Chronic low back pain (CLBP) is the most common cause of disability worldwide, and lumbar spine fusion (LSF) is often chosen to treat pain caused by advanced degenerative disease when clinical treatment failed certain cases, the post-surgical outcomes are not what was expected. Several studies highlight how important are. In psychological variables during the postoperative spine surgery period. The aim of this study is to assess the role of preoperative depression on postoperative clinical outcomes. We included patients who underwent LSF since December 2021. Preoperative depression was assessed administering Beck Depression Inventory questionnaire (BDI). And pain and disability were evaluated at 1, 3, and 6 months, administering respectively Visual Analogic Scale (VAS) and Oswestry Disability Index (ODI). As statistical analysis Mann-Whitney test was performed. We included 46 patients, 20 female (43,5%) and 26 male (56,5%) with an average age of 64,2. The population was divided in two groups, fixing the BDI cut-off point at 10. Patients with BDI < 10 points (N=28) had normal mental health status, instead patients with BDI > 10 points (N=16) had depressive disorders. At 3 months patients with healthy mental status reported statistically significant reduction of pain (U = 372,5, p = .006) and improvement of disability but without statistical significancy (U = 318, p = 0,137). At 6 months patients without psychological disease reported statistically significant reduction of pain (U = 342, p = 0,039) and disability (U = 372,5, p = 0,006).

This study demonstrates the correlation between pre-existing depressive state and poorer clinical outcomes after spine surgery. These results are consistent with the literature. Therefore, during the surgical decision making it is crucial to take psychological variables into account in order to predict the results after surgery and inform patients on the potential influence of mental status.

Low back pain (LBP) is the main cause of disability worldwide and is primarily triggered by intervertebral disc degeneration (IDD). Although several treatment options exist, no therapeutic tool has demonstrated to halt the progressive course of IDD. Therefore, several clinical trials are being conducted to investigate different strategies to regenerate the intervertebral disc, with numerous studies not reaching completion nor being published. The aim of this study was to analyze the publication status of clinical trials on novel regenerative treatments for IDD by funding source and identify critical obstacles preventing their conclusion.

Prospective clinical trials investigating regenerative treatments for IDD and registered on ClinicalTrials.gov were included. Primary outcomes were publication status and investigational treatment funding. Fisher's exact test was utilized to test the association for categorical variables between groups.

25 clinical trials were identified. Among these, only 6 (24%) have been published. The most common source of funding was university (52%), followed by industry (36%) and private companies (12%). Investigational treatments included autologous (56%) or allogeneic (12%) products alone or in combination with a carrier or delivery system (32%). The latter were more likely utilized in industry or privately funded studies (Fig. 1, p=0.0112). No significant difference was found in terms of funding regarding the publication status of included trials (Table 1, p=0.9104).

Most clinical trials investigating regenerative approaches for the treatment of IDD were never completed nor published. This is likely due to multiple factors, including difficult enrollment, high dropout rate, and publication bias³. More accurate design and technical support from stakeholders and clinical research organization (CROs) may likely increase the quality of future clinical trials in the field.

For any figures or tables, please contact the authors directly.

Despite promising results in attempting intervertebral disc regeneration, intradiscal cell transplantation is affected by several drawbacks, including poor viability in the harsh disc environment, low cost-effectiveness, and immunogenic/tumorigenic concerns. Recently, the development of cell-free approaches is gaining increasing interest in the field, with a particular regard towards extracellular vesicles (EVs). Nucleus pulposus cell (NPC) progenitors characterized by Tie2 expression have shown a higher chondrogenic differentiation potential compared to MSCs. The aim of this study was to investigate the putative regenerative effects of EVs isolated from Tie2-overexpressing NPC progenitors on degenerative NPCs.

NPCs were isolated from young donors and underwent an optimized culture protocol to maximize Tie2 expression (NPCs^Tie2+) or a standard protocol (NPCs^STD). Following EV characterization, NPC isolated from patients affected by intervertebral disc degeneration (IDD) were treated with either NPCs^Tie2+-EVs or NPCs^STD-EVs. Cell proliferation and viability were assessed with the CCK-8 assay. Cell apoptosis and necrosis were evaluated with the Annexin V/PI assay. Cell senescence was investigated with b-galactosidase staining. EV uptake was assessed with PKH26 staining of EVs under confocal microscopy.

Treatment with EVs isolated from young NPC donors significantly increased degenerative NPC viability, especially in samples treated with NPCs^Tie2+-EVs. Likewise, NPCs^Tie2+-EVs significantly reduced cell senescence and did not show to exert necrotic nor apoptotic effects on recipient cells. Furthermore, EV uptake was successfully observed in all treated cells.

NPCs^Tie2+-EVs demonstrated to significantly enhance degenerative NPC viability, senescence and apoptosis. The use of committed progenitors naturally residing the in the nucleus pulposus may optimize EV regenerative properties and constitute the basis for a new therapy for IDD.

Low back pain (LBP) is a worldwide leading cause of disability. Treatment of intervertebral disc (IVD) with stem cells has been used on degenerate discs (IDD), cause of around 40% of LBP cases. Despite pain reduction, clinical studies' follow-up have not shown a structural IVD improvement. A valid alternative may be the use of notocordal cells (NC) or their precursors. Mesendoderm progenitor cells (MEPC) have the ability to replicate and differentiate toward NC. In this preliminary study we evaluated in a preclinical IDD model the viability and NC differentiation of MEPC derived from induced pluripotent stem cells (iPSC).

MEPC derived from iPSC were developed during the iPSpine project (# 825925), thawed, plated for 24h on laminin and labeled with PKH26.

Two adult sheep were subjected to nucleotomy of five lumbar discs for the induction of IDD. After 5 weeks, 3 degenerated discs were treated with MEPC at 3 different doses (low, medium and high). One sheep was sacrificed after 7 days and one after 30 days. Clinical parameters were collected to evaluate the safety of treatment. Discs were analysed using histological techniques. Survival (PKH26), proliferation (PCNA), notocordal cell differentiation (Brachyury, Cytokeratin 8/18/19, Sox9, Foxa2) and endodermal differentiation (Sox17) were evaluated.

At 7 days from treatment, both sheep lost about 20% of body weight. Only in discs treated with the highest dose PKH26 stained cells were alive up to 30 days. These cells turn out to be: proliferating (PCNA); positive for Brachyury, cytokeratin 8/18/19 and Foxa2; positive for SOX17 in a small percentage.

This preliminary study shows that MEPC, derived from iPSC and injected into ovine discs degenerated by nucleotomy, are able to survive up to 30 days and differentiate within the disc predominantly towards the notocordal phenotype.

Invertebral disc degeneration (IDD) is a degenerative disease involving a variety of musculoskeletal and spinal disorders such as lower back pain (LBP). Secretome derived from mesenchymal stem cells (MSCs) have exerted beneficial effect on tissue regeneration. In this study, the goal was to investigate the paracrine and the anti-inflammatory effects of secretome from interleukin IL1β preconditioned Bone Marrow MSCs (BMSCs) on human nucleus pulposus cells (hNPCs) in a 3D in vitro model.

Secretome was collected from BMSCs (BMSCs-sec) after preconditioning with 10 ng/mL IL1β. hNPCs were isolated from surgical specimens, culture expanded in vitro, encapsulated in alginate beads and treated with: growth medium; IL1β 10 ng/mL; IL1β 10 ng/mL for 24 hours and then BMSCs-sec. We examined: i) cell proliferation and viability (flow cytometry), ii) nitrite production (Griess assay) and ROS quantification (Immunofluorescence) iii) glycosaminoglycan (GAG) amount (DMBB) and iv) gene expression levels of extracellular matrix (ECM) components and inflammatory mediators (qPCR). One-way ANOVA analysis was used to compare the groups under exam and data were expressed as mean ± S.D.

In vitro tests showed an enhancement of hNPCs proliferation after treatment with BMSCs-sec (p ≤ 0.05) compared to IL1β group. After 24 hours, the percentage of dead cells was higher in IL1β treated hNPCs compared to control group and decreased significantly in combined IL1β and BMSCs-sec sample group (p ≤ 0.01). Nitrite and ROS production were significantly mitigated and GAGs content was improved by preconditioned BMSCs-sec (p ≤ 0.05). Furthermore, gene expression levels were modulated by BMSCs-sec treatment compared to controls.

