Article

Outcomes of acute Achilles tendon rupture repair with bone marrow aspirate concentrate augmentation

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Abstract

Optimal treatment of acute Achilles tendon ruptures remains controversial. Positive results using stem-cell-bearing concentrates have been reported with other soft-tissue repairs, but no studies exist on outcomes of bone marrow aspirate concentrate (BMAC) augmentation in primary Achilles tendon repair. We reviewed patients with sport-related Achilles tendon ruptures treated via open repair augmented with BMAC injection from 2009 to 2011. Data on operative complications, strength, range of motion, rerupture, calf circumference and functional improvement through progressive return to sport and the Achilles tendon Total Rupture Score (ATRS) were analysed. A total of 27 patients (28 tendons) treated with open repair and BMAC injection were identified (mean age 38.3 ± 9.6 years). At mean follow-up of 29.7 ± 6.1 months, there were no reruptures. Walking without a boot was at 1.8 ± 0.7 months, participation in light activity was at 3.4 ± 1.8 months and 92 % (25 of 27) of patients returned to their sport at 5.9 ± 1.8 months. Mean ATRS at final follow-up was 91 (range 72-100) points. One case of superficial wound dehiscence healed with local wound care. No soft-tissue masses, bone formation or tumors were observed in the operative extremity. Excellent results, including no re-ruptures and early mobilisation, were observed in this small cohort with open Achilles tendon repair augmented by BMAC. No adverse outcomes of biologic treatment were observed with this protocol. The efficacy of BMAC in the operative repair of acute Achilles tendon ruptures warrants further study. IV - Therapeutic.

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... 33 Given the increasing use of stem cell therapy in clinical practice, the absence of evidence for or against the use of stem cell therapy in 2017, and new studies having become available on the topic in the past 2 years, an update of our study was warranted. 17,18,41,48 Therefore, the main purpose of the current systematic review was to reevaluate the efficacy of stem cell therapy based on patient-reported outcome measures (PROMs) and tendon healing in individuals with tendon disorders. ...
... We included 8 trials, including 4 recent trials that were not included in our 2017 systematic review. 16,23,41,48 Figure 1 shows the study flow diagram. We identified 4 unpublished trials in trial registries. ...
... Of the 8 studies included in this review, 1 was an RCT, 48 3 were non-RCTs, 14,17,18 and 4 were case series. 12,22,34,41 These studies focused on stem cell therapy for tendon disorders of the lateral elbow 22 and rotator cuff 12,14,17,18 and the Achilles 41,48 and patellar tendon, 34 including a total of 289 patients (135 males, 154 females; age range, 14-74 years). The study populations consisted of athletes and nonathletes. ...
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Background Stem cell therapy is an emerging treatment for tendon disorders. Purpose To systematically review the efficacy of stem cell therapy for patients with tendon disorders. Study Design Systematic review; Level of evidence, 4. Methods MEDLINE/PubMed, EMBASE, CINAHL, CENTRAL, PEDro, and SPORTDiscus; trial registers; and gray literature were searched to identify randomized controlled trials (RCTs) and non-RCTs, cohort studies, and case series with 5 or more cases. Studies investigating any type of stem cell therapy for patients with tendon disorders were eligible if they included patient-reported outcome measures or assessed tendon healing. Risk of bias was assessed through use of the Cochrane risk of bias tools. Results This review included 8 trials (289 patients). All trials had moderate to high risk of bias (level 3 or 4 evidence). In Achilles tendon disorders, 1 trial found that allogenic-derived stem cells led to a faster recovery compared with platelet-rich plasma. Another study found no retears after bone marrow–derived stem cell therapy was used in addition to surgical treatment. There were 4 trials that studied the efficacy of bone marrow–derived stem cell therapy for rotator cuff tears. The controlled trials reported superior patient-reported outcomes and better tendon healing. A further 2 case series found that stem cell therapy improved patient-reported outcomes in patients with patellar tendinopathy and elbow tendinopathy. Conclusion Level 3 evidence is available to support the efficacy of stem cell therapy for tendon disorders. The findings of available studies are at considerable risk of bias, and evidence-based recommendations for the use of stem cell therapy for tendon disorders in clinical practice cannot be made at this time. Stem cell injections should not be used in clinical practice given the lack of knowledge about potentially serious adverse effects.
... Five studies evaluating cBMA in tendon repair were included and summarized in Table 5 [34][35][36][37][38] . ...
... One study evaluated open Achilles tendon repair augmented with cBMA and reported excellent functional outcomes, early mobilization, normal range of motion, and no re-ruptures at a mean follow up of 29.7 mo [38] . One study evaluated the use of cBMA during rotator cuff repair and reported enhanced healing rates, improved quality of the repair surface on ultrasound and MRI, and a decreased risk of rerupture when compared to the control group [34] . ...
... It has been demonstrated that MSCs have the potential to develop into tenocytes and can be a source of growth factors to establish an environment conducive to tendon tissue regeneration. MSCs in the form of cBMA have been shown to improve the strength and quality of tissue formed when used in tendon repair [34,35,38] . ...
Article
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AIM To examine the evidence behind the use of concentrated bone marrow aspirate (cBMA) in cartilage, bone, and tendon repair; establish proof of concept for the use of cBMA in these biologic environments; and provide the level and quality of evidence substantiating the use of cBMA in the clinical setting. METHODS We conducted a systematic review according to PRISMA guidelines. EMBASE, MEDLINE, and Web of Knowledge databases were screened for the use of cBMA in the repair of cartilage, bone, and tendon repair. We extracted data on tissue type, cBMA preparation, cBMA concentration, study methods, outcomes, and level of evidence and reported the results in tables and text. RESULTS A total of 36 studies met inclusion/exclusion criteria and were included in this review. Thirty-one of 36 (86%) studies reported the method of centrifugation and preparation of cBMA with 15 (42%) studies reporting either a cell concentration or an increase from baseline. Variation of cBMA application was seen amongst the studies evaluated. Twenty-one of 36 (58%) were level of evidence IV, 12/36 (33%) were level of evidence III, and 3/36 (8%) were level of evidence II. Studies evaluated full thickness chondral lesions (7 studies), osteochondral lesions (10 studies), osteoarthritis (5 studies), nonunion or fracture (9 studies), or tendon injuries (5 studies). Significant clinical improvement with the presence of hyaline-like values and lower incidence of fibrocartilage on T2 mapping was found in patients receiving cBMA in the treatment of cartilaginous lesions. Bone consolidation and time to bone union was improved in patients receiving cBMA. Enhanced healing rates, improved quality of the repair surface on ultrasound and magnetic resonance imaging, and a decreased risk of re-rupture was demonstrated in patients receiving cBMA as an adjunctive treatment in tendon repair. CONCLUSION The current literature demonstrates the potential benefits of utilizing cBMA for the repair of cartilaginous lesions, bony defects, and tendon injuries in the clinical setting. This study also demonstrates discrepancies between the literature with regards to various methods of centrifugation, variable cell count concentrations, and lack of standardized outcome measures. Future studies should attempt to examine the integral factors necessary for tissue regeneration and renewal including stem cells, growth factors and a biologic scaffold.
... Improvement in relative strength intensity was observed in T1W-MRI images after 10 weeks post-intervention [80]. Improved Achilles tendon rupture scores were observed with autologous BMAC augmentation in Achilles tendon rupture [81]. BM-MSCs promote early rehabilitation, lower incidence of re-rupture, improvement of pain scores, and amelioration of tendon structure and strength, without the occurrence of serious complications [81][82][83][84][85][86][87]. ...
... Improved Achilles tendon rupture scores were observed with autologous BMAC augmentation in Achilles tendon rupture [81]. BM-MSCs promote early rehabilitation, lower incidence of re-rupture, improvement of pain scores, and amelioration of tendon structure and strength, without the occurrence of serious complications [81][82][83][84][85][86][87]. van den Boom et al. derived level 4 evidence for BMAC augmentation in Achilles tendon repair in terms of improved PROMs and absence of re-tears in 2.5 years follow-up [88]. ...
Article
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Orthobiologics are biological materials that are intended for the regeneration of bone, cartilage, and soft tissues. In this review, we discuss the application of orthobiologics in Achilles tendinopathy, more specifically. We explain the concepts and definitions of each orthobiologic and the literature regarding its use in tendon disorders. The biological potential of these materials can be harnessed and administered into injured tissues, particularly in areas where standard healing is disrupted, a typical feature of Achilles tendinopathy. These products contain a wide variety of cell populations, cytokines, and growth factors, which have been shown to modulate many other cells at local and distal sites in the body. Collectively, they can shift the state of escalated inflammation and degeneration to reestablish tissue homeostasis. The typical features of Achilles tendinopathy are failed healing responses, persistent inflammation, and predominant catabolic reactions. Therefore, the application of orthobiologic tools represents a viable solution, considering their demonstrated efficacy, safety, and relatively easy manipulation. Perhaps a synergistic approach regarding the combination of these orthobiologics may promote more significant clinical outcomes rather than individual application. Although numerous optimistic results have been registered in the literature, additional studies and clinical trials are still highly desired to further illuminate the clinical utility and efficacy of these therapeutic strategies in the management of tendinopathies.
... Preliminary evidence has shown favorable results for the use of BMAC in patients presenting with interstitial tears within the tendon, in addition to persistent Achilles tendinopathy. 41 In these cases, the use of a biologic agent may be beneficial in aiding tendon regeneration and repair of partial tearing, given the promising results that have been shown in aiding tendon rupture repair with BMAC, 40 or other biologic therapy, augmentation. Here, we present a case report of a 25-yearold female distance runner with partial tear of the Achilles tendon treated with BMAC after years of failed conservative management. ...
... 7 BMAC augmentation in human Achilles tendon rupture repair showed promising results, with no reruptures, early mobilization, no adverse outcomes to the biologic treatment, and return to sport at an average of six months. 40 One study has used a combination of adipose derived stem cells and either PRP or BMAC in three patients with Achilles tendinopathy and interstitial tears, and found positive outcomes in all patients. 41 There have been no other studies evaluating the use of BMAC in the human Achilles tendon, however there have been favorable results in the use of BMAC in other tendons. ...
Article
Achilles tendon disorders, including tendinopathy and ruptures, are common among competitive runners. Relatively high complication rates, recurring injuries, and the need to return to sport have led to the use of regenerative medical treatment in tendon disorders in competitive athletes. Biologic therapies, including bone marrow aspirate concentrate (BMAC) injections, have been effective in restoring injured tissue in a limited number of cases. In this case, a collegiate cross country runner with Achilles tendon pain underwent years of failed, non-surgical conservative management. The patient’s MRI demonstrated moderate distal calcaneus tendinosis with high-grade partial thickness tearing of the anterior fibers of the Achilles tendon (50% tear). The patient underwent peritendinous injection of BMAC. Post-procedure MRI demonstrated minimal tendinosis of the distal and lateral margins of the Achilles tendon, and no evidence of Achilles tendon tear. The patient followed a progressive return to running program, ultimately training 40 miles per week with minimal Achilles tendon pain.
... Excellent results have been reported, including no re-ruptures and early mobilisation, by bone-marrow aspirate-concentrate augmentation in primary Achilles tendon repair. 32 Bone-marrow aspirate-concentrate augmentation combined with tendon-bundle technique can be used to improve stump healing. 32 Excessive debridement may cause overtightening and prompt the need for lengthening surgery. ...
... 32 Bone-marrow aspirate-concentrate augmentation combined with tendon-bundle technique can be used to improve stump healing. 32 Excessive debridement may cause overtightening and prompt the need for lengthening surgery. Traditional surgical methods often debride both stumps and realign the bundles, to effectively remove necrotic tissue on the tear stumps. ...
Article
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Objective *These authors contributed equally to this work. To explore tendon-bundle technique for treating Achilles tendon rupture with no defects. Methods Patients with full unilateral Achilles tendon rupture with no defects were included. The Achilles tendon medial edge surgical repair approach was used, revealing horsetail-like rupture bundles. Tendon bundles were anatomically realigned and repaired end-to-end using 5-0 sutures. Patients were followed-up for 1 year, and assessed for differences between the repaired versus healthy limb. Results Out of 24 patients (18 male, 6 female; aged 19–56 years) at 1 year following surgery, mean American Orthopaedic Foot and Ankle Society score was 92.4 ± 5.9; mean differences between the surgically repaired versus contralateral side in dorsiflexion and plantarflexion angle were 3.5 ± 2.3° and 5.6 ± 3.2°, respectively; mean difference in calf circumference between the two sides was 0.9 ± 0.5 cm; and mean increase in Achilles tendon width versus the healthy side was 0.8 ± 0.2 cm. By 1 year post-surgery, there were no significant between-side differences in dorsiflexion and plantarflexion angle, or calf circumference. Conclusions Tendon-bundle surgery resulted in good ankle function restoration and low complication rates. Tendon-bundle surgery may reduce blood supply destruction and maximally preserve Achilles tendon length, and may be effective for treating Achilles tendon rupture with no defects.
... There have been multiple studies assessing the use of biological augmentation following surgical repair of ATR. [47][48][49] These cohort studies suggest an earlier return to work with no adverse outcomes. De Carli et al. went on step further and evaluated all patients with MRI imaging. ...
... A small cohort, level 4 study in patients with sport-related Achilles tendon ruptures showed excellent results with no reruptures when open Achilles tendon repair was augmented with bone marrow aspirate concentrate (BMAC). 49 Kadakia et al. showed promising results of use of bone marrowderived stem cells in animal models. 52 In another animal model, Yuksel et al showed the efficacy of local bone marrow mesenchymal stem cell therapy, and plateletrich plasma positively affected the recovery of the tendon histopathologically, immunohistochemically, and biomechanically and increase the structural strength. ...
