Use of biologics in rotator cuff disorders: Current concept review

Poor tendon to bone healing following rotator cuff repair has led to the continued interest and investigation into biological augmentation. The biology of tendinopathy is not fully understood and consequently the availability of disease modifying therapeutic targets is limited. A ceiling of benefit has been reached by mechanical optimisation of rotator cuff repair and thus, in order to improve healing rates, a biological solution is required. This review focuses on the strategies to biologically augment rotator cuff disorders with an emphasis on rotator cuff repair. Leucocyte rich platelet rich plasma has been shown to improve healing rates without clinically relevant improvements in outcome scores. Similarly, improved healing rates have also been reported with bone marrow stimulation and in long-term follow-up with bone marrow concentrate. Extracellular matrix (ECM) and synthetic scaffolds can increase healing through mechanical and or biological augmentation. A potential third category of scaffold is bio-inductive and has no mechanical support. Studies involving various scaffolds have shown promising results for augmentation of large to massive tears and is likely to be most beneficial when tendon quality is poor, however level I evidence is limited.     

Blood styrene concentrations in a “normal” population and in exposed workers 16 hours after the end of the workshift

Summary Blood styrene was measured by a gas chromatography-mass spectrometry method in 81 normal people and in 76 workers exposed to styrene. In the normal subjects, styrene was also tested in alveolar and environmental air. Styrene was found in nearly all (95%) blood samples. Average styrene levels in the normal subjects were 221 ng/1 in blood (Cb), 3 ng/1 in alveolar air (Ca) and 6 ng/1 in environmental air (Ci). Styrene levels did not differ significantly between smokers and non-smokers, 95% of values being below 512 ng/1 in Cb, 7 ng/1 in Ca and 15 ng/l in Ci. In workers with an average exposure to styrene of 204 g/l, at the end of the workshift, mean blood styrene concentration was 1211 g/l. In blood samples collected at the end of the Thursday shift, styrene levels were significantly higher (1590 g/1) than those found at the end of the Monday shift (1068 g/l. A similar difference was found in samples taken the morning after exposure (60 and 119 g/l, respectively). Significant correlations between blood and environmental styrene were found both at the end of the shift and the morning after exposure (r=0.61 and 0.41, respectively). In workers occupationally exposed to styrene, 16 h after the end of the workshift, blood styrene (94 g/l) was significantly higher than that found in the normal subjects (0.22 g/l). The half-life of blood styrene was 3.9 h.     

Late complications following autologous and homologous fat transplantation for breast augmentation

Summary Three cases of homologous and one of autologous free fat block transplantation for breast augmentation were seen 10 to 20 years after operation due to late complications. Displacement of heavy tumors, local mastitis or disrupted capsules following local trauma led to admission. The calcified centrally necrotic cysts were treated by subcutaneous mastectomy or local enucleation and immediate reconstruction by subpectoral augmentation with silicone-gel implants or reduction mammoplasty.     

Respiratory effects of tracheal gas insufflation in spontaneously breathing COPD patients

Objective To evaluate the effect of tracheal gas insufflation (TGI) in spontaneously breathing, intubated patients with chronic obstructive pulmonary disease (COPD) undergoing weaning from the mechanical ventilation.Design A prospective study in humans.Setting Polyvalent intensive care unit (14-bed ICU) in a 700-bed general university hospital.Patients Twelve patients with chronic obstructive pulmonary disease (COPD) who required intubation and mechanical ventilation were studied. All patients met standard criteria for weaning from mechanical ventilation. Seven patients (group 1) had been transorally intubated during episodes of acute respiratory failure. Five patients, all men (group 2), had previously undergone tracheostomy and had a transtracheal tube in place.Interventions Intratracheal, humidified, O₂-mixture insufflation (TGI) was given via a catheter placed in distal or proximal position. Gas delivered through the intratracheal catheter was blended to match the fractional of inspired gas through the endotracheal tube. Continuous flows of 3 and 6 l/min in randomized order were used in each catheter position. Prior to data collection at each stage, an equilibration period of at least 30 min was observed, and thereafter blood gases were analyzed every 5 min. A new steady state was assumed to have been established when values of bothP _aCO₂ and CO₂ changed by less than 5% between adjacent measurements. The last values of blood gases were taken as representative. The new steady state was confirmed within 35–50 min. Baseline measurements with zero were made at the beginning and end of the experiment.Results This study shows that V_T, MV,P _aCO₂, and V_D/V_T are reduced in a flow-dependent manner when gas is delivered through an oral-tracheal tube (group 1). The distal catheter position was more effective than the proximal one. In contrast, when gas was delivered through tracheostomy (group 2), TGI was ineffective in the proximal position and less effective than in group 1 in distal position.Conclusion Under the experimental conditions, tracheal gas insufflation decreased dead space, increased alveolar ventilation and possibly reduced work of breathing. From the preliminary data reported here, we believe that TGI may help patients experiencing difficulty during weaning.     