Our results supported the potential use of BMSCs' secretome as a cell-free strategy for IDD, overcoming the side effects of cell-therapy. Moreover, secretome derived from IL1β preconditioned BMSCs was able to reduce hNPCs death, attenuate ECM degradation and oxidative stress counteracting IDD progression.

Acknowledgements: Financial support was received from the “iPSpine” and “RESPINE” Horizon 2020 projects.

The use of intraoperative navigation and robotic surgery for minimally invasive lumbar fusion has been increasing over the past decade. The aim of this study is to evaluate postoperative clinical outcomes, intraoperative parameters, and accuracy of pedicle screw insertion guided by intraoperative navigation in patients undergoing lumbar interbody fusion for spondylolisthesis. Patients who underwent posterior lumbar fusion interbody using intraoperative 3D navigation since December 2021 were included. Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Short Form Health Survey-36 (SF-36) were assessed preoperatively and postoperatively at 1, 3, and 6 months. Screw placement accuracy, measured by Gertzbein and Robbins classification, and facet joint infringement, measured by Yson classification, were assessed by intraoperative Cone Beam CT scans performed at the end of instrumentation. Finally, operation time, intraoperative blood loss, hospital stay, and screw insertion time were evaluated. This study involved 50 patients with a mean age of 63.7 years. VAS decreased from 65.8±23 to 20±22 (p<.01). ODI decreased from 35.4%±15 to 11.8%±14 (p<.01). An increase of SF-36 from 51.5±14 to 76±13 (p<.01) was demonstrated. The accuracy of “perfect” and “clinically acceptable” pedicle screw fixation was 89.5% and 98.4%, respectively. Regarding facet violation, 96.8% of the screws were at grade 0. Finally, the average screw insertion time was 4.3±2 min, hospital stay was 4.2±0.8 days, operation time was 205±53 min, and blood loss was 169±107 ml. Finally, a statistically significant correlation of operation time with hospital stay, blood loss and placement time per screw was found. We demonstrated excellent results for accuracy of pedicle screw fixation and violation of facet joints. VAS, ODI and SF-36 showed statistically significant improvements from the control at one month after surgery.

Navigation with intraoperative 3D images represents an effective system to improve operative performance in the surgical treatment of spondylolisthesis.

This study aimed to investigate the effect of irisin on human nucleus pulposus cells (hNPCs) in vitro. Our hypothesis was that irisin would improve hNPC metabolism and proliferation.

hNPCs were isolated from intervertebral discs and cultured in alginate beads. hNPCs were exposed to phosphate-buffered saline (PBS) or recombinant irisin (r-irisin) at 5, 10 and 25 ng/mL (n=4). Each experiment was performed in triplicate. Cell proliferation was assessed with trypan blue staining-automated cell counting and PicoGreen assay. Glycosaminoglycan (GAG) content was measured using the DMMB assay. Metabolic activity was assessed with the MTT assay and the Griess Reagent System. Gene expression of collagen type II (COL2), matrix metalloproteinase (MMP)-13, tissue inhibitor of matrix metalloproteinase (TIMP)-1 and −3, aggrecan, interleukin (IL)-1β, a disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS)-5 was measured by RT-PCR. MTT assay and ADAMTS-5, COL2, TIMP-1 and IL-1β gene expression were evaluated following incubation with 5, 10 and 25 ng/mL r-irisin for 24 hours and subsequent culture with 10 ng/ml IL-1β and vice versa (incubation for 24 hours with IL-1β and subsequent culture with r-irisin).

Irisin increased hNPC proliferation (p<0.001), metabolic activity (p<0.05), GAG content (p<0.01), as well as COL2 (p<0.01), aggrecan (p<0.05), TIMP-1 and −3 (p<0.01) gene expression, while decreasing MMP-13 (p<0.05) and IL-1β (p<0.001) mRNA levels. r-irisin pretreatment of hNPCs cultured in pro-inflammatory conditions resulted in a rescue of metabolic activity (p<0.001) and a decrease of IL-1β (p<0.05) levels. Similarly, incubation of hNPCs with IL-1β and subsequent exposure to r-irisin increased hNPC metabolic activity (p<0.001), COL2 gene expression (p<0.05) and decreased IL-1β (p<0.05) and ADAMTS-5 levels (p<0.01).

Irisin stimulates hNPC proliferation, metabolic activity, and anabolism by reducing IL-1β and catabolic enzyme expression while promoting matrix synthesis.

The purpose of this study was to evaluate the beneficial effects of r-Irisin (IR) on human primary tenocytes (hTCs) in vitro. Indeed, Irisin is secreted from muscles in response to exercise and mediates many beneficial effects on tissues and organs.

Tissue samples (n=3) were analyzed by histology and immunohistochemistry for αVβ5 receptor. hTCs isolated, culture expanded were treated with: 1) RPMI medium as control; 2) IR at different concentrations; 3) IL-1β; 4) pre-treated with IL-1β for 24 h and then co-treated with IR; 5) pre-treated with IR for 24 h and then co-treated with IL-1β. We evaluated: cell metabolic activity (MTT); cell proliferation (trypan blue staining and PicoGreen); nitrite concentration (Griess). The analysis were performed in triplicate for each donor and each experiment was repeated at least three times. Data were expressed as mean ± S.D. One-way ANOVA analysis was used to compare the groups under exam.

We found the presence of the αVβ5 receptor on hTCs plasma membrane supporting the potential interaction with irisin. Cell proliferation was significantly increased with IR at 5, 10 and 25 ng/mL. IR 25 ng/mL after IL1β pre-treatment was able to counteract the increase of nitrite production (p < 0.001) compared to the inflamed hTCs (p < 0.01; p < 0.0001), as well as IR at 10 and 25 ng/ml showed a protective role from oxidative damage. We observed a significant increase in cell metabolic viability in culture under IR at 5 and 25 ng/mL (p < 0.001; p < 0.05) in the pre-treated IR groups, whereas IR showed anti-inflammatory effects at the highest concentration of r-Irisin (p < 0.05).

This is the first study reporting the capability of irisin to attenuate tendinopathy in vitro by acting on acute inflamed tenocytes. Our results confirmed and highlighted the potential cross-talk mechanism between muscle and tendon.

The aim of this study was to investigate the regenerative effects of Wharton's Jelly Mesenchymal Stem Cells (WJ-MSCs) derived exosomes (WJ-Exos) on human nucleus pulposus cells (hNPCs) in an in vitro 3D model.

WJ-Exos were isolated by tangent flow filtration of WJ-MSCs conditioned media and characterized by TEM, WB for markers expression and quantified with NTA. WJ-Exos PKH26-labeled uptake in hNPCs was detected by confocal microscopy. hNPCs, isolated from surgical specimens (n=4), culture expanded in vitro and encapsulated in alginate beads, were pre-treated with IL1β (10 ng/ml) for 24 hours, then with WJ-Exos at 10, 50 and 100 µg/ml. Cells with growth medium were used as control. We examined: i) cell proliferation and viability (flow cytometry), ii) nitrite production (Griess) iii) glycosaminoglycan (GAG) amount (DMBB), iv) histological staining for extracellular matrix (ECM) analysis and v) gene expression levels of catabolic and anabolic genes (qPCR). The investigations were performed in triplicate for each donor. One-way ANOVA analysis was used to compare the groups under exam and data were expressed as mean ± S.D.

A dose dependent increase in hNPCs proliferation was noticed at all exos concentrations under study. Cell death decreased significantly in WJ-Exos 50 µg/ml samples (p ≤ 0,05) compared to IL1β treated hNPCs. Nitrite production was significantly attenuated at 10µg/ml of WJ-Exos (p ≤ 0,01). GAG content and histological analysis showed a difference in ECM synthesis between treated and untreated hNPCs (p ≤ 0,05). Catabolic and inflammatory markers were modulated by WJ-Exos at 100 µg/ml concentration (p ≤ 0,05) whereas 10 µg/ml group increased anabolic gene expression levels (p ≤ 0,05).

These findings offer new opportunities for the potential use of exosomes as an attractive alternative cell-free strategy of IDD. WJ-MSC exosomes ameliorate hNPCs growth and viability, attenuate ECM degradation and oxidative stress-related IDD progression after IL1β stimulation.

Financial support was received from the “iPSpine” and “RESPINE” Horizon 2020 projects.