Article
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Objective Our objective was to review the current literature regarding acute Achilles tendon ruptures and provide a succinct summary of the use of clinicians treating Achilles tendon ruptures. We aim to provide guidance for treatment based upon current literature. Methods We reviewed current literature and subjectively assessed for quality and influence of studies in current practice. Review The Achilles Tendon Rupture Score (ATRS) has become a vital tool in assessing functional outcome following interventions as re-rupture rates have balanced out for all treatment modalities. There remains continued debate between surgical and non-surgical treatment options. Both patterns have evolved over the past decade. Percutaneous fixation techniques are superseding traditional open surgery. Functional dynamic non-surgical regimes are also being developed to create the optimum environment for the Achilles tendon to heal and provide high functional outcomes. There even remains limited evidence that platelet-rich plasma aids healing, the significance of gap between tendon ends or of thromboprophylaxis lowering the incidence of symptomatic venous thromboembolism. Conclusions Acute Achilles tendon ruptures should either be managed in a functional rehabilitation regime or by percutaneous surgical repair. The decision depends upon both patient and clinician factors.
... In both direct-to-consumer advertising and the existing literature, cBMA is often falsely equated to MSC therapy. Studies often report utilizing cBMA as a source of MSCs [39][40][41], despite evidence that only 0.01 to 0.001% of the cells contained in cBMA are MSCs [3]. Although cBMA is not equivalent to BM-MSC therapy, it may still provide therapeutic benefits for orthopedic pathologies. ...
... Use of cBMA for tendon injuries is also being studied as an augment to surgical treatment. Stein et al. presented a retrospective study on the effects of cBMA on primary Achilles tendon repairs [39]. While the study lacked a control group, it cited randomized control trials from literature as a historical control. ...
Article
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Purpose of Review The purpose of the current article is to review the available literature related to bone marrow-derived mesenchymal stem cell therapy in the management of musculoskeletal pathologies and demonstrate the critical need for additional well-designed clinical studies. Recent Findings In recent years, there has been a rapid increase in interest regarding the use of bone marrow-derived mesenchymal stem cells in the treatment of musculoskeletal injury and disease. The clinical use of BM-MSCs and other forms of stem cell therapy has far outpaced the basic and translational science evidence required to elucidate the potential efficacy of this orthobiologic treatment approach. Early studies have demonstrated potential clinical benefit of utilizing bone marrow-derived mesenchymal stem cell therapy in the management of knee osteoarthritis, focal chondral lesions, shoulder pathology including rotator cuff tears and glenohumeral arthritis, and degenerative disk disease in the spine. To date, most published studies are small case series often lacking a control group or a standardized method of treatment. Summary Bone marrow-derived mesenchymal stem cell therapy is becoming an increasingly common treatment for musculoskeletal injuries and disease. Although early clinical studies have shown promising outcomes, methodological flaws and lack of standardization among trials have limited the conclusions that can be drawn from the existing literature. A better understanding of the underlying mechanism of action and more carefully designed clinical trials will help reveal the efficacy and utility of BM-MSCs as a treatment modality for various orthopedic pathologies.
... The PM is a biarticular muscle, which is particularly active at the plantar flexion of the foot, which occurs with simultaneous full straightening of the knee joint. Most of the injuries of this muscle occur in combination with a break in the continuity of the gastrocnemius, the soleus muscle or the anterior cruciate ligament and very often calcaneal tendon [9,18]. In recent years, there was an increase re-rupture of Achilles tendon, which may be associated with increasing physical activity in modern societies [10,16]. ...
... In recent years, there was an increase re-rupture of Achilles tendon, which may be associated with increasing physical activity in modern societies [10,16]. Therefore, the optimal treatment of both acute Achilles tendon ruptures and Achilles tendon reruptures also remains of great clinical importance [10,18]. ...
Article
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Purpose: Achilles tendinopathy is a significant clinical lower limb issue observed in recent years. Neither the location nor the mechanism behind the pain has yet been sufficiently explained. Patients frequently experience pain on the medial side of the calcaneal tendon, and between 2 and 7 cm above the calcaneal tuberosity, which may suggests that the plantaris tendon plays an important role. The purpose of this study was to determine the anatomical relationships between the course of the plantaris tendon and the calcaneal tendon, as well as the type of insertion of the plantaris tendon. Methods: The tests were carried out on 50 randomized lower limbs (23 left and 27 right) fixed in 10 % formalin solution. Results: Five insertion types of the plantaris tendon were identified in relation to the calcaneal tendon: four with their insertion on the calcaneal tuberosity (Types 1, 2, 3, 5), while the fifth (Type 4) had its insertion in the crural fascia. In addition, two variants of the course of the plantaris tendon were identified, the most common being termed Variant A, in which the tendon crosses the space between the gastrocnemius and the soleus muscles, thus reaching the medial crural region, and is located on the medial side of the calcaneal tendon (84 % cases). The course of the Variant B is similar to the course of the Variant A, but upon leaving the space located between the gastrocnemius and soleus muscle, it turned to the medial crural region and ran directly anterior to the calcaneal tendon (12 %). The plantaris muscle was found to be absent in two lower limbs (4 %). The most frequent insertion type of the plantaris tendon into the calcaneal tuberosity is fan-shaped, occurring on the medial side of the Achilles tendon (Type 1-44 % cases). Conclusion: The course of the plantaris tendon and its mobility range in relation to the calcaneal tendon may be likely to affect the occurrence of pains in the lower medial part of the leg (Achilles tendinopathy).
... To the authors' knowledge, no clinical studies have evaluated the efficacy of BMA in stimulating the healing response in patients with chronic tendinopathy. Stein et al. reported no adverse effects or re-ruptures in patients with acute Achilles tendon ruptures treated with surgical repair and adjuvant BMA injections, and acknowledged the potential for earlier ankle mobilization in these patients [19]. ...
Article
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Background Achilles tendinopathy is a common cause of posterior ankle and heel pain in both active and sedentary patients. Though the majority of patients respond to first-line non-operative management including activity modification, immobilization, orthotics, and physical therapy with stretching and eccentric strengthening, there is no consensus for patients who fail these treatments. We evaluate the role of iliac crest bone marrow aspirate (BMA) injections as a treatment option for recalcitrant cases.MethodsA retrospective chart review was conducted of patients with refractory Achilles tendinopathy treated with iliac crest BMA concentrate injection. Symptoms were assessed using the numeric rating system (NRS) pain score at the pre-operative visit and at six, 12, 24, and 48 weeks postoperatively. Post-operative complications were recorded.ResultsA total of 15 patients (15 feet) with recalcitrant Achilles tendinopathy (5 insertional, 8 non-insertional, 2 combined) treated with iliac crest BMA concentrate injections were included in the study. Average age was 53.2 years (range, 25 to 64), average BMI was 27.1 kg/m2 (range, 18.4 to 34.4), and average duration of symptoms prior to BMA injection was 2.3 years (range, 1 to 7). Pre-operatively, average NRS was 6.26 (95% CI, 5.04 to 7.49), with significant improvement at six weeks (mean, 4.26; 95% CI, 2.94 to 5.59; p = 0.04), ten weeks (mean, 4.13; 95% CI, 2.91 to 5.35; p = 0.012), 24 weeks (mean, 3.40; 95% CI, 2.05 to 4.75; p = 0.03), and 48 weeks (mean, 2.60; 95% CI, 1.14 to 4.06; p = 0.007) post-operatively. Overall, there was trending improvement over the 48-week follow-up period, with a mean improvement in NRS of − 3.22 (95% CI, − 1.06 to − 5.38; p = 0.007) at final follow-up. There was no discernable difference between insertional and non-insertional tendinopathy, and there were no incidences of post-operative complications.Conclusion Iliac crest BMA appears to be a safe, effective, and potentially lasting treatment option for patients with intractable, insertional and non-insertional Achilles tendinopathy. Patients demonstrated and maintained statistically significant decrease in NRS pain score post-operatively with no complications at the donor or injection site.
... In a retrospective study, Stein et al. used BMC for primary Achilles tendon repairs, following traumatic injuries [128]. The BMC was adjunct to augment the surgical correction. ...
... Osteochondral defect of knee Gobbi et al. 23 Cartilage 2011 IV Osteochondral defect of knee Gobbi et al. 24 American Journal of Sports Medicine 2014 IV Osteochondral defect of knee Gobbi et al. 25 Cartilage 2015 II Osteochondral defect of knee Gobbi and Whyte 7 American Journal of Sports Medicine 2016 II Osteochondral defect of knee Gobbi et al. 26 Knee Surgery, Sports Traumatology, Arthroscopy 2017 II Osteochondral defect of knee Hannon et al. 27 Arthroscopy 2016 III Osteochondral defect of talus Hart et al. 28 Spine 2014 I Spinal fusion Hendrich et al. 29 Orthopaedic Reviews 2009 IV Multiple indications Hernigou et al. 30 International Orthopaedics 2014 IV Osteointegration of implant Hernigou et al. 30 International Orthopaedics 2014 III Acetabular bone defect in revision hip surgery Hernigou et al. 31 International 38 Clinical Orthopaedics and Related Research 2014 I Distraction osteogenesis of tibia Le Nail et al. 39 International Orthopaedics 2014 IV Open tibial fracture Mao et al. 8 Bone 2013 IV Osteonecrosis of femoral head Martin et al. 40 Croatian Medical Journal 2013 IV Osteonecrosis of femoral head Mishima et al. 41 European 43 European Spine Journal 2012 II Spinal fusion Pepke et al. 44 Orthopaedic Reviews 2016 II Osteonecrosis of femoral head Pettine et al. 45 Stem Cells 2015 II Discogenic back pain Pettine et al. 46 International Orthopaedics 2016 II Discogenic back pain Rastogi et al. 47 Musculoskeletal Surgery 2013 II Osteonecrosis of femoral head Sampson et al. 48 Regenerative Medicine 2016 IV Osteoarthritis of multiple joints Scaglione et al. 49 Musculoskeletal Surgery 2014 IV Nonunion of long bones Shapiro et al. 9 American Journal of Sports Medicine 2017 II Osteoarthritis of knee Skowronski and Rutka 50 Ortopedia, Traumatologia, Rehabilitacja 2013 II Osteochondral defect of knee Stein et al. 51 International Orthopaedics 2015 IV Achilles tendon repair Sugaya et al. 52 European Journal of Orthopaedic Surgery & Traumatology ...
Article
Purpose: To perform a systematic review of clinical studies evaluating bone marrow aspirate concentrate (BMAC) in the treatment of musculoskeletal pathology to compare levels of reporting with recently published minimum standards. Methods: A systematic review of the clinical literature from August 2002 to August 2017 was performed. Human clinical studies published in English and involving the administration of BMAC for musculoskeletal applications were included. Studies evaluating non-concentrated preparations of bone marrow aspirate or preparations of laboratory cultured cells were excluded. Studies evaluating the treatment of dental or maxillofacial conditions were excluded. Similarly, in vitro studies, editorials, letters to the editor, and reviews were excluded. Levels of reporting were compared with previously published minimum standards agreed on through an international Delphi consensus process. Results: Of 1,580 studies identified on the initial search, 46 satisfied the criteria for inclusion. Considerable deficiencies in reporting of key variables including the details of BMAC preparation and composition were noted. Studies reported information on only 42% (range, 25%-60%) of the variables included within established minimum reporting standards. No study provided adequate information to enable the precise replication of preparation protocols and accurate characterization of the BMAC formulation delivered. Conclusions: We found that all existing clinical studies in the literature evaluating BMAC for orthopaedic or sports medicine applications are limited by inadequate reporting of both preparation protocols and composition. Deficient reporting of the variables that may critically influence outcomes precludes interpretation, prevents other researchers from reproducing experimental conditions, and makes comparisons across studies difficult. We encourage the adoption of emerging minimum reporting standards for clinical studies evaluating the use of mesenchymal stem cells in orthopaedics. Level of evidence: Level IV, systematic review of Level I through IV studies.
... We also found that shoulder function improved in the BMAC-PRP group at 3 months by increasing ASES scores. Several studies have reported that PRP or BMAC enhanced function of repaired rotator cuff tendons [36][37][38][39], which support our results. Although we did not investigate the histology of tendon tissues, this improvement in tendon function might be explained by the previous study which demonstrated the enhancement of tendon-bone junction healing by PRP [40]. ...
Article
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Background: We compared the clinical course of rotator cuff tears between rotator cuff exercise and bone marrow aspirate concentration (BMAC)-platelet rich plasma (PRP) injection to identify the therapeutic effects of BMAC-PRP on partial tear of the rotator cuff tendon. Methods: Twenty-four patients with partial tear of the rotator cuff tendon participated in this study. Twelve patients underwent extraction of BMACs and PRP and received the injection of BMAC-PRP at the tear site under ultrasound guidance. Twelve patients in the control group were asked to perform the rotator cuff exercise for 3 months. Visual analog scale (VAS) and manual muscle test (MMT) scores of the supraspinatus muscle were measured, and the American Shoulder and Elbow Surgeons (ASES) score was recorded before, 3 weeks, and 3 months after injection. Tear size was measured by the greatest longitudinal tear length. Results: The change in the VAS differed between groups at 3 months (P = 0.039) but not at 3 weeks (P = 0.147). The ASES scores in the BMAC-PRP group changed from 39.4 ± 13.0 to 54.5 ± 11.5 at 3 weeks and 74.1 ± 8.5 at 3 months while those in the control group changed from 45.9 ± 12.4 to 56.3 ± 12.3 at 3 weeks (P = 0.712) and 62.2 ± 12.2 at 3 months (P = 0.011). The tear size decreased at 3 weeks or 3 months after the BMAC-PRP injection but was not significantly different from that in the control group. Conclusions: BMAC-PRP improved pain and shoulder function in patients with partial tear of the rotator cuff tendon. Trial registration: The patients were registered in the institutional board registry of Samsung Medical Center (registry number 2014-07-173 ).