Nitric oxide synthase activity is inducible in rat,but not rabbit alveolar macrophages,with a concomitant reduction in arginase activity

Alveolar macrophages were obtained by broncho-alveolar lavage of isolated rat and rabbit lungs and cultured (2.5 × 10⁶ cells/dish) for 18 h in the absence or presence of bacterial lipopolysaccharides (LPS) alone or in combination with cytokines. Thereafter, accumulation of ³H-citrulline (NO synthase activity) and ³H-ornithine (arginase activity) were determined.During incubation of rat alveolar macrophages with ³H-arginine clear amounts of ³H-citrulline and ³H-ornithine (3.8 and 4.6% of the added ³H-arginine, respectively) were formed and most of these metabolites appeared in the incubation medium (ratios extra-/intracellular of 17 and 70 for ³H-citrulline and ³H-ornithine, respectively). When rat alveolar macrophages had been cultured with LPS the formation of ³H-citrulline was increased about 30-fold and this was accompanied by a reduction in ³H-ornithine formation of about 60%. The effects of LPS were largely attenuated by dexamethasone (10 mol/1). Inhibition of NO synthase by N^G-monomethyl-l,-arginine (l-NMMA, 100 mol/1) in LPS treated alveolar macrophages reduced the formation ³H-citrulline by more than 90% and restored the ³H-ornithine formation. After culturing in the presence of LPS the ratios extra/intracellular of ³H-citrulline and ³H-ornithine were markedly enhanced and this effect was not dexamethasone sensitive. During incubation of rabbit alveolar macrophages a marked formation of ³H-ornithine (about 5.3% of the added ³H-arginine), but no significant formation of ³H-citrulline could be detected. Pretreatment with LPS tended to enhance the formation of ³H-ornithine (by 50%) without effects on ³H-citrulline. Rabbit-interferon and/or tumor necrosis factor- present together with LPS during the culture period did not result in a significant ³H-citrulline formation. Under all conditions tested, culture media of rabbit alveolar macrophages did not contain significant amounts of nitrite (less than 0.5 nmol) whereas in culture media of untreated rat alveolar macrophages 22 nmol nitrite (per 18 h) were detected, and LPS induced a 3-fold nitrite accumulation, an effect prevented by dexamethasone.In conclusion, in rabbit alveolar macrophages NO synthase activity was not detectable and could also not be induced by LPS and different cytokines, whereas in rat alveolar macrophages NO synthase was readily inducible. Alveolar macrophages of both species showed marked arginase activity. After induction of marked NO synthase activity, ornithine formation was largely reduced possibly by concomitant inhibition of arginase and/or withdrawn of arginine from arginase.     

Comparison of augmented and non-augmented anterior cruciate ligament reconstruction combined with high tibial osteotomy

In a follow-up study 27 patients were evaluated after anterior cruciate ligament (ACL-)reconstruction combined with high tibial osteotomy because of chronic rupture of the ACL, cartilaginous lesions of the medial compartment and varus malalignment. They were divided into two groups. In 14 patients (non-LAD group) ACL reconstruction was performed using the central third of the autologous patellar tendon modified according to Eriksson-Trillat. Thirteen patients (LAD group) underwent repair with the same technique, but a Kennedy ligament augmentation device (LAD) in hot dog technique and fixed over the top was added. The postoperative treatment was the same in both groups. All patients were examined according to IKDC criteria. KT-1000 arthrometer testing at maximum manual traction was performed. Although the mean follow-up interval was more than double in the non-LAD group (non-LAD: 127 months vs LAD: 58 months), the subjective and clinical results, IKDC evaluation and KT-1000 arthrometer testing results were similar, showing no statistically significant difference. Further, no complications due to the use of LAD occurred. In this study no evident functional or clinical advantage from the augmentation performed could be shown.Investigation performed at the Department of Orthopaedic and Trauma Surgery, University Hospital Basle, Switzerland. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding sources were SUVA Assurance, Lucerne, and the science fund of the University Hospital Basle     

Interim report in humans of a previously described technique in an animal model: closure of bladder exstrophy with rectus abdominis muscle flap

The aim of this study was to present the results of a new bladder closure and augmentation technique in children born with bladder exstrophy where primary surgical closure was impossible. The technique was performed in four children with small, noncompliant, inelastic bladders in which secondary changes such as squamous epithelial metaplasia and polypoid transformation had developed. During the opration, a full-thickness rectus abdominis muscle island flap with an intact neurovascular pedicle was prepared from the left abdominal quadrant and rotated to cover the bladder defect and aid in augmentation. The inner layer formed by peritoneum was sutured to the edges of the bladder defect. Postoperative endoscopic and histopathologic investigations revealed the inner, peritoneal layer of the flap to be completely covered by transitional urinary bladder epithelium. Considering the advantages of the technique from this limited experience, the evidence suggests that there is no need for a major gastrointestinal operation for bladder augmentation. A reasonable bladder capacity was available, there was no mucus production from the inner layer of the flap, and metabolic and electrolyte disturbances were reduced.