Intraneural electrodes can be harnessed to control neural prosthetic devices in human amputees. However, in chronic implants we witness a gradual loss of device functionality and electrode isolation due to a nonspecific inflammatory response to the implanted material, called foreign body reaction (FBR). FBR may eventually lead to a fibrous encapsulation of the electrode surface. Poly(ethylene glycol) (PEG) is one of the most common low-fouling materials used to coat and protect electrode surfaces. Yet, PEG can easily undergo encapsulation and oxidative damage in long-term in vivo applications. Poly(sulfobetaine methacrylate) - poly(SBMA) - zwitterionic hydrogels may represent more promising alternatives to minimize the FBR due to their ultra-low fouling features. Here, we tested and compared the poly(SBMA) zwitterionic hydrogel coating with the PEG coating in reducing adhesion and activation of pro-inflammatory and pro-fibrotic cells to polyimide surfaces, which are early hallmarks of FBR. We aimed to coat polyimide surfaces with a hydrogel thin film and analysed the release of a model drug from the hydrogel.

We performed hydrogel synthesis, mechanical characterization and biocompatibility analysis. Cell adhesion, viability and morphology of human myofibroblasts cultured on PEG- and hydrogel-coated surfaces were evaluated through confocal microscopy-based high-content analysis (HCA). Reduced activation of pro-inflammatory human macrophages cultured on hydrogels was assessed as well as the hydrogel drug release profile.

Because of its high hydration, biocompatibility, low stiffness and ultra-low fouling characteristics the hydrogel enabled lower adhesion and activation of pro-inflammatory and pro-fibrotic cells vs. polystyrene controls, and showed a long-term release of the anti-fibrotic drug Everolimus. Furthermore, a polyimide surface was successfully coated with a hydrogel thin film.

Our soft zwitterionic hydrogel could outperform PEG as more suitable coating material of neural electrodes for mitigating the FBR. Such poly(SBMA)-based biomaterial could also be envisioned as long-term delivery system for a sustained release of anti-inflammatory and anti-fibrotic drugs in vivo.

With the coronavirus disease 2019 (COVID-19) pandemic, remote working has been ubiquitously implemented to reduce disease transmission via minimization of in-person interactions. Low back pain (LBP) is the first cause of disability worldwide and is frequently reported by workers with sedentary occupations. This cross-sectional study aimed to assess the role of remote working in a population of adults affected by LBP through an online questionnaire.

We enrolled 136 teleworkers affected by LBP. A total of 101 responses were received and 93 suitable questionnaires were included in the final analysis. Demographic data, remote working features and tasks, and LBP burden were analysed. The psychological burden of remote working was evaluated with the World Health Organization Five Well-Being Index (WHO-5) and the Patient Health Questionnaire-2 (PHQ-2). LBP severity was evaluated using a visual analog scale (VAS). LBP-related disability was assessed using the Oswestry Disability Index (ODI). The effect of LBP on working capacity was examined with the Occupational Role Questionnaire (ORQ). Independent risk factors related to LBP worsening were identified using a multivariate logistic regression model.

LBP severity was significantly higher compared to previous in-person working (p<0.0001) as well as average weekly work hours (p<0.001). Furthermore, the risk of LBP deterioration was associated with being divorced (OR: 4.28, 95% CI: 1.27-14.47; p=0.019) or living with others (OR: 0.24, 95% CI: 0.07-0.81; p=0.021), higher ill-being (OR: 0.91, 95% CI: 0.83-0.99; p=0.035) and depression scores (OR: 1.38, 95% CI: 1.00-1.91; p=0.048), as well as having reported unchanged (OR: 0.22, 95% CI: 0.08-0.65; p=0.006) or decreased job satisfaction (OR: 0.16, 95% CI: 0.05-0.54; p=0.003) and increased stress levels (OR: 3.00, 95% CI: 1.04-8.65; p=0.042).

These findings highlight key factors to consider for improving remote workers’ physical and mental wellbeing and decrease their LBP burden.

Intervertebral disc degeneration (IDD) affects more than 80% of the population all over the world. Current strategies for the treatment of IDD are based on conservative or surgical procedures with the aim of relieving pain. Mesenchymal stem cell (MSC) transplantation has emerged as a promising therapy in recent decades, but studies showed that the particularly hostile microenvironment in the intervertebral disc (IVD) can compromise cells survival rate. The use of exosomes, extracellular vesicles released by various cell types, possess considerable economic advantages including low immunogenicity and toxicity. Exosomes allow intercellular communication by conveying functional proteins, RNA, miRNA and lipids between cells. The purpose of this study is to assess the therapeutic effects of exosomes derived from Wharton Jelly mesenchymal stromal cells (WJ-MSC) on human nucleuspulposus cells (hNPC) in an in vitro 3D culture model.

Exosomes (exos) were isolated by tangential flow filtration of WJ-MSC conditioned media and characterized by: quantification with BCA test; morphological observation with TEM, surface marker expression by WB and size evaluation by NTA. Confocal microscopy has been used to identify exosomes marked with PKH26 and monitor fusion and/or incorporation in hNPC. hNPC were isolated from waste surgical material from patients undergoing discectomy (n = 5), expanded, encapsulated in alginate beads and treated with: culture medium (control group); WJ-MSC exos (WJ-exos) at different concentrations (10 μg/ml, 50 μg/ml and 100 μg/ml).

They were then analysed for: cell proliferation (Trypan Blu); viability (Live/Dead Assay); quantification of nitrites (Griess) and glycosaminoglycans, GAG (DMBB). The hNPC in alginate beads treated for 7 days were included in paraffin and histologically analysed to determine the presence of extracellular matrix (ECM) components. Finally, the expression levels of catabolic and anabolic genes were evaluated through real-time polymerase chain reaction (qPCR).

All concentrations of WJ-exos under exam were capable to induce a significant increase in cell proliferation after 10 and 14 days of treatment (p < 0.01 and p < 0.001, respectively). Live/Dead assay showed a decrease in cell death at 50 μg/ml of WJ-exos (p < 0.05). While cellular oxidative stress indicator, nitrite production, was reduced in a dose-dependent way and statistically significant only with 100 μg/ml of WJ-exos (p < 0.05). WJ-exos at 10 and 100 μg/ml induced a significant increase in GAG content (p < 0.05; p < 0.01, respectively) confirmed by Alcian Blu staining. Exos derived from WJ-MSC modulated gene expression levels by increasing expression of ACAN and SOX-9 genes and reducing significantly of IL-6, MMP-1, MMP-13 and ADAMTS-5 levels (p < 0.05; p < 0.01) compared to the control group.

Our results supported the potential use of exosomes from WJ-MSC for the treatment of IDD. Exosomes improved hNPC growth, attenuated ECM degradation and reduced oxidative stress and inflammation. This study offers a new scenario in IVD regeneration, promoting the potential use of extracellular vesicles as an alternative strategy to cell therapy.

Low back pain (LBP) is the leading cause of disability worldwide. Recently, treatment of the intervertebral disc (IVD) with stem cells has been used for the treatment of degenerate discs (IDD) which cause at least the 40% of LBP cases. Despite pain reduction, follow-up in clinical studies have not shown an improvement in the structural integrity of IVD. A valid alternative could be the use of progenitor disc cells (notocordal cells, NC) or of their precursors. Mesendoderm progenitor cells (MEPC) have the ability to replicate and differentiate toward NC. In this preliminary study we evaluated in a preclinical large animal IDD model the viability and NC differentiation of MEPC derived from induced pluripotent stem cells (iPSC).

MEPC, derived from iPSC and developed during the iPSpine project (# 825925), were thawed and plated on laminin for 24h and labeled with PKH26.

Two adult sheep were subjected to nucleotomy of five lumbar discs for the induction of IDD. After 5 weeks, 3 of the 5 degenerate discs were treated with MEPC at 3 different doses (low, medium and high). One sheep was sacrificed after 7 days and the other after 30 days from the treatment injection procedure. Clinical parameters were collected to evaluate the safety of treatment. Discs were paraffin embedded and analysed using histological techniques. Survival (PKH26), proliferation (PCNA), notocordal cell differentiation (Brachyury, Cytokeratin 8/18/19, Sox9, Foxa2) and endodermal differentiation (Sox17) were evaluated.

After the injection of the cells, both sheep lost about 20% of body weight. The analysis showed that only in discs treated with the highest dose the PKH26 stained cells resulted alive after 30 days from the procedure. These cells turn out to be:

This preliminary study shows that MEPC, derived from iPSC and injected into ovine discs degenerated by nucleotomy, are able to survive 30 days from treatment and differentiate within the disc predominantly towards the notocordal phenotype.