... However, there were no differences in clinical outcomes scores at the later post op time marks. The ADSC group obtained earlier significant results; therefore, the authors suggested that this should be taken into consideration to early return to play or daily activities [79]. However, this is novel and must be further investigated with higher-level studies. ...
Article
Introduction: The use of orthobiologics as supplemental treatment for foot and ankle pathologies have increased in the past decades. They have been used to improve the healing of bone and soft tissue injuries. There have been several studies that examined the use of biologics for knee and hip pathologies but the foot and ankle construct has unique features that must be considered. Areas covered: The biologics for foot and ankle injuries that are covered in this review are platelet-rich plasma (PRP), stem cells, growth factors, hyaluronic acid, bone grafts, bone substitutes, and scaffolds. These modalities are used in the treatment of pathologies related to tendon and soft tissue as well as cartilage. Expert opinion: The utilization of biological adjuncts for improved repair and regeneration of ankle injuries represents a promising future in our efforts to address difficult clinical problems. The application of concentrated bone marrow and PRP each represents the most widely studied and commonly used injection therapies with early clinical studies demonstrating promising results, research is also being done using other potential therapies such as stem cells and growth factors; further investigation and outcome data are still needed.
... [44][45][46][47] Bone marrow aspirate concentrate was also tried with good results. [48] Biologic matrix augmentation is another method of orthobiologics in Achilles tendon repair which offers increased repair strength and acts as a scaffold for cellular ingrowth. Its use is especially beneficial in chronic and complex injuries but there is still not enough evidence to conclude augmentation's superiority over traditional methods. ...
Article
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Orthobiologics are biologically derived materials which aim to promote healing and regeneration of tissues that are the focus of orthopedic surgery. Since bones, ligaments, tendons, and cartilage have different healing and regeneration characteristics, treatment strategies and clinical problems related to these tissues greatly differ. Although orthobiolgics are an old concept, most of the advancements in this field have been accomplished within the last two decades. A large number of promising laboratory studies show that orthobiolics hold a great potential in launching the next chapter of orthopedics. In this article, the use, research on this subject, future potential of orthobiologics, and the tissues in focus have been briefly reviewed.
... Recently, Stein et al. [45] reviewed 27 patients (28 tendons) with a mean age of 38.3 years with sport-related Achilles tendon rupture treated with combined open tendon repair and injection of BMAC. Their outcomes included complications, restoration of strength, range of motion, re-rupture, calf circumference, and the Achilles tendon Total Rupture Score (ATRS). ...
Article
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Tendon pathologies are a group of musculoskeletal conditions frequently seen in clinical practice. They can be broadly classified into traumatic, degenerative and overuse-related tendinopathies. Rotator cuff tears, Achilles tendinopathy and tennis elbow are common examples of these conditions. Conventional treatments have shown inconsistent outcomes and might fail to provide satisfactory clinical improvement. With the growing trend towards the use of mesenchymal stem cells (MSCs) in other branches of medicine, there is an increasing interest in treating tendon pathologies using the bone marrow MSC. In this article, we provide a systematic literature review documenting the current status of the use of bone marrow aspirate concentrate (BMAC) for the treatment of tendon pathologies. We also asked the question on the safety of BMAC and whether there are potential complications associated with BMAC therapy. Our hypothesis is that the use of BMAC provides safe clinical benefit when used for the treatment of tendinopathy or as a biological augmentation of tendon repair. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist while preparing this systematic review. A literature search was carried out including the online databases of PubMed, EMBASE, ClinicalTrial.gov and the Cochrane Library from 1960 to the end of May 2015. Relevant studies were selected and critically appraised. Data from eligible studies were extracted and classified per type of tendon pathology. We included 37 articles discussing the application and use of BMAC for the treatment of tendon pathologies. The Critical Appraisal Skills Program (CASP) appraisal confirmed a satisfactory standard of 37 studies. Studies were sub-categorised into: techniques of extraction, processing and microscopic examination of BMAC (n = 18), where five studies looked at the evaluation of aspiration techniques (n = 5), augmentation of rotator cuff tears (n = 5), augmentation of tendo-achilles tendon (n = 1), treatment of gluteal tendon injuries (n = 1), management of elbow epicondylitis (n = 2), management of patellar tendinopathy (n = 1) and complications related to BMAC (n = 5). Multiple experimental studies investigated the use of BMAC for tendon repair; nonetheless, there are only limited clinical studies available in this field. Unfortunately, due to the scarcity of studies, which were mainly case series, the current level of evidence is weak. We strongly recommend further future randomised controlled studies in this field to allow scientists and clinicians make evidence-based conclusions.
... These applications range from surgical injection augmentation, scaffolding augmentation, and conservative injection therapy. In a recent study, Achilles rupture repair following BMAC injection resulted in early mobilization and zero secondary ruptures over a 2-year period compared to the untreated group [71]. However, an in vitro histological observation of the ACL graft integration site resulted in nonsignificant differences between the treated and untreated groups at 4 and 8 weeks [72]. ...
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Please provide affiliation for the authors “Jorge Chahla”; “Robert F. LaPrade”; “Mark Cinque”.
... Later, Connolly and Shindell 2 and Connolly et al. 3 reported successful clinical use of percutaneous injections of unprocessed bone marrow aspirate for the treatment of nonunion of the tibia. Many other reports have shown the use of bone marrow aspirate in osteonecrosis 4-8 , nonunion [9][10][11][12][13] , bone defects 14-16 , surgical fusion 17 , augmentation of distraction osteogenesis 18 , chondral defects [19][20][21] , osteoarthritis [22][23][24][25] , tendinopathy 26 , and augmentation of tendon repair 27 . However, although some of these findings are promising, the use of the cell populations available through bone marrow aspiration has not been systematically optimized in clinical practice. ...
... No soft tissue masses, bone formation, or tumors were observed in the operative extremity. 103 ...
Article
Regenerative medicine is gaining more and more space for the treatment of Achilles pathologic conditions. Biologics could play a role in the management of midportion Achilles tendinopathy as a step between conservative and surgical treatment or as an augmentation. Higher-level studies are needed before determining a level of treatment recommendation for biologic strategies for insertional Achilles tendinopathy. Combining imaging with patient's functional requests could be the way to reach a protocol for the use of biologics for the treatment of midportion Achilles tendinopathy and, for this perspective, the authors describe the Foot and Ankle Reconstruction Group algorithm of treatment.
... В. Е. Stein и соавт. [29] сообщили об отличных результатах открытой реконструкции сухожилий без повторного разрыва у пациентов, получавших инъек цию аспирата костного мозга, состоящего в основном из МСК и факторов роста. Только у одного пациента наблюдалось поверхностное расхождение раны через 30 мес. ...
Article
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The mechanical properties of tendons are thought to be affected by different loading levels. Changes in the mechanical properties of tendons, such as stiffness, have been reported to influence the risk of tendon injuries chiefly in athletes and the elderly, thereby affecting motor function execution. Unloading resulted in reduced tendons stiffness, and resistance exercise exercise counteracts this. Transforming growth factor-1 is a potent inducer of type I collagen and mechanosensitive genes encoding tenogenic differentiation markers expression which play critical roles in tendon tissue formation, tendon healing and their adaptation during exercise. In recent years, our understanding of the molecular biology of tendons growth and repair has expanded. It is probable that the next advance in the treatment of tendon injuries will result from the application of this basic science knowledge and the clinical solution will encompass not only the the best postoperative rehabilitation protocols, but also the optimal biological modulation of the healing process.
... The use of BMC for acute sports-related Achilles tendon rupture was demonstrated in studies with 27 patients (485). In this group of patients, there were no adverse outcomes or reruptures. ...
Article
Full-text available
Background: The use of bone marrow concentrate (BMC) for treatment of musculoskeletal disorders has become increasingly popular over the last several years, as technology has improved along with the need for better solutions for these pathologies. The use of cellular tissue raises a number of issues regarding the US Food and Drug Administration's (FDA) regulation in classifying these treatments as a drug versus just autologous tissue transplantation. In the case of BMC in musculoskeletal and spine care, this determination will likely hinge on whether BMC is homologous to the musculoskeletal system and spine. Objectives: The aim of this review is to describe the current regulatory guidelines set in place by the FDA, specifically the terminology around "minimal manipulation" and "homologous use" within Regulation 21 CFR Part 1271, and specifically how this applies to the use of BMC in interventional musculoskeletal medicine. Methods: The methodology utilized here is similar to the methodology utilized in preparation of multiple guidelines employing the experience of a panel of experts from various medical specialties and subspecialties from differing regions of the world. The collaborators who developed these position statements have submitted their appropriate disclosures of conflicts of interest. Trustworthy standards were employed in the creation of these position statements. The literature pertaining to BMC, its effectiveness, adverse consequences, FDA regulations, criteria for meeting the standards of minimal manipulation, and homologous use were comprehensively reviewed using a best evidence synthesis of the available and relevant literature.RESULTS/Summary of Evidence: In conjunction with evidence-based medicine principles, the following position statements were developed: Statement 1: Based on a review of the literature in discussing the preparation of BMC using accepted methodologies, there is strong evidence of minimal manipulation in its preparation, and moderate evidence for homologous utility for various musculoskeletal and spinal conditions qualifies for the same surgical exemption. Statement 2: Assessment of clinical effectiveness based on extensive literature shows emerging evidence for multiple musculoskeletal and spinal conditions.• The evidence is highest for knee osteoarthritis with level II evidence based on relevant systematic reviews, randomized controlled trials and nonrandomized studies. There is level III evidence for knee cartilage conditions. • Based on the relevant systematic reviews, randomized trials, and nonrandomized studies, the evidence for disc injections is level III.• Based on the available literature without appropriate systematic reviews or randomized controlled trials, the evidence for all other conditions is level IV or limited for BMC injections. Statement 3: Based on an extensive review of the literature, there is strong evidence for the safety of BMC when performed by trained physicians with the appropriate precautions under image guidance utilizing a sterile technique.Statement 4: Musculoskeletal disorders and spinal disorders with related disability for economic and human toll, despite advancements with a wide array of treatment modalities.Statement 5: The 21st Century Cures Act was enacted in December 2016 with provisions to accelerate the development and translation of promising new therapies into clinical evaluation and use. Statement 6: Development of cell-based therapies is rapidly proliferating in a number of disease areas, including musculoskeletal disorders and spine. With mixed results, these therapies are greatly outpacing the evidence. The reckless publicity with unsubstantiated claims of beneficial outcomes having putative potential, and has led the FDA Federal Trade Commission (FTC) to issue multiple warnings. Thus the US FDA is considering the appropriateness of using various therapies, including BMC, for homologous use.Statement 7: Since the 1980's and the description of mesenchymal stem cells by Caplan et al, (now called medicinal signaling cells), the use of BMC in musculoskeletal and spinal disorders has been increasing in the management of pain and promoting tissue healing. Statement 8: The Public Health Service Act (PHSA) of the FDA requires minimal manipulation under same surgical procedure exemption. Homologous use of BMC in musculoskeletal and spinal disorders is provided by preclinical and clinical evidence. Statement 9: If the FDA does not accept BMC as homologous, then it will require an Investigational New Drug (IND) classification with FDA (351) cellular drug approval for use. Statement 10: This literature review and these position statements establish compliance with the FDA's intent and corroborates its present description of BMC as homologous with same surgical exemption, and exempt from IND, for use of BMC for treatment of musculoskeletal tissues, such as cartilage, bones, ligaments, muscles, tendons, and spinal discs. Conclusions: Based on the review of all available and pertinent literature, multiple position statements have been developed showing that BMC in musculoskeletal disorders meets the criteria of minimal manipulation and homologous use. Key words: Cell-based therapies, bone marrow concentrate, mesenchymal stem cells, medicinal signaling cells, Food and Drug Administration, human cells, tissues, and cellular tissue-based products, Public Health Service Act (PHSA), minimal manipulation, homologous use, same surgical procedure exemption.
... Of those patients, 92% returned to their sport at 5.9 months. No soft tissue masses, bone formation, or tumors were observed in the operated extremity [85]. ...
Chapter
Tendinopathy is a common clinical problem which affects a substantial portion of recreational and professional athletes and those in many occupations involving repetitive work [1].
... After removal of duplicates, 684 singular articles were found. After title and abstract selection seven articles [34][35][36][37][38][39][40] were selected for full-text evaluation (figure 1). Two trials 37 39 were excluded because we were unable to determine whether stem cells had actually been injected as no analyses were performed to investigate whether stem cells were actually present. ...
Article
Introduction: Stem cells have emerged as a new treatment option for tendon disorders. We systematically reviewed the current evidence for stem cell therapy in tendon disorders. Methods: Randomised and non-randomised controlled trials, cohort studies and case series with a minimum of 5 cases were searched in MEDLINE, CENTRAL, EMBASE, CINAHL, PEDro and SPORTDiscus. In addition, we searched grey literature databases and trial registers. Only human studies were included and no time or language restrictions were applied to our search. All references of included trials were checked for possibly eligible trials. Risk of bias assessment was performed using the Cochrane risk of bias tool for controlled trials and the Newcastle-Ottawa scale for case series. Levels of evidence were assigned according to the Oxford levels of evidence. Results: 4 published and three unpublished/pending trials were found with a total of 79 patients. No unpublished data were available. Two trials evaluated bone marrow-derived stem cells in rotator cuff repair surgery and found lower retear rates compared with historical controls or the literature. One trial used allogenic adipose-derived stem cells to treat lateral epicondylar tendinopathy. Improved Mayo Elbow Performance Index, Visual Analogue Pain scale and ultrasound findings after 1-year follow-up compared with baseline were found. Bone marrow-derived stem cell-treated patellar tendinopathy showed improved International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score subscales and Tegner scores after 5-year follow-up. One trial reported adverse events and found them to be mild (eg, swelling, effusion). All trials were at high risk of bias and only level 4 evidence was available. Conclusions: No evidence (level 4) was found for the therapeutic use of stem cells for tendon disorders. The use of stem cell therapy for tendon disorders in clinical practice is currently not advised.
