the failure rate after surgery, several experimental in vitro and in vivo therapy methods have been developed for biological improvement of the reinsertion. This article provides an overview of the current evidence for augmentation of RC reconstruction with growth factors. Furthermore, potential future therapeutic approaches are discussed. We performed a comprehensive search of the PubMed database using various combinations of the keywords "tendon," "rotator cuff," "augmentation," "growth factor," "platelet-rich fibrin," and "platelet-rich plasma" for publications up to 2011. Given the linguistic capabilities of the research team, we considered publications in English, German, French, and Spanish. We excluded literature reviews, case reports, and letters to the editor.

Device for lengthening of a musculotendinous unit by direct continuous traction in the sheep

Background Retraction, atrophy and fatty infiltration are signs subsequent to chronic rotator cuff tendon tears. They are associated with an increased pennation angle and a shortening of the muscle fibers in series. These deleterious changes of the muscular architecture are not reversible with current repair techniques and are the main factors for failed rotator cuff tendon repair. Whereas fast stretching of the retracted musculotendinous unit results in proliferation of non-contractile fibrous tissue, slow stretching may lead to muscle regeneration in terms of sarcomerogenesis. To slowly stretch the retracted musculotendinous unit in a sheep model, two here described tensioning devices have been developed and mounted on the scapular spine of the sheep using an expandable threaded rod, which has been interposed between the retracted tendon end and the original insertion site at the humeral head. Traction is transmitted in line with the musculotendinous unit by sutures knotted on the expandable threaded rod. The threaded rod of the tensioner is driven within the body through a rotating axis, which enters the body on the opposite side. The tendon end, which was previously released (16 weeks prior) from its insertion site with a bone chip, was elongated with a velocity of 1 mm/day. Results After several steps of technical improvements, the tensioner proved to be capable of actively stretching the retracted and degenerated muscle back to the original length and to withstand the external forces acting on it. Conclusion This technical report describes the experimental technique for continuous elongation of the musculotendinous unit and reversion of the length of chronically shortened muscle.

Hindfoot varus and neurologic disorders

Muscle imbalance from numerous underlying neurologic disorders can cause dynamic and static hindfoot varus deformity. Most etiologies are congenital, and therefore affect bone morphology and the shape of the foot during growth. Weak and strong muscle groups, bone deformity, and soft-tissue contractures have to be carefully assessed and considered for successful management. Because of the variety of the etiologies and the differences in presentation, treatment decisions in varus hindfoot caused by neurologic disorders must be individualized. Deformity correction includes release of soft tissue contractures, osteotomies and arthrodeses, and tenotomies or tendon transfers to balance muscle strength and prevent recurrence. To decrease elevated anteromedial ankle joint contact stress and provide lateral hindfoot stability during the entire gait cycle, the goal of static and dynamic hindfoot varus realignment is to fully correct all components of the deformity, but particularly the varus tilt of the talus.