Introduction:

Exercise has showed to reduce pain and improve function in patients with discogenic low back pain (LBP). Although there is currently no biologic evidence that the intervertebral disc (IVD) can respond to physical exercise in humans, a recent study has shown that chronic running exercise is associated with increased IVD hydration and hypertrophy1. Irisin, a myokine released upon muscle contraction, has demonstrated to yield anabolic effects on different cell types, including chondrocytes2. This study aimed to investigate the effect of irisin on human nucleus pulposus cells (hNPCs). Our hypothesis is that irisin may improve hNPCs metabolism and proliferation.

Introduction and Objective

Carpal tunnel syndrome (CTS) is a very common compressive neuropathy involving the median nerve. The typical symptoms are paraesthesia, dysesthesia and loss of strength; in severe case, this compression deteriorates the sensorimotor control of the hand and interferes with the adjustment of the forces at the level of the fingers, thus affecting the components that are the basis of dexterity and control of fine movements. For these reasons, the CTS has repercussions on various activities of daily life, including writing skills. Word processing via PC and mobile device (touch-typing) require a fine control of the hand-wrist movement and of the opposition of the thumb, while in handwriting, gripping and gripping movements are carried out in a protracted manner. In modern society, present skills play a role of fundamental importance from an educational, professional and social point of view.

The aim of the study is to describe the effects of carpal tunnel release (CTR) on handwriting and digital writing performance.

Introduction and Objective

Several factors contribute to the duration of the hospital stay in patients that undergo to total hip arthroplasty (THA), either subjective or perioperative. However, no definite evidence has been provided on the role of any of these factors on the hospitalization length. The aim of this retrospective investigation is to evaluate the correlation between several preoperative and perioperative factors and the length of hospital stay (LOS) in patients that underwent elective total hip arthroplasty.

Introduction and Objective

Osteoarthritis (OA) represents one of the leading cause of disability all over the world. Cell therapies, mainly based on mesenchymal stem cells (MSCs), have shown to modulate the pathogenesis of OA in basic, preclinical and clinical studies. Adipose tissue (AT) have emerged as a rich and promising source of MSCs called adipose derived stem cells (ASCs). Different systems are available for processing lipoaspirate to purify the samples from oily and haemorrhagic fractions, minimizing the risk of complications and maximizing the biological yield for subsequent grafting. However, few studies compared the efficacy of the different processing devices already used in clinical practice. This study aims to characterize the products obtained by the use of two different systems such as micro-fragmentation or nano-fragmentation comparing them with the starting material (AT) and the collagenase isolated ASCs.

Introduction and Objective

Low back pain (LBP) is a disorder strongly associated with intervertebral disc degeneration (IDD) with an important impact on the quality of life of affected people. To date, LBP treatment is based on conservative methods with the aim to reduce back pain without restoring the degenerative environment of the disc. The main cause of IDD is the drastic reduction of the proteoglycan content within the nucleus pulposus (NP), eventually leading to the loss of disc water content, micro-architecture, biochemical and mechanical properties. A promising approach for disc regeneration is represented by the transplantation of mesenchymal stromal cells (MSCs). The exact mechanism remains unknown. Growing evidence suggests that MSCs can influence cells and modulate cells’ behaviour by secreting a set of bioactive factors. MSCs secretome is composed of several molecules such as soluble protein, lipids, nucleic acids and extracellular vesicles (EVs) involved in inflammation, immunomodulation, cell survival and intercellular communication. The aim of this study was to evaluate the in vitro effects of MSCs secretome on human NP cells (hNPCs) in a 3D culture model with and without inflammatory stimulus.

Intervertebral disc degeneration (IDD) is a major cause of low back pain, which affects 80% of the adult population at least once in their life. The pathophysiological conditions underlying IDD are still poorly understood. Genetic makeup, aging, smoking, physical inactivity and mechanical overloading, especially due to obesity, are among the strongest risk factors involved. Moreover, IDD is often associated with chronic inflammation within disc tissues, which increases matrix breakdown, glycosaminoglycan (GAG) loss and cell death. This micro-inflammatory environment is typical of several metabolic disorders, including diabetes mellitus (DM). As the etiopathogenesis of IDD in diabetic subjects remains scarcely understood, we hypothesised that this may be driven by a DM-induced inflammation leading to a combination of reduced GAG levels, decreased proteoglycan synthesis and increased matrix breakdown within the disc. The objective of the study was to investigate the pathogenesis of IDD in a murine model of type 1 DM (T1DM), namely non-obese diabetic (NOD) mouse.

Total disc glycosaminoglycan (GAG) content, proteoglycan synthesis, aggrecan fragmentation mediated by matrix metalloproteinases (MMPs) and a Disintegrin and Metalloproteinase with Thrombospondin motifs (ADAMTS), glucose transporter (mGLUT1) gene expression and apoptosis (TUNEL assay) were assessed in NOD mice and wild-type euglycemic control mice. Spinal structural and molecular changes were analysed by micro-computed tomography (mCT), histological staining (Safranin-O and fast green) and quantitative immunofluorescence (anti-ADAMTS-4 and 5 antibodies). Statistical analysis was conducted considering the average of 35 samples ± standard error for each measurement, with 95% confidence intervals calculated to determine statistical significance (p-value < 0.05).

IVDs of NOD mice showed increased disc apoptosis (p < 0.05) and higher aggrecan fragmentation mediated by ADAMTS (p < 0.05). However, ADAMTS-4 and −5 did not appear to be involved in this process. The total GAG content normalized to DNA and PG synthesis showed no statistically significant alterations, as well as Safranin O staining. Although not significantly, NOD mice showed reduced glucose uptake. In addition, the vertebral structure of NOD mice at mCT seemed not to be altered.

These data demonstrate that DM may contribute to IDD by increasing aggrecan degradation and promoting cell apoptosis, which may represent early indicators of the involvement of DM in the pathogenesis of IDD.

Intervertebral disc degeneration (IDD) affects more than 80% of the population and is often linked to a reduction of the proteoglycan content within the nucleus pulposus (NP). The nutritional decline and accumulation of degraded matrix products promote the inflammatory process favoring the onset of disease. Several regenerative approaches based on cell therapy have been explored. Recently, paracrine factors and extracellular vesicles (EVs) such as exosomes have been described to play a fundamental role in the cross-talk between mesenchymal stem cells (MSCs) and NP in the microenvironment. EVs vehicule different molecules: proteins, nucleic acids and lipids involved in intercellular communication regulating the homeostasis of recipient cells. Therefore, MSCs-derived exosomes are an interesting emerging tool for cell-free therapies in IDD.

The aim of this study was to evaluate the in vitro effects of MSCs derived exosomes on human NP cells (hNPCs).

Exosomes were isolated through a multistep ultracentrifugation of bone marrow-MSCs (BM-MSCs) conditioned media (CM), obtained by culturing BM-MSCs without fetal bovine serum (FBS) for 48 hours. Exosomal morphology was characterized by transmission electron microscope (TEM). The exosomes were quantified by bicinchoninic acid assay (BCA) and cryopreserved at –80 °C. hNPCs derived from surgical speciments digested with type II collagenase. After culture expansion in vitro, hNPCs in alginate beads (three-dimensional culture system) were treated with growth medium (controls), exosomes, CM, interleukin-1 beta (IL-1b), IL-1b plus exosomes, IL-1b plus CM. After 24 hours, total RNA was extracted and reverse-transcribed. Gene expression levels of catabolic and anabolic genes were analyzed through real time-polymerase chain reaction (qPCR).

TEM analysis confirmed the cup-shaped vescicles in our preparations. Gene expression levels resulted to be modulated by both exosomes and CM compared to controls. In addition, both treatments were capable to alter the inflammatory stimuli of IL-1b. Interestingly, exosomes were able to change anabolic and catabolic gene expression levels differently from CM.

In our experimental conditions, both exosomes and CM from BM-MSCs could be an interesting alternative strategy in intervertebral disc regeneration, overcoming the costs and translational limits of cell therapy to the clinical practice.