... 28,29 This progress has been achieved following a transformation from recognized primary surgery to minimally invasive repairs and functional treatments that are in vogue. 11,30 In addition, current evidence indicates that adjunct biologics such as fibrin glues (adhering rupture ends), 31 platelet-rich fibrin matrix (releasing highly complex pools of signaling factors), 32 bone marrow aspirate concentrate (injecting mesenchymal stem cells) 33 and platelet-rich plasma (releasing more than 300 bioactive proteins), 34 have the potential to help accelerate tendon healing. There were several reasons for addressing the trend toward minimally invasive injection combined with bioactive agents. ...
Article
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Objective: Tissue engineering approaches seem to be an attractive therapy for tendon rupture. Novel injectable porous gelatin microcryogels (GMs) can promote cell attachment and proliferation, thus facilitating the repair potential for target tissue regeneration. The research objectives of this study were to assess the efficacy of tissue-like microunits constructed by multiple GMs laden with adipose-derived mesenchymal stem cells (ASCs) in accelerated tendon regeneration in a rat model. Methods: Through a series of experiments, such as isolation and identification of ASCs, scanning electron microscopy, mercury intrusion porosimetry (MIP), laser scanning confocal microscopy and the CCK-8 test, the biocompatibility of GMs was evaluated. In an in vivo study, 64 rat right transected Achilles tendons were randomly divided into four groups: the ASCs+GMs group (microunits aggregated by multiple ASC-laden GMs injected into the gap), the ASCs group (ASCs injected into the gap), the GMs group (GMs injected into the gap) and the blank defect group (non-treated). At 2 and 4 weeks postoperatively, the healing tissue was harvested to evaluate the gross observation and scoring, biomechanical testing, histological staining and quantitative scoring. Gait analysis was performed over time. The 64 rats were randomly assigned into 4 groups: (1) micro-unit group (ASCs+GMs) containing ASC (105)-loaded 120 GMs in 60 μL DMEM; (2) cell control group (ASCs) containing 106 ASCs in 60 μL DMEM; (3) GM control group (GMs) containing 120 blank GMs in 60 μL DMEM; (4) blank defect group (Defect) containing 60 μL DMEM, which were injected into the defect sites. All animals were sacrificed at 2 and 4 weeks postsurgery (Table 1). Results: In an in vitro study, GMs (from 126 μm to 348 μm) showed good porosities and a three-dimensional void structure with a good interpore connectivity of the micropores and exhibited excellent biocompatibility with ASCs. As the culture time elapsed, the extracellular matrix (ECM) secreted by ASCs encased the GMs, bound multiple microspheres together, and then formed active tendon tissue-engineering microunits. In animal experiments, the ASCs+GMs group and the ASCs group showed stimulatory effects on Achilles tendon healing. Moreover, the ASCs+GMs group was the best at improving the macroscopic appearance, histological morphology, Achilles functional index (AFI), and biomechanical properties of repair tissue without causing adverse immune reactions. Conclusion: Porous GMs were conducive to promoting cell proliferation and facilitating ECM secretion. The ASCs-GMs matrices showed an obvious therapeutic efficiency for Achilles tendon rupture in rats.
... The use of BMAC in surgery is not entirely new as it has been widely used by orthopaedic surgeons in the treatment of bone defects, bone healing disorders and osteonecrosis with promising results [15,[22][23][24]. Furthermore, BMAC was used to augment the healing of hip capsular injury [25], Achilles tendon rupture [26], rotator cuff injury [27] and tennis elbow [28]. ...
Article
Full-text available
Background and aim: Overlapping anal sphincter repair (OASR) is used for treatment of faecal incontinence (FI) due to an external anal sphincter (EAS) defect; however, it is not the optimal treatment as its functional results tend to deteriorate significantly with time. The present study aimed to evaluate the effect of local injection of bone marrow aspirate concentrate (BMAC) on the outcome of OASR. Patients and methods: We compared a prospective group of 20 patients with EAS defect who were managed with OASR and BMAC injection (group I) with a historical control group of equal number of patients managed with OASR alone (group II). Patients were assessed preoperatively and during follow-up by Wexner continence score and endoanal ultrasound (EAUS). The primary endpoints were the improvement of the continence level measured by Wexner score, and residual EAS defect size measured by EAUS. Results: At the end of follow-up, group I had significantly lower mean postoperative Wexner score (5.4 ±7.6 Vs 10.6 ± 7.4; p= 0.03) and smaller EAS defect% (12.2±17.5 Vs 18.3 ±18.9). These findings were statistically significant in patients with a small preoperative EAS defect equal to or less than one-third of the anal circumference. Patients with larger preoperative EAS did not show significant improvement of the continence level after repair in both groups. Conclusion: Augmenting OASR with local injection of BMAC in patients with FI caused by a EAS defects, particularly the smaller defects, can improve both functional and anatomical outcomes of OASR. This article is protected by copyright. All rights reserved.
... One study evaluated open Achilles tendon repair augmented with BMA and reported excellent functional outcomes, early mobilization, normal range of motion, and no re-ruptures at a mean follow-up of 29.7 months [62]. One study evaluated the use of BMA during rotator cuff repair and reported enhanced healing rates, improved quality of the repair surface on ultrasound and MRI, and a decreased risk of re-rupture when compared to the control group [63]. ...
Article
PurposeThree hundred seventy million years ago, bone marrow appeared in skeleton of a fish. More than one hundred years ago, the concept of bone marrow transplantation was proposed to treat human diseases. During the last five decades, this concept became a reality first in hematology and later for orthopaedic diseases.Material and methodsThese advances were possible due to the comprehension of the three major components of bone marrow: the fat part, the haematologic part, and the stroma part. Each part has a different history, but the three parts are linked in physiology as in history.ResultsDuring many centuries, bone marrow was considered just as food; however, one hundred years ago, the concept of bone marrow transplantation to treat humans was proposed by the French physician Brown-Séquard. During the last five decades, this concept became a reality first in haematology and later for orthopaedic diseases. Transferring what was known from experimental animal models to humans was met with many challenges, the atomic bomb research, and many deaths. Yet through the recognition and subsequent understanding of fundamental processes, medical resiliency, and the determination of a few pioneers, local bone marrow transplantation in orthopaedic surgery became a therapeutic option first for a limited number of diseases and patients. Over the last two decades, mesenchymal stromal cells (MSCs) have been the focus of intense research by acadaemia and industry due to their unique features. MSCs can be easily isolated and expanded through in vitro culture by taking full advantage of their self-renewing capacity. In addition, MSCs exert immunomodulatory effects and can be differentiated into various lineages, which makes them highly attractive for clinical applications in cell-based therapies.Conclusion In this review, we attempted to provide a historical overview of bone marrow history, MSC discovery, characterization, and the first clinical studies conducted.
... One retrospective cohort study showed good Achilles tendon rupture scores and a high return to sport rate of 92% after open repair of an Achilles tendon rupture in combination of BMAC injection. 38 ...
Article
Full-text available
In the past 2 decades, there has been a rapid expansion of clinical studies investigating the safety and efficacy of biological treatment methods for a wide range of diseases. These biological treatment methods increasingly are used in clinical practice based on limited available evidence. This article provides an overview of evidence on biological treatment methods for foot and ankle pathologies, including ankle osteoarthritis, osteochondral lesions of the talus, and Achilles tendinopathy.
Chapter
Until relatively recently, regenerative medicine has been a research term used to describe engineering or regrowing tissue to re-establish normal function [1]. Though research in this field and its clinical applications are novel, the central tenets are ancient. The idea that noxious stimuli applied to injured tissue can induce healing is traceable to 500 BC in Rome, where soldiers with joint dislocations were treated with hot needle therapy [2]. In the twentieth century, a practice known as prolotherapy, in which hyperosmolar substances were injected into damaged tissue, was popularized. As we have learned more about inflammation and its mediators, platelet-rich plasma (PRP) injections have been investigated as a method to regenerate tissue in a manner that is theoretically similar to prolotherapy. It is reasoned that because platelets contain inflammatory mediators and these molecules are critical to the healing process, injecting a higher than physiologic concentration of platelets could induce tissue regeneration with normal cell architecture.
Article
Background: The changing demographics of Achilles tendon rupture (ATR) patients have not fully been investigated. However, there has been a general suspicion that this injury is occurring in an increasingly older population, in terms of mean age. The aim of this study was to objectively show an increase in age in Achilles tendon rupture patients over time. Methods: Published literature on Achilles tendon ruptures was searched for descriptive statistics on the demographics of patients in the studies, specifically mean and median age of Achilles tendon rupture patients, gender ratio, percentage of athletics-related injuries, percentage of smokers, and BMI. Linear regression analyses were performed to determine the trend of patient demographics over time. A Welch one-way ANOVA was carried out to identify any possible differences in data obtained from different types of studies. Results: The patient demographics from 142 studies were recorded, with all ATR injuries occurring between the years 1953 and 2014. There was no significant difference in the mean age data reported by varying study types, i.e. randomized controlled trial, cohort study, case series, etc. (P=0.182). There was a statistically significant rise in mean age of ATR patients over time (P<0.0005). There was also a statistically significant drop in percentage of male ATR patients (P=0.02). There is no significant trend for percentage of athletics-related injuries, smoking or BMI. Conclusion: Since 1953 to present day, the mean age at which ATR occurs has been increasing by at least 0.721 years every five years. In the same time period, the percentage of female study patients with ATR injuries has also been increasing by at least 0.6% every five years. Level of evidence: Level III; Retrospective cohort study.
Article
Background: although Achilles tendon’s rupture is a frequent entity, its rupture at the level of its insertion is not common. Objective: to show a patient who suffered an Achilles' tendon rupture at its insertion and was repaired by an arthroscopic anchor. Clinical case: a 55-year-old white woman. The patient was taken to the Orthopedic Emergency Department because of left Achilles tendon sharp pain, and inability to walk and move the ankle. At that time a cast was applied in flexion position of the ankle: After three days, having performed previous regional anesthesia and asepsis and aseptic measures the patient underwent surgery, a medial incision was made. The full section was confirmed at this insertion. Later an arthroscopic anchor was used to fix the tendon to bone and the tendon fascia was stitched. Conclusions: Achilles tendon re-insertion at the level of its insertion could be performed by using arthroscopic anchors. It is a feasible method for patients with ruptures at this level.
Chapter
Bone marrow provides an invaluable source of cells for cell-based therapies in the orthopedic setting. Bone marrow aspirates (BMAs) contain a diversity of stem and progenitor cell systems, including connective tissue progenitors (CTPs), hematopoietic stem and progenitor cells (HSCs), and progenitors of vascular endothelium (EPCs). Bone marrow can be harvested by percutaneous minimally invasive aspiration or excavation with minimal morbidity. With appropriate anticoagulation, this provides a cell suspension that can be readily processed through a variety of methods.
Article
Orthobiologics are a family of treatments including molecules, cells, or tissues that aid in reparative musculoskeletal processes, employed in the setting of surgical or nonsurgical therapies to supplement bone, cartilage, and tissue regeneration. They are classified as bone grafts, growth factors, stem cell therapy, blood-based preparations, viscosupplementation, and scaffold-based therapy. The most common orthobiologic products used in foot and ankle include platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), bone morphogenic proteins (BMPs), and platelet derived growth factor (PDGF). While extracorporeal shock wave therapy (ESWT) is not itself a biologic, it does stimulate a biologic response, and is included in this chapter. There is ample level I evidence supporting PRP use for OLTs, plantar fasciitis, chronic remitting non-insertional Achilles tendinopathy, and diabetic foot ulcers. PRP may also provide benefit in ankle OA and fracture healing. rhPDGF has been consistently proven in level I studies as a safe and effective alternative to autograft to augment ankle and hindfoot fusions, eliminating the morbidity associated with autograft harvesting. BMAC may be considered as an adjuvant treatment for bone healing, OLTs, and Achilles tendon repair. ESWT is a treatment option for patients with plantar fasciitis and Achilles tendinosis. Cell-based therapies may provide cells capable of osteoblastic differentiation and osteogenic potential, however, further investigation is warranted. In general, orthobiologics have rapidly expanding indications and are becoming increasingly accepted given their clinical benefits of improved pain and function, minimally invasive delivery, and positive safety profiles. To strengthen future evidence-based guidelines for biologic use in foot and ankle, higher evidence studies are required with improved standardization of concentration, treatment protocols, and outcome measures.
Article
Aim This systematic review and meta-analysis sought to identify return to play (RTP) rates following Achilles tendon rupture and evaluate what measures are used to determine RTP. Design A systematic review and meta-analysis were performed. Studies were assessed for risk of bias and grouped based on repeatability of their measure of RTP determination. Data sources PubMed, CINAHL, Web of Science and Scopus databases were searched to identify potentially relevant articles. Eligibility criteria for selecting studies Studies reporting RTP/sport/sport activity in acute, closed Achilles tendon rupture were included. Results 108 studies encompassing 6506 patients were included for review. 85 studies included a measure for determining RTP. The rate of RTP in all studies was 80% (95% CI 75% to 85%). Studies with measures describing determination of RTP reported lower rates than studies without metrics described, with rates being significantly different between groups (p<0.001). Conclusions 80 per cent of patients returned to play following Achilles tendon rupture; however, the RTP rates are dependent on the quality of the method used to measure RTP. To further understand RTP after Achilles tendon rupture, a standardised, reliable and valid method is required.
Article
Bone marrow aspirate has been used for the adjunctive treatment of numerous pathologic conditions in orthopedics. Viable cells are found in aspiration from many different anatomic regions of the body. Concentration of these cells has been shown to improve healing due to the increased number of certain important cells. This article discusses the mechanisms involved and reviews the literature.
Article
Regenerative medicine has shown dramatic expanse and evolution in the past decade. Within that milieu, physiatrists are taking an active role in research, clinical care delivery, and education. The purpose of this review is to provide a balance among evidence, theory, experience, clinical trends, and the foreseeable future. We focus on the literature that reports the research with the best methodology in each practice area, recognizing that the level of evidence varies substantially among different treatment modalities and conditions. The following elements are included: an overview of the evolution of currently available regenerative techniques, evidence base for each available modality (prolotherapy, platelet rich plasma, bone marrow aspirate concentrate and stem cells, adipose-derived stem cells, and amniotic tissue products), general principles in the application of these treatments, and discussion and a vision of what lies ahead. We expect that practitioners will use this review to facilitate clinical decision making and to provide a core knowledge base to assist when counseling patients. Level of evidence: To be determined.
Article
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Background: Interest in the therapeutic potential of bone marrow aspirate concentrate (BMAC) has grown exponentially. However, comparisons among studies and their processing methods are challenging because of inconsistent reporting of protocols, as well as poor characterization of the composition of the initial bone marrow aspirate and of the final products delivered. The purpose of this study was to perform a systematic review of the literature to evaluate the level of reporting related to the protocols used for BMAC preparation and the composition of BMAC utilized in the treatment of musculoskeletal diseases in published clinical studies. Methods: A systematic review of the literature was performed by searching PubMed, MEDLINE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials from 1980 to 2016. Inclusion criteria were human clinical trials, English language, and manuscripts that reported on the use of BMAC in musculoskeletal conditions. Results: After a comprehensive review of the 986 identified articles, 46 articles met the inclusion criteria for analysis. No study provided comprehensive reporting that included a clear description of the preparation protocol that could be used by subsequent investigators to repeat the method. Only 14 (30%) of the studies provided quantitative metrics of the composition of the BMAC final product. Conclusions: The reporting of BMAC preparation protocols in clinical studies was highly inconsistent and studies did not provide sufficient information to allow the protocol to be reproduced. Moreover, comparison of the efficacy and yield of BMAC products is precluded by deficiencies in the reporting of preparation methods and composition. Future studies should contain standardized and stepwise descriptions of the BMAC preparation protocol, and the composition of the BMAC delivered, to permit validating and rationally optimizing the role of BMAC in musculoskeletal care.
Book
Mesenchymal Stem Cells in the form of expanded stem cells are believed to have multipotent plasticity. The expanded stem cells are capable of being differentiated into various cell lineages such as cartilage, bone, tendon, muscle, and nerve. These unique purported properties can play a significant role in the repair and regeneration of various tissues across a number of orthopaedic specialties. Bone marrow is regarded as the most used source of Mesenchymal Stem Cells in orthopaedic surgery and historically many surgeons have utilised unprocessed Bone Marrow Aspirate, in attempt to stimulate healing. The main concern in using Bone Marrow Aspirate to stimulate tissue repair/regeneration is the low concentration of stem cells found within it. To address this issue, various protocols have been developed to concentrate the nucleated cell numbers to produce Bone Marrow Aspirate Concentrate. The concept of Bone Marrow Aspirate Concentrate is to improve the recovery of the nucleated cells from the marrow aspirate, while decreasing the recovery of non-nucleated cells such as RBCs. This book aims to examine the current reported clinical applications of bone marrow aspirate concentrate and expanded stem cells and their effectiveness in orthopaedic surgery.
Chapter
Mesenchymal stem cells (MSCs) are perceived as an innovative approach to manage osteoarthritis (OA). There are anticipations that MSCs might improve symptoms, function, suppress inflammation and improve cartilage healing. Notwithstanding, the usage of MSCs in the treatment of osteoarthritis needs to be adequately represented, as there are many crucial determinants that should be considered before definitive reliable conclusions concerning the role of MSCs as a treatment option of OA can be drawn.
Article
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In this report, we describe a rare complication of an open re-rupture of the Achilles tendon following a minimally invasive Achilles tendon repair on a healthy 29-year-old active male. The reinjury happened 19 weeks following the primary surgical repair of a spontaneous rupture, performed by minimally invasive technique with the help of a jig using partially absorbable sutures and four locking stitches. The wound of the open re-rupture was transverse, in a perpendicular orientation relative to the longitudinal approach used in the index procedure. Increased scar tissue formation, the absence of an adequate layer of paratenon overlying the primary tendon repair, and foreign-body reaction to the suture may have been involved in the occurrence of this unusual complication in the surgical treatment of Achilles tendon rupture.
Article
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This work provides easily accessible guidelines for the diagnosis, treatment and rehabilitation of Achilles tendon ruptures. These guidelines could be considered as recommendations for good clinical practice developed through a process of systematic review of the literature and expert opinion, to improve the quality of care for the individual patient and rationalize the use of resources. This work is divided into two sessions: 1) questions about hot topics; 2) answers to the questions following Evidence Based Medicine principles. Despite the frequency of the pathology andthe high level of satisfaction achieved in treatment of Achilles tendon ruptures, a global consensus is lacking. In fact, there is not a uniform treatment and rehabilitation protocol used for Achilles tendon ruptures.
Chapter
Achilles tendinopathy (AT) is a chronic degenerative process that can occur at its insertion on the calcaneus or midsubstance. Presenting signs and symptoms include pain and swelling over a region of nodular tendon thickening. Biologic therapies for AT aim to restore the properties of the native tendon, thereby reducing pain, improving function, and reducing the risk of rupture. Biologic therapies may help facilitate a more robust healing response compared to other commonly used nonsurgical treatment modalities, thereby resulting in a tendon with biomechanical properties that are more similar to the native uninjured tendon. These therapies may also have a role as an adjuvant treatment in the surgical setting. Several different types of injectable biologic therapies have been described including corticosteroids, autologous blood products, platelet-rich plasma, sodium hyaluronate, and cell-based solutions. The role of cell-based therapies continues to evolve and includes peripheral blood mononuclear cells, bone marrow aspirate concentrate, and culture-expanded cells including mesenchymal stromal cells and adipose-derived stromal cells. This chapter specifically focuses on injectable biologic therapies for Achilles tendon pathology. While the main focus will be on AT, results of injectable biologics in the setting of Achilles tendon repair will be briefly discussed. Based on currently available evidence, no definite treatment recommendations can be made, and biologic therapies should be used judiciously, tailoring the treatment to the needs of the patient while setting appropriate expectations for treatment outcomes.
Article
Full-text available
I.S.Mu.L.T. achilles tendon ruptures guidelines
Article
Bone marrow aspirate concentrate (BMAC) is now commonly used in orthopedic surgery. Animal studies showed promising results for cartilage, bone, and soft tissue healing; however, many of these outcomes have yet to be translated to human models. While there has been an increase in the use of BMAC in foot and ankle procedures, the associated clinical evidence is limited. The purpose of this review is to analyze the existing literature in order to evaluate the safety and efficacy of BMAC in foot and ankle surgery.
Chapter
Musculoskeletal disorders such as osteoarthritis and tendinopathies affect a large number of the population leading to activity limitations and disability. With limited suboptimal treatment options available and the current advancements in medicine, regenerative medicine is being looked at as the new frontier for interventional therapies. In addition to prolotherapy and PRP, stem cell therapy is quickly becoming the focus of therapeutic autologous treatment options. Stem cells, to be more specific, are multipotent cells that can be found in various parts of the body; they can be accessed and harvested through minimally invasive means and then processed to create an injectate. Autologous stem cells for use in the orthopedic setting are either adipocytes or mesenchymal, derived from fat tissue or bone marrow, respectively. The growing body of research has demonstrated favorable clinical outcomes, such as decreased pain and increased function, and as the research regarding stem cell therapies continues to grow, this could prove to be a safe and efficacious treatment option for those suffering from both acute and chronic pain and functional limitations.
Chapter
Orthobiologics is an evolving field in the management of soft tissue injuries in athletes. This field has grown exponentially in the past decade and an abundance of new treatments have emerged. However, current evidence is limited, conflicting, and heterogenous, and therefore determining the best clinical practice for specific soft tissue injuries is challenging. This chapter aims to relay the best available evidence regarding the role of orthobiologics in the management of tendon and fascia pathologies in athletes.
Article
Full-text available
Introduction: Sport injuries, most of the time affect muscles, tendons, ligaments, cartilage and bones and range from very mild to severe, prompting different therapeutic approaches. Overuse is the most common cause of sports injuries and half of those injuries affect tendon, tendon sheet and tendon insertion to the bone. The number of ligament injuries, particularly anterior cruciate ligament (ACL) increasing. Aim: We were searching PubMed, Google Scholar and Medline focusing on human clinical studies related to stem cell therapy for tendinopathies and ligament injuries. Considering small number of published articles, we accepted papers with all level of evidence without following strict PRISMA guidelines. Results: The number of studies related to ligament injuries is very low compared to tendon injuries. In human clinical trials there have been only a few studies published so far. In double blind randomized control trial (RCT) Wang and coauthors combined allogenic precursor mesenchymal stem cells (MPC) with hyaluronic acid (HA) and compared with hyaluronic acid alone in 17 patients underwent ACL reconstruction. Intensity of pain and quality of life were assessed by Knee Injury and Osteoarthritis Outcome Score (KOOS) and SF-36v2 scores. A width of joint space, volume of cartilage and bone were recorded by magnetic resonance imaging (MRI). Moderate arthralgia and swelling were detected within 24 hours after the injection in 4 out of 11 patients in the group receiving MSC+HA. In the group receiving only HA, there were no adverse reactions. The signs of slowing down of regenerative process were presented on MRI by preserving joint space and reducing degradation of cartilage volume. Conclusion: Clinical application of MSCs for treatment of tendon and ligament injuries might be good alternative option for athletes. Published clinical studies confirmed clinical improvement and integrity of impaired tissues. However, RTCs are needed to confirm real potential of cell therapy and their advantages comparing to other treatment options.
Article
Introduction Tendon healing is a complicated process that results in inferior structural and functional properties when compared with healthy tendon; the purpose of this study was to assess the effects of the adjunct of microfragmented adipose tissue (M-FATS) after the suture of a series of Achilles tendons. Methods After complete Achilles tendon tear, 8 patients underwent open suture repair in conjunction with perilesional application of a preparation of M-FATS rich in mesenchymal stem cells. Results were compared with a similar group of patients treated with conventional open suture. Outcomes were evaluated based on range of motion, functional recovery, and complications according to the American Orthopedic Foot and Ankle Society (AOFAS) score and Foot and Ankle Disability Index (FADI). Achilles tendons were examined by ultrasound (US) at 3 months. Results The AOFAS and FADI scores showed no differences between the 2 groups. US evaluation showed quicker tendon remodeling in the M-FATS group. Adverse events were not documented for both procedures. Conclusions The combined application of derived M-FATS for tendon rupture is safe and presents new possibilities for enhanced healing. Levels of Evidence Level IIIb: Case control study
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Objectives: The incidence of acute Achilles tendon rupture appears to be increasing. The aim of this study was to summarize various therapies for acute Achilles tendon rupture and discuss their relative merits. Methods: A PubMed search about the management of acute Achilles tendon rupture was performed. The search was open for original manuscripts and review papers limited to publication from January 2006 to July 2017. A total of 489 papers were identified initially and finally 323 articles were suitable for this review. Results: The treatments of acute Achilles tendon rupture include operative and nonoperative treatments. Operative treatments mainly consist of open repair, percutaneous repair, mini-open repair, and augmentative repair. Traditional open repair has lower re-rupture rates with higher risks of complications. Percutaneous repair and mini-open repair show similar re-rupture rates but lower overall complication rates when compared with open repair. Percutaneous repair requires vigilance against nerve damage. Functional rehabilitation combining protected weight-bearing and early controlled motion can effectively reduce re-rupture rates with satisfactory outcomes. Biological adjuncts help accelerating tendon healing by adhering rupture ends or releasing highly complex pools of signalling factors. Conclusion: The optimum treatment for complete rupture remains controversial. Both mini-open repair and functional protocols are attractive alternatives, while biotherapy is a potential future development.Cite this article: X. Yang, H. Meng, Q. Quan, J. Peng, S. Lu, A. Wang. Management of acute Achilles tendon ruptures: A review. Bone Joint Res 2018;7:561-569. DOI: 10.1302/2046-3758.710.BJR-2018-0004.R2.
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Purpose: Open fibrin gluing is reported to enable anatomical reconstruction with less soft tissue compromise than suture repair. Our main objective was to compare the complication rate, function, pain and disability of the two operative approaches of percutaneous suture using the Paessler technique and open fibrin gluing. Methods: Sixty-four patients (two centres, retrospective cohort study, 2000-2009) who had undergone acute Achilles tendon repair with either percutaneous suture (n = 27; 44 years) or open fibrin glue (n = 37; 45 years) took part in a follow-up examination after a median of 63 months (range, six to 180). Ankle range of motion, calf and ankle circumferences and return to work and sports activities were evaluated. Isokinetic und sonographic evaluation results were retrieved. Results: Complications were noted in 22 patients (34 %). Delayed wound healing without evidence of surgical site infection was found in three patients in the fibrin group and two patients in the suture group. Postoperative scar tenderness described as pain at the rim of the shoe was significantly more frequent in the suture group (p = 0.03). Re-rupture requiring re-operation occurred in one patient. Transient paresthesia of the heel occurred in 12 patients. No sural nerve lesions were reported. There was no significant difference between groups regarding lower leg circumference, disability, or function. Ultrasound and isokinetic measurements did not reveal a significant difference between the two methods. Conclusions: The present study suggests that open fibrin gluing is a reasonable alternative to percutaneous repair of acute ruptures of the Achilles tendon and both techniques can yield reliably good results.