In the last decade, skeletal muscle has been recognized as an endocrine organ able to release molecules that may act as paracrine or endocrine factors, namely myokines. Among these, irisin is secreted upon muscle contraction after physical exercise (PE) and has been demonstrated to yield anabolic effects on different cell types. Recently, irisin has been shown to improve cortical bone mass, geometry and strength, hence resembling the effect of PE. It has also been reported that irisin levels in the serum and synovial fluid of patients with knee osteoarthritis (OA) were negatively correlated with OA severity. Therefore, we hypothesized that irisin may improve cartilage metabolism and blunt the osteoarthritic process.

Human osteoarthritic chondrocytes (hOAC) were isolated from osteochondral specimens of patients undergoing total knee joint replacement. After in vitro expansion, hOAC were put in a three-dimensional culture system (alginate beads) and treated with either phosphate-buffered saline (control) or irisin (25 ng/mL). After 1 week, the amount of glycosaminoglycans (GAG) was evaluated using dimethylmethylene blue (DMMB) and PicoGreen assays. Quantitative real-time polymerase chain reaction (qRT-PCR) was performed to detect interleukin (IL)-1 and -6, matrix metalloproteinase (MMP)-1 and -13, inducible nitric oxide synthase (iNOS) and tissue inhibitor of matrix metalloproteinases (TIMP)-1 and -3 gene expression levels.

hOAC treated with irisin showed a significant higher GAG content compared to the control group (p < 0.01). Moreover, irisin was able to reduce the expression of catabolic (MMP-1, -13, iNOS) and pro-inflammatory (IL-1, IL-6) markers, while incrementing the expression of TIMP-1 and -3 (p < 0.001).

Our results showed that irisin was able to stimulate GAG synthesis and diminish extracellular matrix catabolism in hOAC, demonstrating the existence of a cross-talk between cartilage and muscle possibly supporting the beneficial role of PE on cartilage homeostasis.

Cartilage neoangiogenesis holds a key role in the development of osteoarthritis (OA) by promoting cartilage degradation with proteoglycan loss, subchondral bone sclerosis, osteophyte formation and synovial hyperplasia. This study aimed to assess the in vivo efficacy of bevacizumab, an antibody against vascular endothelial growth factor (VEGF) in an OA animal model.

24 New Zealand white rabbits underwent anterior cruciate ligament transection in order to spontaneously develop knee OA. Animals were divided into four groups: one receiving a sham intraarticular knee injection (saline) and three groups treated with 5, 10, and 20 mg intraarticular bevacizumab injections. The biological effect of the antibody on cartilage and synovium was evaluated through histology and quantified with the Osteoarthritis Research Society International (OARSI) scores. Immunohistochemical analysis was conducted to investigate type 2 collagen, aggrecan, and matrix metalloproteinase 13 (MMP-13) expression in both cartilage and synovium.

Intraarticular bevacizumab led to a significant reduction of cartilage degeneration and synovial OA alterations. Immunohistochemistry showed a significantly reduced MMP-13 expression in all experimental groups, with the one receiving 20 mg bevacizumab showing the lowest. Furthermore, the antibody showed to increment the production of aggrecan and type 2 collagen after administration of 5, 10, and 20 mg. The group treated with 20 mg showed the highest levels of type 2 collagen expression, while aggrecan content was even higher than in the healthy cartilage.

Intraarticular bevacizumab has demonstrated to effectively arrest OA progression in our model, with 20 mg being the most efficacious dose. By inhibiting cartilage and synovial neoangiogenesis, bevacizumab may serve as a possible disease-modifying osteoarthritis drug (DMOAD) in the next future.

Anterior cruciate ligament injury is the most common and economically costly sport injuries, frequently requiring expensive surgery and rehabilitation. Post-operative knee septic arthritis represents a serious complication with an incidence rate between 0.14% and 1.7%. A common practice to avoid septic arthritis is the “vancomycin wrap”, consisting in the soaking of the graft for 10–15 minutes within a sterile gauze swab previously saturated with 5 mg/mL vancomycin. Even though several studies have been conducted to investigate vancomycin toxicity on different musculoskeletal tissues or cells, little is known about the effect of such antimicrobial on tendon-derived cells.

The aim of this study was to determine the in vitro toxicity of different concentrations of vancomycin at different time points on human primary tenocytes (hTCs).

hTCs were isolated from hamstring grafts of patients undergoing anterior cruciate ligament reconstruction. After expansion, cells were treated with different concentrations of vancomycin (2.5, 5, 10, 25, 50 and 100 mg/mL) for 10, 15, 30 and 60 minutes. In vitro toxicity was evaluated measuring: metabolic activity through the reduction of 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT Assay); cytotoxicity (Live/Dead assay); and cell apoptosis (Annexin V apoptosis kit).

The metabolic activity of hTCs was affected by vancomycin treatment starting from 10 mg/mL at all time points (p < 0.05) and dropped down at 100 mg/mL at all time points (0.05 < p < 0.001). Cells viability resulted to be unaffected only by 2.5 mg/mL vancomycin at all time points. Vancomycin resulted to be cytotoxic starting from 10 mg/mL after 15 minutes of treatment and at all higher concentrations under study at all time points. Cells died when treated with vancomycin concentrations higher than 5 mg/mL but not through apoptosis, as confirmed by negative staining for Annexin V.

In our experimental conditions, vancomycin resulted to be toxic on hTCs at concentrations higher than 5 mg/mL. The use of this antibiotic on tendons to prevent infections could be useful and safe for resident cells if used at a concentration of 2.5 mg/mL up to 1 hour of treatment.

Invasive intraneural electrodes implanted in peripheral nerves are neural prosthetic devices that are exploied to control advanced neural-interfaced prostheses in human amputees. One of the main issues to be faced in chronic implants is represented by the gradual loss of functionality of such intraneural interfaces due to an electrical impedance increase caused by the progressive formation of a fibrotic capsule around the electrodes, which is originally due to a nonspecific inflammatory response called foreign body reaction (FBR).

In this in vitro work, we tested the biocompatibility and ultra-low fouling features of the synthetic coating - poly(ethylene glycol) (PEG) - compared to the organic polymer - zwitterionic sulfated poly(sulfobetaine methacrylate) (SBMA) hydrogel - to prevent or reduce the first steps of the FBR: plasma protein adsorption and cell adhesion to the interface.

Synthesis and characterization of the SBMA hydrogel was done. Preliminary biocompatibility analysis of the zwitterionic hydrogel, using hydrogel-conditioned medium, showed no cytotoxicity at all vs. control. We seeded GFP-labelled human myofibroblasts on PEG- and SBMA hydrogel-coated polyimide surfaces and evaluated their adhesion and cell viability at different time-points. Because of the high hydration, low stiffness reflecting the one of neural tissue, and ultra-low fouling characteristics of the SBMA hydrogel, this polymer showed lower myofibroblast adhesion and different cell morphology compared to adhesion controls, thereby representing a better coating than PEG for potentially mitigating the FBR.

We conclude that soft SBMA hydrogels could outperform PEG coatings in vitro as more suitable dressings of intraneural electrodes. Furthermore, such SBMA-based antifouling materials can be envisioned as long-term diffusion-based delivery systems for controlled release of anti-inflammatory and anti-fibrotic drugs in vivo.

The use of stem cells transplanted into the intervertebral disc (IVD) is a promising regenerative approach to treat intervertebral disc degeneration (IDD). The aim of this study was to assess the effect of a hydrogel composed of hyaluronic acid (HA) and platelet-rich plasma (PRP) loaded with human mesenchymal stem cells (hMSCs), on IVD extracellular matrix synthesis and nucleus pulposus (NP) marker expression in a whole IVD culture model.

HA was blended with batroxobin (BTX), a gelling agent activated in presence of PRP to construct a hydrogel. Bovine IVDs (n=25) were nucleotomised and filled with 1×10⁶ or 2×10⁶ hMSCs suspended in ∼150 mL of the PRP/HA/BTX hydrogel. IVDs harvested at day 0 and nucleotomised IVDs with no hMSCs and/or hydrogel were used as controls. hMSCs alone or encapsulated in the hydrogel were also cultured in well plates to examine the effect of the IVD microenvironment on hMSCs. After 1 week, tissue structure, scaffold integration and gene expression of anabolic (collagen type I, collagen type II and aggrecan), catabolic (matrix metalloproteinase 3 – MMP-3 –, MMP-13 and a disintegrin and metalloproteinase with thrombospondin motifs 4) and NP cell (cytokeratin 19, carbonic anhydrase 12, cluster of differentiation 24) markers were assessed.