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Objectives The purpose of this study was to investigate the efficacy of a composite surgical mesh for delivery of mesenchymal stem cells (MSCs) in tendon repair. Methods The MSC-loaded mesh composed of a piece of conventional surgical mesh and a layer of scaffold, which supported MSC-embedded alginate gel. A 3-mm defect was surgically created at the Achilles tendon-gastrocnemius/soleus junction in 30 rats. The tendon defects were repaired with either 1) MSC-loaded mesh; or 2) surgical mesh only; or 3) routine surgical suture. Repaired tendons were harvested at days 6 and 14 for histology, which was scored on the bases of collagen organization, vascularity and cellularity, and immunohistochemisty of types I and III collagen. Results In comparison with the other two repair types, at day 6, the MSC-loaded mesh significantly improved the quality of the repaired tendons with dense and parallel collagen bundles, reduced vascularity and increased type I collagen. At day 14, the MSC-loaded mesh repaired tendons had better collagen formation and organization. Conclusion The MSC-loaded mesh enhanced early tendon healing, particularly the quality of collagen bundles. Application of the MSC-loaded mesh, as a new device and MSC delivery vehicle, may benefit to early functional recovery of the ruptured tendon.
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Mesenchymal stromal cells attract much interest in tissue regeneration because of their capacity to differentiate into mesodermal origin cells, their paracrine properties and their possible use in autologous transplantations. The aim of this study was to investigate the safety and reparative potential of implanted human mesenchymal stromal cells (hMSCs), prepared under Good Manufacturing Practice (GMP) conditions utilizing human mixed platelet lysate as a culture supplement, in a collagenase Achilles tendon injury model in rats. Eighty-one rats with collagenase-induced injury were divided into two groups. The first group received human mesenchymal stromal cells injected into the site of injury 3 days after lesion induction, while the second group received saline. Biomechanical testing, morphometry and semiquantitative immunohistochemistry of collagens I, II and III, versican and aggrecan, neovascularization, and hMSC survival were performed 2, 4, and 6 weeks after injury. Human mesenchymal stromal cell-treated rats had a significantly better extracellular matrix structure and a larger amount of collagen I and collagen III. Neovascularization was also increased in hMSC-treated rats 2 and 4 weeks after tendon injury. MTCO2 (Cytochrome c oxidase subunit II) positivity confirmed the presence of hMSCs 2, 4 and 6 weeks after transplantation. Collagen II deposits and alizarin red staining for bone were found in 6 hMSC- and 2 saline-treated tendons 6 weeks after injury. The intensity of anti-versican and anti-aggrecan staining did not differ between the groups. hMSCs can support tendon healing through better vascularization as well as through larger deposits and better organization of the extracellular matrix. The treatment procedure was found to be safe; however, cartilage and bone formation at the implantation site should be taken into account when planning subsequent in vivo and clinical trials on tendinopathy as an expected adverse event.
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BACKGROUND:The optimal treatment for acute Achilles tendon ruptures is still a subject of debate. Early loading of the tendon is a factor that has been shown to be beneficial to recovery and to minimize complications. The main outcome of previous studies has been complications such as reruptures and deep infections, without focusing on the functional outcome relevant to the majority of patients who do not experience these complications. PURPOSE:To evaluate whether stable surgical repair and early loading of the tendon could improve patient-reported outcome and function after an acute Achilles tendon rupture. STUDY DESIGN:Randomized controlled trial; Level of evidence, 1. METHODS:A total of 100 patients (86 men, 14 women; mean age, 40 years) with an acute total Achilles tendon rupture were randomized to either surgical treatment, including an accelerated rehabilitation protocol, or nonsurgical treatment. The primary outcome was the Achilles tendon Total Rupture Score (ATRS). The patients were evaluated at 3, 6, and 12 months for symptoms, physical activity level, and function. RESULTS:There were no significant differences between the groups in terms of symptoms, physical activity level, or quality of life. There was a trend toward improved function in surgically treated patients; the results were significantly superior when assessed by the drop countermovement jump (95% CI, 0.03-0.15; P = .003) and hopping (95% CI, 0.01-0.33; P = .040). No reruptures occurred in the surgical group, while there were 5 in the nonsurgical group (P = .06). There were 6 superficial infections in the surgically treated group; however, these superficial infections had no bearing on the final outcome. Symptoms, reduced quality of life, and functional deficits still existed 12 months after injury on the injured side in both groups. CONCLUSION:The results of the present study demonstrate that stable surgical repair with accelerated tendon loading could be performed in all (n = 49) patients without reruptures and major soft tissue-related complications. However, this treatment was not significantly superior to nonsurgical treatment in terms of functional results, physical activity, or quality of life.
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Purpose: Ideally, a classification should have some prognostic value, and should therefore include precise information upon extent and location of the Achilles tendon disorders. We propose a new imaging and anatomical system to classify Achilles tendon disorders at imaging using US and MRI. Approach: We consider the non-insertional region as the tendon mid-portion, and distinguish the insertional component into a pre-insertion site, located about two centimetres above the calcaneum, and a calcaneal insertion, where the tendon is attached to the bone. On sagittal scans, we introduced a new classification which considers two main portions: "musculotendinous" and "insertional". In the context of the muscolotendinous portion, it is possible to find muscle fibres proximally, and the free tendon distally. This latter is made up of proximal, middle and distal portions. We also propose a 5 grade Doppler classification system to quantify blood flow, in which Grades I and II are respectively characterised by the presence of one and two vessels within the tendon; in Grades III, IV and V, the neovascularisation respectively involves less than 50 %, from 50 to 90 %, and more than 90 % of the tendon tissue. These proposed systems will require validation and possible modification to be applied to different tendons.
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Purpose Surgical treatment of an acute Achilles tendon rupture can effectively reduce the risk of re-rupture, but it increases the probability of surgical complications. We postulated that a minimally invasive surgical treatment might reduce the number of complications related to open surgery and improve the functional results. Method We enrolled 47 patients with acute Achilles tendon ruptures in a prospective, randomised trial to compare clinical results and complications between a minimally invasive procedure with the Achillon® device and traditional open surgery with Krackow-type sutures. The average patient age was 46 years. The follow up time was 24 months. Results No Achilles tendon re-rupture or nerve injury occurred in treated patients. There were two cases of wound infections in the open surgery group, and one superficial wound infection occurred in the minimally invasive group. The groups were not significantly different in the amount of pain, range of ankle movements, the single heel-rise test, calf circumference, or time to return to work and sports. Conclusion After a two year follow-up period, we found no significant differences in clinical outcomes between groups treated with traditional open surgery or minimally invasive surgery.
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After reinsertion on the humerus, the rotator cuff has limited ability to heal. Growth factor augmentation has been proposed to enhance healing in such procedure. This study was conducted to assess the efficacy and safety of growth factor augmentation during rotator cuff repair. Randomized controlled trial; Level of evidence, 1. Eighty-eight patients with a rotator cuff tear were randomly assigned by a computer-generated sequence to receive arthroscopic rotator cuff repair without (n = 45) or with (n = 43) augmentation with autologous platelet-rich fibrin matrix (PRFM). The primary end point was the postoperative difference in the Constant score between the 2 groups. The secondary end point was the integrity of the repaired rotator cuff, as evaluated by magnetic resonance imaging. Analysis was on an intention-to-treat basis. All the patients completed follow-up at 16 months. There was no statistically significant difference in total Constant score when comparing the results of arthroscopic repair of the 2 groups (95% confidence interval, -3.43 to 3.9) (P = .44). There was no statistically significant difference in magnetic resonance imaging tendon score when comparing arthroscopic repair with or without PRFM (P = .07). Our study does not support the use of autologous PRFM for augmentation of a double-row repair of a small or medium rotator cuff tear to improve the healing of the rotator cuff. Our results are applicable to small and medium rotator cuff tears; it is possible that PRFM may be beneficial for large and massive rotator cuff tears. Also, given the heterogeneity of PRFM preparation products available on the market, it is possible that other preparations may be more effective.
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Animal studies have shown that local application of platelet-rich plasma (PRP) stimulates tendon repair. Preliminary results from a retrospective case series have shown faster return to sports. Autologous PRP stimulates healing of acute Achilles tendon ruptures. Study Randomized controlled trial; Level of evidence, 2. Thirty patients were recruited consecutively. During surgery, tantalum beads were implanted in the Achilles tendon proximal and distal to the rupture. Before skin suture, randomization was performed, and 16 patients were injected with 10 mL PRP (10 times higher platelet concentration than peripheral blood) whereas 14 were not. With 3-dimensional radiographs (roentgen stereophotogrammetric analysis; RSA), the distance between the beads was measured at 7, 19, and 52 weeks while the patient resisted different dorsal flexion moments over the ankle joint, thereby estimating tendon strain per load. An estimate of elasticity modulus was calculated using callus dimensions from computed tomography. At 1 year, functional outcome was evaluated, including the heel raise index and Achilles Tendon Total Rupture Score. The primary effect variables were elasticity modulus at 7 weeks and heel raise index at 1 year. The mechanical variables showed a large degree of variation between patients that could not be explained by measuring error. No significant group differences in elasticity modulus could be shown. There was no significant difference in heel raise index. The Achilles Tendon Total Rupture Score was lower in the PRP group, suggesting a detrimental effect. There was a correlation between the elasticity modulus at 7 and 19 weeks and the heel raise index at 52 weeks. The results suggest that PRP is not useful for treatment of Achilles tendon ruptures. The variation in elasticity modulus provides biologically relevant information, although it is unclear how early biomechanics is connected to late clinical results.
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Tendon disorders (tendinopathies) pose serious biomedical and socioeconomic problems. Despite diverse treatment approaches, the best treatment strategy remains unclear. Surgery remains the last resort because of the associated morbidity and inconsistent outcomes. We hypothesized that, similar to fibroblasts in various organs, tendon fibroblasts (tenocytes) might be responsive to stimulation with interleukins (ILs), particularly IL-4 and IL-13. These two cytokines share sequence homology, receptor chains and functional effects, including stimulation of fibrogenesis. It is unknown whether tenocytes are responsive to stimulation with IL-4 or IL-13. If true, local use of these cytokines might be used to facilitate tendon repair in patients with tendinopathies or used for tendon tissue-engineering approaches to facilitate tenocyte growth on scaffolds in culture. Tendon tissues that would normally be discarded were obtained during reconstructive surgery procedures performed for clinical indications. Primary tenocytes were derived from Achilles, posterior tibial, flexor digitorum longus and flexor hallucis longus tendon tissue samples. Reverse transcriptase quantitative PCR (RT-qPCR) experiments revealed that mRNAs for the receptor (R) chains IL-4Ralpha, IL-13Ralpha1 and IL-13Ralpha2, but not the common gamma-chain were present in all tested tendon tissues and in cultured tenocytes. Levels of IL-13R chain mRNAs were significantly higher than those of IL-4R mRNA. The cultures responded, in a dose-dependent fashion, to stimulation with recombinant human IL-4 or IL-13, by increasing proliferation rates 1.5 to 2.0-fold. The mRNA levels of 84 genes related to cell cycle regulation were measured by RT-qPCR after 6 h and 24 h of activation. The expression levels of several genes, notably CDK6 and CDKN2B changed more than twofold. In contrast to their effects on proliferation, stimulation with IL-4 or IL-13 had little if any effect on the levels of collagen mRNA or protein in cultured primary tenocytes. The mRNA levels of 84 other genes related to extracellular matrix and cell adhesion were also measured by RT-qPCR; expression of only five genes was consistently changed. Stimulation with IL-4 or IL-13 could be used to facilitate tendon repair in vivo or to aid in tendon tissue engineering, through stimulation of tenocyte proliferation.
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There have been reports about the increasing number of Achilles tendon ruptures. The most of the reports are based on records in a few hospitals only. We wanted to verify the increasing trend by investigating the epidemiology of Achilles tendon rupture in a very large population. The retrospective data was collected from 1987 to 1999 in Finnish National Hospital Discharge Register. The study includes 7 375 tendon rupture patients. We recorded their age, gender, home district and the date of admission in a hospital. The incidence of operatively treated Achilles tendon rupture was 11.2/105. The number of the patients was increasing particularly in the old age-groups. The change during the study period was statistically significant (p = 0.015). The females with a tendon rupture were on average 2-3 years older than men (p < 0.01). The urban areas around the capital city had a higher occurrence of tendon ruptures than the rural areas (p < 0.05). The number of Achilles tendon ruptures is increasing, but the reasons for this remain unknown. The geographical variations in rupture rate might indicate the role of the urban life-style as a risk factor. One reason for the differences between the men and the women might be the different level of the sport activities, especially ball-games.
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To ascertain whether there is an association between tendinopathic and ruptured Achilles tendons, hypothesizing that the histopathological aspects of tendinosis in tendinopathic tendons are less advanced than those found in ruptured Achilles tendons. This was a comparative cohort study at a university teaching hospital. Histological examination was performed using hematoxylin and eosin and alcian blue/periodic acid-Schiff stained slides. The slides were interpreted using a semiquantitative grading scale assessing fiber structure, fiber arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, hyalinization, and glycosaminoglycan. We calculated a pathology score giving up to three marks for each of the above variables, with 0 being normal and 3 being maximally abnormal. All the histology slides were assessed twice in a blinded manner, the agreement between two readings ranging from 0.170 to 0.750 (kappa statistics). We studied biopsy samples from the Achilles tendon of patients undergoing open repair for a subcutaneous rupture of their Achilles tendon (N = 35; average age (+/- SD), 48.4 +/- 16.9 yr; range, 26-80), biopsy specimens from the Achilles tendon of patients undergoing exploration for Achilles tendinopathy (N = 13; average age, 35.7 +/- 12.9 yr; range, 18-67) and specimens of Achilles tendons from individuals with no known tendon pathology (N = 16; average age, 65 +/- 19.1 yr; range, 46-82). The highest mean score of ruptured tendons was significantly greater than that of tendinopathic tendons (17.4 +/- 4.9 vs 10.5 +/- 6.1, P < 0.001), and highest mean score of tendinopathic tendons was greater that that of control tendons (10.5 +/- 6.1 vs 5.9 +/- 7.3) (P < 0.001). Ruptured and tendinopathic tendons are histologically significantly more degenerated than control tendons. The general pattern of degeneration was common to the ruptured and tendinopathic tendons, but there was a statistically significant greater degree of degeneration in the ruptured tendons. It is therefore possible that there is a common, as yet unidentified, pathological mechanism that has acted on both of these tendon populations.
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There is no consensus on the best method for management of acute Achilles tendon ruptures. Individual preferences, drawn from experience and study, determine whether treatment is operative or nonoperative. Our goal was to review the literature to try to determine what management method was the most popular and effective. We wanted to ascertain the best results in terms of complication rates and patient outcomes. Retrospective review of retrospectively and prospectively collected data. We analyzed 125 articles in peer-reviewed journals for year of publication, patient numbers, sex, management method, follow-up complications, and patient satisfaction. Each article was graded using a validated methods score. Methods, patient satisfaction, and complication rates were correlated with the year each article was published. Skin-healing complications were lowest in conservatively managed patients (3 of 578, 0.5%) and highest in open repair and immobilized patients (543 of 3718, 14.6%). General complication rates were lowest in open repair and early-mobilization groups (16 of 238, 6.7%) and highest in percutaneous and early-mobilization groups (19 of 122, 15.6%). Rerupture rates were highest in immobilized conservative management groups (62 of 578, 10.7%) and lowest in groups with external fixation (0%). In general, the number of publications reporting Achilles tendon ruptures is increasing, the quality of articles is increasing, and the trend for the number of reported complications is decreasing. The published articles had a low methods score (mean, 50.9; range, 25 to 77) and showed a trend toward earlier mobilization. Open repair and early mobilization give the best functional recovery and an acceptable complication rate.
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The optimal management strategy for acute Achilles tendon rupture is controversial. To determine the optimal management by using expected-value decision analysis. Cross-sectional study. Outcome probabilities were determined from a systematic literature review, and patient-derived utility values were obtained from a visual analog scale questionnaire. A decision tree was constructed, and fold-back analysis was used to determine optimal treatment. Sensitivity analyses were used to determine the effect of varying outcome probabilities and utilities on decision-making. Outcome probabilities (expressed as operative; nonoperative) were as follows: well (0.762; 0.846), rerupture (0.022; 0.121), major complication (0.030; 0.025), moderate complication (0.075; 0.003), and mild complication (0.111; 0.005). Outcome utility values were well operative (7.9), well nonoperative (7.0), rerupture (2.6), major complication (1.0), moderate complication (3.5), and mild complication (4.7). Fold-back analysis revealed operative treatment as the optimal management strategy (6.89 versus 6.30). Threshold values were determined for the probability of a moderate complication from operative treatment (0.21) and the utility of rerupture (6.8). Operative management was the optimal strategy, given the outcome probabilities and patient utilities we studied. Nonoperative management was favored by increasing rates of operative complications; operative, by decreasing utility of rerupture. We advocate a model of doctor-patient shared decision-making in which both outcome probabilities and patient preferences are considered.
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Platelet-rich fibrin matrices release a natural mixture of growth factors that play central roles in the complex processes of tendon healing. Application of autologous platelet-rich matrices during Achilles tendon surgery may promote healing and functional recovery. Case-control study and descriptive laboratory study; Level of evidence, 3. Twelve athletes underwent open suture repair after complete Achilles tendon tear. Open suture repair in conjunction with a preparation rich in growth factors (PRGF) was performed in 6 athletes and retrospectively compared with a matched group that followed conventional surgical procedure. The outcomes were evaluated on the basis of range of motion, functional recovery, and complications. Achilles tendons were examined by ultrasound at 50 +/- 11 months in retrospective controls and 32 +/- 10 months in the PRGF group. In the laboratory portion of the study, PRGF treatment was characterized by the number of platelets and concentration of insulin (IGF-I), transformed (TGF-beta1), platelet-derived (PDGF-AB), vascular endothelial (VEGF), hepatocyte (HGF), and epidermal (EGF) growth factors in patients affected by musculoskeletal traumatic injuries. Athletes receiving PRGF recovered their range of motion earlier (7 +/- 2 weeks vs 11 +/- 3 weeks, P = .025), showed no wound complication, and took less time to take up gentle running (11 +/- 1 weeks vs 18 +/- 3 weeks, P = .042) and to resume training activities (14 +/- 0.8 weeks vs 21 +/- 3 weeks, P = .004). The cross-sectional area of the PRGF-treated tendons increased less (t = 3.44, P = .009). TGF-beta1 (74.99 +/- 32.84 ng/mL), PDGF-AB (35.62 +/- 14.57 ng/mL), VEGF (383.9 +/- 374.9 pg/mL), EGF (481.5 +/- 187.5 pg/mL), and HGF (593.87 +/- 155.76 pg/mL) significantly correlated with the number of platelets (677 +/- 217 platelets/microL, P < .05). The operative management of tendons combined with the application of autologous PRGF may present new possibilities for enhanced healing and functional recovery. This needs to be evaluated in a randomized clinical trial.
Article
Background and Aims: There have been reports about the increasing number of Achilles tendon ruptures. The most of the reports are based on records in a few hospitals only. We wanted to verify the increasing trend by investigating the epidemiology of Achilles tendon rupture in a very large population. Material and Methods: The retrospective data was collected from 1987 to 1999 in Finnish National Hospital Discharge Register. The study includes 7 375 tendon rupture patients. We recorded their age, gender, home district and the date of admission in a hospital. Results: The incidence of operatively treated Achilles tendon rupture was 11.2/10(5). The number of the patients was increasing particularly in the old age-groups. The change during the study period was statistically significant (p = 0.015). The females with a tendon rupture were on average 2-3 years older than men (p < 0.01). The urban areas around the capital city had a higher occurrence of tendon ruptures than the rural areas (p < 0.05). Conclusion: The number of Achilles tendon ruptures is increasing, but the reasons for this remain unknown. The geographical variations in rupture rate might indicate the role of the urban life-style as a risk factor. One reason for the differences between the men and the women might be the different level of the sport activities, especially ball-games.
Article
Tendon healing is a slow and complicated process that results in inferior structural and functional properties when compared to healthy tendon tissue. It may be possible to improve outcomes of tendon healing with enhancement of biological aspects of the repair including tissue structure, organization, and composition. The purpose of this study was to determine whether use of a stem cell-bearing suture improves Achilles tendon healing in a rat model. The Achilles tendon was transected in 108 bilateral hind limbs from 54 rats. Each limb was randomized to repair with suture only (SO), suture plus injection (SI) of mesenchymal stem cells (MSCs) at the repair site, or suture loaded with MSCs (suture with stem cells, SCS). One half of the animals were randomly sacrificed at 14 and 28 days after surgery and the Achilles tendon was harvested. From each repair group at each time point, 12 limbs were randomized to biomechanical testing and 6 to histologic analysis. Tendons were loaded using a 223-N load cell at 0.17 mm/s. A blinded pathologist scored the histology sections. Ultimate failure strength (N/mm(2)) was significantly higher in the SI and SCS groups versus the SO group. In the SI group, ultimate failure strength decreased significantly at 28 days versus 14 days. Histology score in the SCS group was significantly lower (better) than in both other groups (P ≤ .001). Histology findings at day 28 were significantly higher versus day 14 for all groups (P = .01). Both the SI and the SCS groups had significantly higher ultimate failure strength versus the SO group, and strength was maintained at 28 days in the SCS group but not in the SI group. Histology in the SCS group was significantly better than in both other groups. These findings in a rat model suggest that the use of stem cells enhances healing after Achilles repair and that embedding of stem cells directly into suture offers sustained early benefit to tendon healing.
Article
Surgical repair is a common method of treatment of acute Achilles rupture in North America because, despite a higher risk of overall complications, it has been believed to offer a reduced risk of rerupture. However, more recent trials, particularly those using functional bracing with early range of motion, have challenged this belief. The aim of this meta-analysis was to compare surgical treatment and conservative treatment with regard to the rerupture rate, the overall rate of other complications, return to work, calf circumference, and functional outcomes, as well as to examine the effects of early range of motion on the rerupture rate. A literature search, data extraction, and quality assessment were conducted by two independent reviewers. Publication bias was assessed with use of the Egger and Begg tests. Heterogeneity was assessed with use of the I2 test, and fixed or random-effect models were used accordingly. Pooled results were expressed as risk ratios, risk differences, and weighted or standardized mean differences, as appropriate. Meta-regression was employed to identify causes of heterogeneity. Subgroup analysis was performed to assess the effect of early range of motion. Ten studies met the inclusion criteria. If functional rehabilitation with early range of motion was employed, rerupture rates were equal for surgical and nonsurgical patients (risk difference = 1.7%, p = 0.45). If such early range of motion was not employed, the absolute risk reduction achieved by surgery was 8.8% (p = 0.001 in favor of surgery). Surgery was associated with an absolute risk increase of 15.8% (p = 0.016 in favor of nonoperative management) for complications other than rerupture. Surgical patients returned to work 19.16 days sooner (p = 0.0014). There was no significant difference between the two treatments with regard to calf circumference (p = 0.357), strength (p = 0.806), or functional outcomes (p = 0.226). The results of the meta-analysis demonstrate that conservative treatment should be considered at centers using functional rehabilitation. This resulted in rerupture rates similar to those for surgical treatment while offering the advantage of a decrease in other complications. Surgical repair should be preferred at centers that do not employ early-range-of-motion protocols as it decreased the rerupture risk in such patients. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Article
Exogenously administered mesenchymal stem cells and bioactive molecules are known to enhance tendon healing. Biomolecules have been successfully delivered using sutures that elute growth factors over time. We sought to evaluate the histologic and biomechanical effect of delivering both cells and bioactive substrates on a suture delivery vehicle in comparison with sutures coated with bioactive substrates alone. Bone marrow-derived stem cells were harvested from Sprague-Dawley rat femurs. Experimental cell and substrate-coated, coated suture (CS) group sutures were precoated with intercellular cell adhesion molecule 1 and poly-L-lysine and seeded with labeled bone marrow-derived stem cells. Control (substrate-only [SO] coated) group sutures were coated with intercellular cell adhesion molecule 1 and poly-L-lysine only. Using a matched-paired design, bilateral Sprague-Dawley rat Achilles tendons (n = 105 rats) were transected and randomized to CS or SO repairs. Tendons were harvested at 4, 7, 10, 14, and 28 days and subjected to histologic and mechanical assessment. Labeled cells were present at repair sites at all time points. The CS suture repairs displayed statistically greater strength compared to SO repairs at 7 days (12.6 ± 5.0 N vs 8.6 ± 3.7 N, respectively) and 10 days (21.2 ± 4.9 N vs 16.4 ± 4.8 N, respectively). There was no significant difference between the strength of CS suture repairs compared with SO repairs at 4 days (8.1 ± 5.1 N vs 6.6 ± 2.3 N, respectively), 14 days (22.8 ± 7.3 N vs 25.1 ± 9.7 N, respectively), and 28 days (40.9 ± 12.4 N vs 34.6 ± 15.0 N, respectively). Bioactive CS sutures enhanced repair strength at 7 to 10 days. There was no significant effect at later stages. The strength nadir of a tendon repair occurs in the first 2 weeks after surgery. Bioactive suture repair might provide a clinical advantage by jump-starting the repair process during this strength nadir. Improved early strength might, in turn allow earlier unprotected mobilization.
Article
Acute Achilles tendon rupture is a relatively common injury resulting in substantial morbidity in young, active patients. It occurs most frequently in male individuals, and the incidence is thought to be increasing1. There has been a lack of consensus among orthopaedic surgeons regarding the best management of this injury. Treatment can be broadly divided into surgical (open or percutaneous) and nonsurgical (cast immobilization or functional bracing). In 2004 and 2005, our group published a meta-analysis of randomized controlled trials concerning treatment of acute Achilles tendon rupture, including different splinting techniques2,3. We concluded that open operative treatment of Achilles tendon rupture significantly reduced the risk of rerupture compared with nonoperative treatment, but that such treatment was associated with a significantly higher risk of other complications. Since the 2004 meta-analysis, several new randomized controlled trials on the treatment of acute Achilles tendon rupture have been published. In the present meta-analysis, we tested the hypothesis that surgical repair of Achilles tendon rupture reduces the rerupture rate and results in improved long-term function, without an increase in other complications. We focused purely on comparisons between surgical and nonsurgical methods and between different surgical techniques. We present data from fourteen studies involving 1085 patients4-17. We followed the Cochrane guidelines for conducting meta-analyses18. The principal investigators searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (July 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 3), MEDLINE (1966 to July 20, 2009), EMBASE (1966 to 2009 week 29), CINAHL (1983 to July 2007), and reference lists of articles. All randomized and quasi-randomized trials comparing surgical with nonsurgical treatment or comparing different surgical treatments of acute Achilles tendon rupture in adults were included. Retrospective studies, studies with insufficient reporting …
Article
There is a strong need for methods to improve the biological potential of rotator cuff tendon healing. Platelet-rich fibrin matrix (PRFM) allows delivery of autologous cytokines to healing tissue, and limited evidence suggests a positive effect of platelet-rich plasma on tendon biology. To evaluate the effect of platelet-rich fibrin matrix on rotator cuff tendon healing. Randomized controlled trial; Level of evidence, 2. Seventy-nine patients undergoing arthroscopic rotator cuff tendon repair were randomized intraoperatively to either receive PRFM at the tendon-bone interface (n = 40) or standard repair with no PRFM (n = 39). Standardized repair techniques were used for all patients. The postoperative rehabilitation protocol was the same in both groups. The primary outcome was tendon healing evaluated by ultrasound (intact vs defect at repair site) at 6 and 12 weeks. Power Doppler ultrasound was also used to evaluate vascularity in the peribursal, peritendinous, and musculotendinous and insertion site areas of the tendon and bone anchor site. Secondary outcomes included standardized shoulder outcome scales (American Shoulder and Elbow Surgeons [ASES] and L'Insalata) and strength measurements using a handheld dynamometer. Patients and the evaluator were blinded to treatment group. All patients were evaluated at minimum 1-year follow-up. A logistic regression model was used to predict outcome (healed vs defect) based on tear severity, repair type, treatment type (PRFM or control), and platelet count. Overall, there were no differences in tendon-to-bone healing between the PRFM and control groups. Complete tendon-to-bone healing (intact repair) was found in 24 of 36 (67%) in the PRFM group and 25 of 31 (81%) in the control group (P = .20). There were no significant differences in healing by ultrasound between 6 and 12 weeks. There were gradual increases in ASES and L'Insalata scores over time in both groups, but there were no differences in scores between the groups. We also found no difference in vascularity in the peribursal, peritendinous, and musculotendinous areas of the tendon between groups. There were no differences in strength between groups. Platelet count had no effect on healing. Logistic regression analysis demonstrated that PRFM was a significant predictor (P = .037) for a tendon defect at 12 weeks, with an odds ratio of 5.8. Platelet-rich fibrin matrix applied to the tendon-bone interface at the time of rotator cuff repair had no demonstrable effect on tendon healing, tendon vascularity, manual muscle strength, or clinical rating scales. In fact, the regression analysis suggests that PRFM may have a negative effect on healing. Further study is required to evaluate the role of PRFM in rotator cuff repair.