Histological analysis showed a good integration of the scaffold within the NP area with cell repopulation. At the gene expression level, the hMSC-loaded hydrogels demonstrated to increase disc cell anabolic and catabolic marker expression and promoted hMSC differentiation towards a NP cell phenotype.

This study demonstrated that the HA/PRP/BTX may represent a valid carrier for hMSCs being capable of stimulating cell activity and NP marker expression as well as achieving a good integration with the surrounding tissues.

Aims

Different methods of anterior cruciate ligament (ACL) reconstruction have been described for skeletally immature patients before closure of the growth plates. However, the outcome and complications following this treatment remain unclear. The aim of this systematic review was to analyse the outcome and complications of different techniques which may be used for reconstruction of the ACL in these patients.

Background

Stem cell based intervertebral disc (IVD) regeneration is quickly moving towards clinical applications. However, many aspects need to be investigated to routinely translate this therapy to clinical applications, in particular, the most efficient way to deliver cell to the IVD. Cells are commonly delivered to the IVD through the annulus fibrosus (AF) injection. However, recent studies have shown serious drawbacks of this approach. As an alternative we have described and tested a new surgical approach to the IVD via the endplate-pedicles (transpedicular approach). The Purpose of the study was to test MSCs/hydrogel transplantation for IVD regeneration in a grade IV preclinical model of IDD on large size animals via the transpeducular approach with cell dose escalation.

Introduction

One of the major concerns in the use of modular hip prostheses is the structural failure of one or more components of the prosthesis, with total mechanical failure. In literature there are sporadic cases of breakage of the prosthetic neck in patients with high functional demand.

Introduction

Rotator cuff healing after an arthroscopic repair is discussible because of the high incidence of failures. Among biologic augmentations currently used, platelet-rich plasma (PRP) is one of the most applied, supposed to enhance and accelerate the healing process in different musculoskeletal disorders. However, the evidence supporting its successful administration is still lacking, especially in the field of the rotator cuff repair. Our purpose is to clarify if the recovery is accelerated and the integrity of repaired construct is increased in patients undergoing PRP injections after arthroscopic repair of the rotator cuff.

Introduction

recent studies recognised metabolic abnormalities as additional factors in the development of rotator cuff (RC) tendinopathy. It has been hypothesised that the insertional area of this tendon is susceptible to degenerative changes due to intrinsic hypovascularization. The mechanisms underlying this process are not yet clear. In this study we attempted to confirm if larger lesions of the RC are related to impaired vasodilatatory response of the local circulation in conditions of “hemodynamic stress”.

Summary Statement

To test regenerative therapies for the intervertebral disc it is necessary to create a cavity in the nucleus polposus mantaining the annulus fibrosus intact. The transpedicular mechanical nucleotomy represents the best method for this purpose.

Introduction

Ostochondral lesion of the knee is a common cause of chronic knee pain. Arthroscopic treatment with subcondral microfracture is a widespread technique leading to noticeable improvement of knee function and pain. To improve the effectiveness of this treatment options, we thought to add intra (PRF) or post-operative (PRP) growth factors. Platelet rich plasma (PRP) is obtained by centrifugation of the blood to produce a plasma with high concentration of platelets and growth factors. This latter represents a promising method to manage degenerative cartilage lesion and can be used postoperatively to improve clinical results of patients treated arthroscopically. Platelet Rich Fibrin (PRF) has been presented as a second-generation platelet concentrate, and it is used intraoperatively to cover the microfracuteres’ holes. No literature was found about using of PRF intraoperative in association with arthroscopic microfracture technique. The aim of this study is to compare clinical outcomes of the treatment of knee osteochondral lesion using arthroscopic microfracture technique alone or in association with PRF Intraoperative application using “Vivostat” system or with PRP “ReGen Lab” postoperative injection.

Summary Statement

Intra-articular injection of humanised monoclonal anti-VEGF antibody (Bevacizumab, Avastin®) in a osteoarthritis rabbit model is related to positive restorative effects in terms of histopathologic evaluation.

Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery.

Osteoporotic vertebral compression fractures (VCFs) are an increasing public health problem. Recently, randomised controlled trials on the use of kyphoplasty and vertebroplasty in the treatment of these fractures have been published, but no definitive conclusions have been reached on the role of these interventions. The major problem encountered when trying to perform a meta-analysis of the available studies for the use of cementoplasty in patients with a VCF is that conservative management has not been standardised. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing.

In this review, we report the best evidence available on the conservative care of patients with osteoporotic VCFs and associated back pain, focusing on the role of the most commonly used spinal orthoses. Although orthoses are used for the management of these patients, to date, there has been only one randomised controlled trial published evaluating their value. Until the best conservative management for patients with VCFs is defined and standardised, no conclusions can be drawn on the superiority or otherwise of cementoplasty techniques over conservative management.

This is a prospective analysis on 30 physically active individuals with a mean age of 48.9 years (35 to 64) with chronic insertional tendinopathy of the tendo Achillis. Using a transverse incision, the tendon was debrided and an osteotomy of the posterosuperior corner of the calcaneus was performed in all patients. At a minimum post-operative follow-up of three years, the Victorian Institute of Sports Assessment scale – Achilles tendon scores were significantly improved compared to the baseline status. In two patients a superficial infection of the wound developed which resolved on antibiotics. There were no other wound complications, no nerve related complications, and no secondary avulsions of the tendo Achillis. In all, 26 patients had returned to their pre-injury level of activity and the remaining four modified their sporting activity. At the last appointment, the mean pain threshold and the mean post-operative tenderness were also significantly improved from the baseline (p < 0.001). In patients with insertional tendo Achillis a transverse incision allows a wide exposure and adequate debridement of the tendo Achillis insertion, less soft-tissue injury from aggressive retraction and a safe osteotomy of the posterosuperior corner of the calcaneum.

To evaluate the effects of eccentric strengthening exercises (ESE) in athletic patients with Achilles tendinopathy. Forty five athletic patients (29 men, average age 26 years; 16 women, average age 28 years; average height: 173 ± 16.8, range 158 to 191; average weight 70.8 kg ± 15.3, range 51.4 to 100.5) with clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks.

The mean pre-management VISA-A scores of 36 (SD 23.8; 95% C.I.: 29 – 46) improved to 52 (SD 27.5; 95% C.I.: 41.3 – 59.8) at the latest follow up (p = 0.001). Twenty seven of the 45 patients responded to the eccentric exercises. Of the 18 patients who did not improve with eccentric exercises, 5 (mean age: 33 years) improved with two peritendinous aprotinin and local anaesthetic injections. 10 of the 18 patients (9 men, mean age 35 years; 1 woman aged 40 years) who did not improve with eccentric exercises and aprotinin injections proceeded to have surgery. The remaining three patients (3 women, mean age 59.6 years; 2 men, mean age 63 years) of the 18 non-responders to eccentric exercises and aprotinin injections declined surgical intervention.

ESE in athletic patients provide comparable clinical outcome compared to our previous results in non-athletic patients. ESE are a viable option for the management of AT in athletes, but, in our hands, only around 60% of our athletic patients benefited from an intensive, heavy load eccentric heel drop exercise regimen alone. If ESE fail to improve the symptoms, aprotinin and local anaesthetic injections should be considered. Surgery is indicated in recalcitrant cases after 3 to 6 months of non operative management.

Our objective was to determine the plasma levels of substance P (SP) in patients with postoperative stiffness after arthroscopic rotator cuff repair.

Plasma samples were obtained at 15 months from surgery from 2 groups of patients who underwent arthroscopic repair of a rotator cuff tear. In Group 1, 30 subjects (14 men and 16 women, mean age: 64.6 years, range 47 to 78) with shoulder stiffness 15 months after arthroscopic rotator cuff repair were recruited. In Group 2, 30 patients (11 men and 19 women, mean age: 57.8 years, range 45 to 77) were evaluated 15 months after successful arthroscopic rotator cuff repair. Immunoassays were performed with commercially available assay kits to detect the plasma levels of SP.

The mean plasma levels of SP in patients with postoperative stiffness were significantly greater than those in the control group (81.06 ± 27.76 versus 23.49 ± 5.64, P < 0.05).