Article
Rotator cuff regeneration using tissue engineering techniques is a challenging treatment in elderly patients with irreparable rotator cuff tears. A polyglycolic acid sheet scaffold with seeded mesenchymal stem cells (MSCs) may enhance the expression of type I collagen products and increase the mechanical strength of the regenerated tendon in vivo. Controlled laboratory study. A surgically created defect of infraspinatus tendons of rabbits was reconstructed with 2 different materials, a polyglycolic acid (PGA) sheet alone (PGA group) (n = 34) and a PGA sheet seeded with autologously cultured MSCs (MSC group) (n = 34). The authors created a tendon defect model without embedding any graft as the control model (control group) (n = 34). The rabbits were sacrificed at 4, 8, and 16 weeks after the operation and then were histologically evaluated. The rabbits were also biomechanically evaluated by measuring the ultimate failure loads and Young's modulus at 4 and 16 weeks following implantation. In the MSC group, the fibrocartilage layers and Sharpey fibers were found regularly in the insertion site at 8 weeks compared with the PGA group. In control group, thin membranes with many fibroblasts arranged in an irregular pattern linked the end of the torn cuff to the bone without any Sharpey fibers and type I collagen. A large volume of type I collagen was found in comparison with type III collagen at 16 weeks in the MSC group, whereas type III collagen was more prevalent than type I in the PGA group. The tendon maturing score in the MSC group had higher values than the PGA and control groups at 8 and 16 weeks (mean values were 21.0 ± 0.89, 24.0 ± 2.53 in the MSC group; 16.7 ± 2.25, 21.3 ± 2.42 in the PGA group; and 10.2 ± 0.98, 12.2 ± 1.72 in the control group, respectively) (P < .05). The results of the mechanical analysis revealed that the regenerated tendons in the MSC group had better tensile strength than in the PGA and control groups at 16 weeks (mean values were 3.04 ± 0.54 in the MSC group, 2.38 ± 0.63 in the PGA group, and 1.58 ± 0.13 in the control group) (P < .05). Bone marrow-derived MSCs were able to regenerate tendon-bone insertions and the tendon belly, including the production of type I collagen, and increased the mechanical strength of the regenerated rotator cuff tendon. Rotator cuff regeneration using MSCs is a promising treatment for massive rotator cuff defects.
Article
Local application of autologous platelet rich plasma (PRP) improves tendon healing in patients undergoing arthroscopic rotator cuff repair. Study design: Prospective, randomized, controlled, double blind study; considering an alpha level of 5%, a power of 80%, 22 patients for group are needed. Fifty-three patients who underwent shoulder arthroscopy for the repair of a complete rotator cuff tear were randomly divided into 2 groups, using a block randomization procedure. A treatment group (N = 26) consisted of those who received an intraoperative application of PRP in combination with an autologous thrombin component. A control group (N = 27) consisted of those who did not receive that treatment. Patients were evaluated with validated outcome scores. A magnetic resonance image (MRI) was performed in all cases at more than 1 year post-op. All patients had the same accelerated rehabilitation protocol. The 2 groups were homogeneous. The pain score in the treatment group was lower than the control group at 3, 7, 14, and 30 days after surgery (P < .05). On the Simple Shoulder Test (SST), University of California (UCLA), and Constant scores, strength in external rotation, as measured by a dynamometer, were significantly higher in the treatment group than the control group at 3 months after surgery (strength in external rotation [SER]: 3 ± 1.6 vs 2.1 ± 1.3 kg; SST: 8.9 ± 2.2 vs 7.1 ± 2.7; UCLA: 26.9 ± 3 vs 24.2 ± 4.9; Constant: 65 ± 9 vs 57.8 ± 11; P < .05). There was no difference between the 2 groups after 6, 12, and 24 months. The follow-up MRI showed no significant difference in the healing rate of the rotator cuff tear. In the subgroup of grade 1 and 2 tears, with less retraction, SER in the PRP group was significant higher at 3, 6, 12, and 24 months postoperative (P < .05). The results of our study showed autologous PRP reduced pain in the first postoperative months. The long-term results of subgroups of grade 1 and 2 tears suggest that PRP positively affected cuff rotator healing.
Article
Platelet-rich plasma (PRP) has generated substantial interest for tendon and ligament regeneration because of the high concentrations of growth factors in platelet alpha-granules. This study compared the temporal release of growth factors from bone marrow aspirate (BMA), PRP, and lyophilized platelet product (PP), and measured their effects on tendon and ligament gene expression. Blood and BMA were collected and processed to yield PRP and plasma. Flexor digitorum superficialis tendon (FDS) and suspensory ligament (SL) explants were cultured in 10% plasma in DMEM (control), BMA, PRP, or PP. TGF-beta1 and PDGF-BB concentrations were determined at 0, 24, and 96 h of culture using ELISA. Quantitative RT-PCR for collagen types I and III (COL1A1, COL3A1), cartilage oligomeric matrix protein (COMP), decorin, and matrix metalloproteinases-3 and 13 (MMP-3, MMP-13) was performed. TGF-beta1 and PDGF-BB concentrations were highest in PRP and PP. Growth factor quantity was unchanged in BMA, increased in PRP, and decreased in PP over 4 days. TGF-beta1 and platelet concentrations were positively correlated. Lyophilized PP and PRP resulted in increased COL1A1:COL3A1 ratio, increased COMP, and decreased MMP-13 expression. BMA resulted in decreased COMP and increased MMP-3 and MMP-13 gene expression. Platelet concentration was positively correlated with COL1A1, ratio of COL1A1:COL3A1, and COMP, and negatively correlated with COL3A1, MMP-13, and MMP-3. White blood cell concentration was positively correlated with COL3A1, MMP3, and MMP13, and negatively correlated with a ratio of COL1A1:COL3A1, COMP, and decorin. These findings support further in vivo investigation of PRP and PP for treatment of tendonitis and desmitis.
Article
During the period 1987-91, 153 cases of total Achilles tendon rupture were diagnosed in the city of Malmo (population 230,000). Almost two thirds were caused by sporting activities, notably badminton. Ruptures caused by nonsports injuries were found in older subjects. Compared to the age-specific incidence in 1950-73, a marked increase in both sports and nonsports injuries was found and patients in the latter group were older than in the former period. Patients with Achilles tendon ruptures can be classified into two subgroups with partly different etiologies: young or middle-aged athletes and older non-athletic persons. The increase in the former group is mostly explained by increased participation in recreational sports; the cause of increase in the latter group is unknown.
Article
Achilles tendon suture combined with a triceps surae tendon tip-over graft was performed in 314 patients with acute rupture of the Achilles tendon between 1980 and 1991. Analysis of these cases showed a low tissue complication rate compared with that reported in the literature. An average of 8.1 years after repair, 223 patients were examined using Holz's scale of clinical assessment after Achilles tendon repair. The results were 'good' in 87.4%, 'fair' in 11.2% and 'poor' in 1.4%. The re-rupture rate was very low (0.4%). These results are better than the re-rupture rate after surgical repair with solely end-to-end suture or after conservative immobilizing or conservative functional treatment. In conclusion, these data show that the fascial reinforcement is a valuable complement to the tendon suture.
Article
Among the tendons in the human body, the Achilles tendon most frequently undergoes a subcutaneous tear. It the tendon is lengthened, more than 3% to 4% of its normal length, it starts to disrupt, and fails at 8% of its physiological length. Microscopic interruptions in the tendinous substance occur during physiological activity, but fibers remodel, and new collagen is continuously formed. However in some cases, the incidence of Achilles tendon rupture is serious that surgery is needed. At present, several important developments enable successful management of such cases.
Article
The incidence of Achilles tendon ruptures specific to the North American population has not been previously reported and current epidemiological data are primarily reported from European communities. The purpose of this study was to determine the incidence of Achilles tendon ruptures in the city of Edmonton, Alberta, Canada, and to compare this data to those reported in European studies. A retrospective chart review from all five acute care hospitals in Edmonton from 1998 to 2002 (inclusive) were reviewed for Achilles tendon ruptures. Data such as gender, age, side, mechanism of injury, and season of injury were obtained. The incidence of Achilles tendon ruptures ranged from an annual average of 5.5 ruptures to 9.9 ruptures per 100,000 inhabitants with an overall mean of 8.3 ruptures per 100,000 people. There was a statistically significant difference in Achilles tendon ruptures over the last two study years for both genders (women, p < 0.02; men, p < 0.03). The mean age for an Achilles tendon rupture was 40.6 years for men and 44.5 years for women. The Achilles tendon ruptures occurred most frequently in the 30 to 39 and 40 to 49 year old age groups in both men and women, respectively (p < 0.02). Most ruptures occurred in the spring season, but there was no statistical difference in the incidence of Achilles tendon ruptures by season (p > 0.05). The incidence of Achilles tendon ruptures in this community was comparable to those reported in European communities (range 6 to 37 ruptures per 100,000 people), although a bimodal age distribution of rupture previously reported was not observed in this study.
Article
There is a need for a patient-relevant instrument to evaluate outcome after treatment in patients with a total Achilles tendon rupture. To develop and validate a new patient-reported instrument for measuring outcome after treatment for total Achilles tendon rupture. Cohort study (diagnosis); Level of evidence, 1. Development of this instrument consisted of item generation and test construction, item reduction, validation, evaluation of structure and internal consistency, test-retest, and test for responsiveness. The final version, the Achilles tendon Total Rupture Score (ATRS), was tested for validity, structure, and internal consistency (Cronbach's alpha) on 82 patients and 52 healthy persons. A correlation analysis was performed of the ATRS with the 2 validated foot/ankle/Achilles tendon scores, the Foot and Ankle Outcome Score (FAOS) and the Swedish version of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A-S). Structure was evaluated with factor analysis. Test-retest reliability was evaluated on 43 patients. The ATRS responsiveness was tested on 43 patients by calculating the effect size. The total score for the patients ranged from 17 to 100 with a mean (median) of 77 (85) and a standard deviation (interquartile range) of 21.4 (23). A significantly (P < .0001) higher total score was found for the healthy subjects, ranging from 94 to 100 with a mean (median) of 99.8 (100) and a standard deviation (interquartile range) of 1.1 (0). The ATRS correlated significantly (P < .01) with all subscales of the FAOS (r = 0.60-0.84) and the VISA-A-S (r = 0.78). The factor analysis gave 1 factor of importance. The internal consistency was 0.96 as measured with Cronbach's alpha. The test-retest produced an intraclass correlation coefficient of 0.98. The tests for responsiveness showed an effect size between 0.87 and 2.21. The ATRS is a patient-reported instrument with high reliability, validity, and sensitivity for measuring outcome after treatment in patients with a total Achilles tendon rupture. The ATRS is a self-administered instrument with high clinical utility, and we suggest the score for measuring the outcome, related to symptoms and physical activity, after treatment in patients with a total Achilles tendon rupture.
The effect of suture coated with mesenchymal stem cells and bioactive substrate on tendon repair strength in a rat model Human multipotent mesenchymal stem cells improve healing after collagenase tendon injury in the rat
  • J Yao
  • Cy Woon
  • A Behn
  • T Korotkova
  • Dy Park
  • V Gajendran
  • L Smith
  • R Sedlacek
  • T Suchy
  • Ruzicka T J Amemori
  • Havlas P V Lesny
  • E Sykova
  • Jendelova
Yao J, Woon CY, Behn A, Korotkova T, Park DY, Gajendran V, Smith RL (2012) The effect of suture coated with mesenchymal stem cells and bioactive substrate on tendon repair strength in a rat model. J Hand Surg Am 37:1639–1645. doi:10.1016/j.jhsa.2012.04.038 21. Machova Urdzikova L, Sedlacek R, Suchy T, Amemori T, Ruzicka J, Lesny P, Havlas V, Sykova E, Jendelova P (2014) Human multipotent mesenchymal stem cells improve healing after collagenase tendon injury in the rat. Biomed Eng Online 13:42-925X-13-42. doi: 10. 1186/1475-925X-13-42