The plasma concentrations of substance P in patients with shoulder stiffness after arthroscopic rotator cuff repair are higher compared to plasma levels of SP in patients with a good postoperative outcome. The neuronal upregulation of SP shown in the plasma of patients with post operative shoulder stiffness may underlay not only the symptoms of adhesive capsulitis, but also its development.

Arthroscopic management has been recommended for some SLAP lesions, but no studies have focused on patients over 50 with rotator cuff tear and Type II SLAP lesion. Our hypothesis was that there was no difference in clinical outcome between repairing of the Type II SLAP lesion and tenotomy of the long head of the biceps tendon after having repaired the rotator cuff tear. This was a randomized controlled clinical trial.

We recruited 63 patients. In 31 patients, we repaired the rotator cuff and the Type II SLAP lesion (Group 1). In the other 32 patients, we repaired the rotator cuff and tenomized the long head of the biceps (Group 2). 7 patients (2 in the group 1 and 5 in the group 2) were lost to final follow up.

At the 5.2 year follow-up, statistically significant differences were seen with respect to the UCLA score and ROM values. In Group 1 (SLAP repair and rotator cuff repair), the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.4 (range 6 to 14) to an average of 27.9 (24–35) postoperatively (P< 0.001). In Group 2 (biceps tenotomy and rotator cuff repair) the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.1 (range 5 to 14) to an average of 32.1 (range 30 to 35) post-operatively (P< 0.001) There was statistically significant difference in total post-operative UCLA scores and ROM when comparing the two groups post-operatively (P< 0.05).

There are no advantages in repairing a Type II SLAP lesion when associated with a rotator cuff tear in patients over 50. Rotator cuff repair alone is sufficient to produce a good post-operative outcome, allowing to avoid post-operative stiffness of the shoulder.

Postoperative stiffness (POS) of the shoulder may occur after an apparently successful reconstruction of a rotator cuff tear.

The role of the peripheral nervous system in tissue healing has only recently been recognized.

We determined the plasma levels of SP in patients with postoperative stiffness after arthroscopic repair of a rotator cuff tear, and compared them with those in patients with a good outcome after arthroscopic rotator cuff repair.

Plasma samples were obtained at 15 months from surgery from 2 groups of patients who underwent arthroscopic repair of a rotator cuff tear. In Group 1, 30 subjects (14 men and 16 women, mean age: 64.6 years, range 47 to 78) with shoulder stiffness 15 months after arthroscopic rotator cuff repair were recruited. In Group 2, 30 patients (11 men and 19 women, mean age: 57.8 years, range 45 to 77) were evaluated 15 months after successful arthroscopic rotator cuff repair. Immunoassays were performed with commercially available assay kits to detect the plasma levels of SP.

Statistical analysis were performed with Wilcoxon Sign Rank test. Significance was set at P< 0.05

The concentrations of the neuropeptide SP in sera were measurable in all patients. Patients with postoperative stiffness had statistically significant greater plasma levels of SP than patients in whom arthroscopic repair of rotator cuff tears had resulted in a good outcome (P < 0.05)

Postoperative stiffness (POS) of the shoulder may occur after an apparently successful reconstruction of a rotator cuff tear.

An increased amount of SP in the subacromial bursa has been correlated with the pain caused by rotator cuff disease.

SP stimulates DNA synthesis in fibroblasts, which are the cellular components of the adhesive capsulitis of the shoulder. Also, SP is a pain transmitter peptide, and pain may cause a secondary muscular and/or capsular contracture.

Our results show that the plasma concentrations of substance P in patients with shoulder stiffness after arthroscopic rotator cuff repair are higher compared to plasma levels of SP in patients with a good postoperative outcome.

We cannot determine the cause of POS in our patients, but the findings of this study suggest a possible neuronal role in the pathophysiology of POS after arthroscopic repair of rotator cuff tears. The knowledge of the pathophysiological role of sensory nerve peptides in tissue repair in these patients could open new therapeutic options to manage conditions of the musculo-skeletal system with impaired tissue-nervous system interaction.

Restoring of anatomic footprint may improve the healing and mechanical strength of repaired tendons. A double row of suture anchors increases the tendon-bone contact area, reconstituting a more anatomic configuration of the rotator cuff footprint.

We aimed to investigate if there were differences in clinical and imaging outcome between single row and double row suture anchor technique repairs of rotator cuff tears.

We recruited 60 patients affected by a rotator cuff tear diagnosed on clinical grounds, magnetic resonance imaging evidence of cuff tear and inadequate response to nonoperative management, an unretracted and sufficiently mobile full-thickness rotator cuff lesion to allow a double row repair found at the time of surgery.

In 30 patients, rotator cuff repair was performed with single row suture anchor technique (Group 1). In the other 30 patients, rotator cuff repair was performed with double row suture anchor technique (Group 2). 8 patients (4 in the single row anchor repair group and 4 in the double row anchor repair group) were lost at follow up.

A modified UCLA shoulder rating scale was used to evaluate preoperative and postoperative shoulder pain, function and range of motion, strength and patient satisfaction. All patients received a post-operative MR arthrography at the final follow up appointment.

At the 2 year follow-up, no statistically significant differences were seen with respect to the UCLA score and ROM values. Post-operative MR arthrography at 2 years of follow up in group 1 showed intact tendons in 14 patients, partial thickness defects in 10 patients and full thickness defects in 2 patients. In group 2, MR arthrography showed an intact rotator cuff in 18 patients, partial thickness defects in 7 patients, and full thickness defects in 1 patient.

Biomechanical studies comparing single versus double row suture anchor technique for rotator cuff repair show that a double row of suture anchors increases the tendonbone contact area and restores the anatomic rotator cuff footprint, providing a better environment for tendon healing.

Our study shows that there are no advantages in using a double row suture anchor technique to restore the anatomical footprint. The mechanical advantages evidenced in cadaveric studies do not translate into superior clinical performance when compared with the more traditionally, technically less demanding, and economically more advantageous technique of single row suture anchor repair.

Several studies showed the efficacy of arthroscopic repair for Type II SLAP lesions without other associated lesions, but the only data reported on the association of arthroscopic repair of Type II SLAP lesion and rotator cuff tears involve young and active patient. To our knowledge, no studies have focused on patients over 50.

We evaluated the results of a randomized controlled trial of arthroscopic repair in patients over 50 with rotator cuff tears and Type II SLAP lesion in whom the repair was effected repairing the two lesions, or repairing the rotator cuff tears and performing a tenotomy of the long head of the biceps.

We recruited 63 patients. In 31 patients, we repaired the rotator cuff and the Type II SLAP lesion (Group 1). In the other 32 patients, we repaired the rotator cuff and tenotomized the long head of the biceps (Group 2). 7 patients (2 in the group 1 and 5 in the group 2) were lost to final follow up.

A modified UCLA shoulder rating scale was used to evaluate pre-operative and post-operative shoulder pain, function, active forward flexion, strength and patient satisfaction.

Of 63 patients randomized to one of the two treatments, 5.2 year results were available for 56. 7 patients (2 in the group 1 and 5 in the group 2) did not return at the final follow up.

Statistically significant differences were seen with respect to the UCLA score and ROM values at final follow-up In Group 1 (SLAP repair and rotator cuff repair), the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.4 (range 6 to 14) to an average of 27.9 (24–35) postoperatively (P< 0.001). In Group 2 (biceps tenotomy and rotator cuff repair), the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.1 (range 5 to 14) to an average of 32.1 (range 30 to 35) post-operatively (P< 0.001) There was statistically significant difference in total post-operative UCLA scores and ROM when comparing the two groups post-operatively (P< 0.05).

Arthroscopic management has been recommended for some SLAP lesions, but no studies have focused on patients over 50 with rotator cuff tear and Type II SLAP lesion.

We compared the clinical outcome of patients over 50 affected with rotator cuff tears and Type II SLAP lesion in whom both the defects were repaired, or the rotator cuff tear was repaired and the long head of the biceps tendon was tenotomized. In our hands, the association of rotator cuff repair and biceps tenotomy provides better clinical outcome compared with repair of Type II SLAP lesion and of the rotator cuff.

The repair of the two defects, in fact, can lead to worst clinical results compared with association Rotator cuff repair alone is sufficient to determine a good post-operative outcome, allowing to avoid post-operative stiffness of the shoulder.

The use of mesenchymal stem cells (MSCs) for cartilage and bone tissue engineering needs to be supported by scaffolds that may release stimuli for modulate cell activity.

The objective of this study was to asses if MSC undergo differentiation when cultured upon a membrane of nanofibers of poly-L-lactic acid loaded with hydroxyapatite nanoparticles (PLLA/HAp).

The PLLA/HAp nanocomposite was prepared by electrospinning. Membranes microstructure was evaluated by SEM. MSCs were seeded on PLLA/HAp membranes by standard static seeding and cultured either in basal medium or Chondrogenic Differentiation Medium. Cell attachment and engraftment was assessed 3 days after seeding and MSC differentiation was evaluated by immunostaining for CD29, SOX-9 and Aggrecan under a confocal microscope after 14 days.

PLLA/HAp membrane obtained was composed by fibers (average diameter of 7μm) with nano-dispersed hydroxyapatite aggregates (average diameter of 0.3μm). 3 days after seeding, MSCs were well adhered on the PLLA/HAp fibers with a spindled shape. After 14 days of culture all MSCs were positive for SOX-9 in both basal and chondrogenic media groups. Aggrecan was present around the cells. MSCs were either CD29 positive or negative.

We demonstrated that PLLA/HAp nanocomposites are able to induce differentiation of MSCs in chondrocyte-like cells. Since HAp has osteoinductive properties, the chondrogenic phenotype acquired by the MSCs may be either stable or an intermediate stage toward enchondral ossification. The presence of CD29 and SOX-9 double positive cells indicate intermediate differentiation phases.

This nanocomposite could be a susceptible scaffold for bone or cartilage tissue engineering using undifferentiated MSCs.

Cervical spinal disc replacement is used in the management of degenerative cervical disc disease in an attempt to preserve cervical spinal movement and to prevent adjacent disc overload and subsequent degeneration. A large number of patients have undergone cervical spinal disc replacement, but the effectiveness of these implants is still uncertain. In most instances, degenerative change at adjacent levels represents the physiological progression of the natural history of the arthritic disc, and is unrelated to the surgeon. Complications of cervical disc replacement include loss of movement from periprosthetic ankylosis and ossification, neurological deficit, loosening and failure of the device, and worsening of any cervical kyphosis. Strict selection criteria and adherence to scientific evidence are necessary. Only prospective, randomised clinical trials with long-term follow-up will establish any real advantage of cervical spinal disc replacement over fusion.

Aims: Free vascularized fibular graft for osteonecrosis of the femoral head is a well established procedure based on the assumption that the graft will provide mechanical support, blood supply to the osteonecrotic head and to introduce mesenchymal stem cells into the affected area of the femoral head.

Methods: We reviewed 25 cases to delineate the pathological features of femoral heads with AVN treated by vascularised fibular grafts which were retrieved at revision surgery when the construct was deemed clinically to have failed.

Results: Review of the patients’ records disclosed that 60.8% were on steroid therapy when the AVN was diagnosed. The recorded time from first symptoms of failure to conversion to total hip arthroplasty was an average of 55 months.

The length of the graft was divided into three zones : zone 3 the femoral neck; zone 2 the lower femoral head or “metaphysis”; zone 1 the more apical or epiphyseal component of the femoral head. The intention was to follow the vascularization of the pedicle and the changes in the three diverse areas of the specimen. The graft showed incorporation with the host bone. In the pedicle there was preservation of vascular patency and tissue viability.

Conclusion: However, this healing process involved a slow reparative resorptive activity which undermined the joint surface. This could suggest that non-resorbable materials in place of tissue grafts can be expected to avoid the negative effect of creeping substitution as an undermining force in the repair and revascularisation of the necrotic area in the head.

Aims: The aim of this study was to analyze the morphological features of the human surgical specimens of normal supraspinatus tendon from patients with rotator cuff tears and glenohumeral instability.

Methods: 41 subjects were recruited for the study. 20 subjects (group 1) sustained a rotator cuff tear and proceeded arthroscopic repair of the lesion. 21 subjects (group 2) underwent surgery due to glenohumeral instability. During surgery, under arthroscopic control, a full thickness supraspinatus tendon biopsy was harvested in the middle portion of the tendon. All slices were processed for histological analysis

Results: On surgical specimens of supraspinatus tendon from patients with rotator cuff tears, but not from patients with instability, we found increased preponderance of hyaline degeneration, fibrocartilaginous or chondroid metaplasia, calcification, lipoid degeneration, mucoid or myxoid.

Degenerative changes were more evident on the articular side of the rotator cuff.

Conclusions: The present study provides a description of the histological architecture of human surgical specimens of normal supraspinatus tendon from patients with rotator cuff tears. Preexisting degenerative change in the supraspinatus tendon seems to be the main cause of rotator cuff tears.

Aims: Recent advances in our understanding of intervertebral disc biology have led to develop novel treatments for intervertebral disc degeneration (IDD). With the ability to provide sustained delivery of a potentially therapeutic agent, gene therapy has shown much promise in regard to the treatment of IDD. The aims of this study are (part 1) to test efficacy in delaying course of IDD by intrediscal injection of adenoviral vectors carrying human BMP-2 and (part 2) to describe the application of an inducible system in order to modulate transgene expression.

Methods: (Part 1) IDD was induced in 13 NZW rabbits by anterolateral stab. Three weeks post-stab, saline with or without virus was injected directly into stabbed lumbar discs. Group 1 (n=8) received Ad/hBMP-2 while group 2 (n=5) received saline only. Rabbits were followed longitudinally with MRIs and X-rays preoperatively for up to 12 weeks post-stab. ELISAs were done to confirm BMP-2 production. (Part 2) Human nucleus pulposus cells (NPC) were transduced with an adenoviral vector that expresses GFP under the control of a tetracycline (Ad/GFP_tet). Cells were cultutred with and without tetracycline. Transgene expression was assessed by detecting GFP signal with both the FACS and the fluorescent microscope.

Results: (Part 1) By 12 weeks, the saline-injected discs had lost 49% of their MRI Index, in contrast to only a 25% decrease for the Ad/hBMP-2 treated discs. X-rays demonstrated no obvious bony intervertebral fusion in either group. ELISAs confirmed vigorous hBMP-2 production 3 weeks after therapeutic gene transfer. (Part 2) NPC expressed GFP after transduction. GFP positivity was not observed two days after administration of tetracycline. The cells expressed GFP again three days after removal of tetracycline.

Discussion: The results of this study demonstrate the efficacy of vector-mediated BMP-2 gene transfer to alter the course of IDD in a reproducible animal model, as well as the potential to control transgene expression, improving safety.

Aims: We reviewed our experience to determine the results of arthroscopic repair in patients over 50 with rotator cuff tears and Type II SLAP lesion in whom the repair was effected repairing the two lesions, or repairing the rotator cuff tears and performing a tenotomy of the long head of the biceps.

Methods: We recruited 121 patients older than 50 years in whom a symptomatic rotator cuff tear had failed non-surgical management and was affecting daily activities.

We assigned them retrospectively to one of the two groups: Group 1 underwent arthroscopic repair of the rotator cuff and repair of the type II SLAP lesion. Group 2 underwent arthoscopic repair of the rotator cuff tear and a tenotomy of the long head of the biceps.

Results: There was statistically significant difference in total postoperative UCLA scores and ROM when comparing the two groups postoperatively (P< 0.05).

Conclusions: We compared the clinical outcome of patients over 50 affected by the association of rotator cuff tears and Type II SLAP lesion, in whom both the defects were repaired, or the rotator cuff tear was repaired and the long head of the biceps tendon was tenotomized. In our hands, the association of rotator cuff repair and biceps tenotomy provides better clinical outcome compared with the association of Type II SLAP lesion repair and rotator cuff repair at three years of follow-up.

There is a trend towards the use of double-bundle techniques for the reconstruction of the anterior cruciate ligament. This has not been substantiated scientifically. The functional outcome of these techniques is equivalent to that of single-bundle methods. The main advantage of a double-bundle rather than a single-bundle reconstruction should be a better rotational stability, but the validity and accuracy of systems for the measurement of rotational stability have not been confirmed.

Despite the enthusiasm of surgeons for the double-bundle technique, reconstruction with a single-bundle should remain the standard method for managing deficiency of the anterior cruciate ligament until strong evidence in favour of the use of the double-bundle method is available.

Among the variety of differential diagnoses for chronic patellar tendinopathy, isolated tuberculosis is extremely rare. We report such a case, without any evident primary contiguous or distant focus, in a 31-year-old immunocompetent male.