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Extracorporeal shock wave therapy (ESWT) is effective in the treatment of tendinopathy. We designed a prospective observational clinical study to assess the correlation between clinical and functional measures and recovery of strength after ESWT for epicondylitis. We analyzed 26 patients. We measured progressive improvement in visual analogue scale values ( p < 0.0005) and Mayo Elbow Performance Index scores ( p = 0.004) for the pathologic limb. Monitoring of handgrip failed to reveal changes in values at any follow-up ( p > 0.05). We found no correlation between degree of clinical function and muscle deficit during follow-up. After ESWT, there was a tendency toward a decrease in grip strength, especially in the dominant limb. This could be related to the effects of ESWT, which reduces spasticity in painful hypertonic muscles. These data may be useful in defining the expectations for function during ESWT for epicondylitis, particularly for elite athletes. [ABSTRACT FROM AUTHOR]

Abstract: The Orthopedic Multidimensional Prognostic Index (Ortho-MPI) was performed and validated in order to ameliorate the decision-making process as regards the elderly with hip or neck femur fractures. A retrospective study was performed. 95 patients 65 years old and over with a diagnosis of hip or femur fracture were enrolled. A standardized comprehensive orthopedic geriatric assessment was performed. It included information on: depressive symptoms, functional and instrumental activities of daily living, cognitive and nutritional status, laboratory tests, risk of pressure sore, comorbidities and comorbidity. The Ortho-MPI was calculated. After six months their initial assessment, patients were recalled in order to know if they live too or not. The survival condition was associated to the prognostic capacity calculated by the Ortho-MPI. Results showed that higher Ortho-MPI Index value was associated with higher six months-later mortality. In an unvaried analysis model the Ortho-MPI index was associated with death event of the elderly patients enrolled (OR=1.05; 95% CI, 1.01–1.10; z =2.27; p =0.023). This association was also validated by considering different ages between participants (OR=1.05; 95% CI, 1.004–1.11; z =2.13; p =0.033). Furthermore, each specific index considered in the total Ortho-MPI was associated with the death event of the elderly patients. In conclusion it was shown that the Ortho-MPI Index could be used to predict outcome in the elderly with hip or femur fracture. [Copyright &y& Elsevier]

Abstract: Research is on-going to identify new methods of biostimulation to increase the effect of botulinum toxin type A (BTX-A) in the treatment of spasticity. The Spasticity treated by Botulinum Toxin and ESWT (SBOTE) study is a prospective, randomized controlled trial assessing the effectiveness of extracorporeal shock wave therapy (ESWT) given immediately after BTX-A injections compared with electrical stimulation (ES) given immediately after BTX-A therapy for the management of focal upper limb spasticity in stroke patients. ES was given for 30 min twice a day for 5 days starting at 5 Hz; ESWT was given once a day for 5 days. At study follow-up, patients treated with BTX-A injections and ESWT showed a statistically greater significance and continuous decrease of spasticity measure (modified Ashworth scale [MAS]: 1.37, 1.75 and 1.58 at 15, 30 and 90 days post-treatment, respectively), of spasms (spasm frequency scale [SFS]: 0.8 and 0.25 at 30 and 90 days post-treatment, respectively) and of pain (visual analogue scale [VAS]: 1.94 and 1.87 at 30 and 90 days, respectively) compared with patients treated with BTX-A injections and ES (MAS: 2.37, 2.18 and 2.18, respectively) (p < 0.05) (SFS: 1.5 and 1.06, respectively) (p < 0.05) (VAS: 2.44 and 2.69 respectively) (p < 0.05). ESWT enhances the effect of BTX-A to a greater extent than ES, probably by modulating rheology of the muscle and neurotransmission at the neuromuscular junction. [Copyright &y& Elsevier]

Abstract: A marked neovascularity has been demonstrated in tendinopathies, due to the inflammatory-degenerative process. The aim of this study was to assess the effect of extracorporeal shock wave therapy (ESWT) on tissue perfusion in the treatment of tendinopathy. An observational clinical study was made of 30 patients undergoing ESWT for tendinopathy of the rotator cuff. A clinical improvement was obtained in 65.6% of patients at 2 and 6 months. This was associated with a statistically significant reduction in the oxygen tissue saturation, measured by oxymetry that was apparent already during treatment, as well as at subsequent follow-up visits. The reduced perfusion achieved with ESWT supports the hypothesis that this treatment can regulate the inflammatory process and offset increased vascularization, restoring physiologic tendon conditions. (E-mail: angelanotarnicola@yahoo.it) [Copyright &y& Elsevier]

Abstract: The aim of this study was to verify the effects on osteoblast cultures of adding a platelet-rich plasma (PRP) concentrate pretreated with 500 shock wave (SW) at an energy flow density of 0.17 mJ/mm2, emitted by an electromagnetic generator Minilith SL1 (STORZ, Germany), reproducing the conditions of our previous study in which we apply SW directly on osteoblasts. Real-time PCR showed that in osteoblast cultures with added PRP pretreated with SW, there was an increased expression at 48 h of insulin-like growth factor binding protein 3 (IGFBP-3) and runt-related transcription factor 2 (RUNX2) and at 72 h, of collagen type I, osteocalcin, insulin-like growth factor 1 (IGF-1) as well as IGFBP-3. Western blotting confirmed the increased protein synthesis of IGFBP-3. This experience suggests that extracorporeal shock wave treatment (ESWT) should stimulate osteogenesis also by indirect platelets-mediated network. It therefore seems possible that combining the two methods, ESWT and bioengineering procedures to infiltrate PRP and growth factors, could be a successful approach. (E-mail: angelanotarnicola@yahoo.it) [ABSTRACT FROM AUTHOR]

Abstract: The aim of this prospective study was to assess the efficacy of shockwave (SW) therapy in the management of complex regional pain syndrome (CRPS). In this study, 30 patients (pts) who were affected by CRPS of the medial femoral condyle and unresponsive to previous standard physiotherapeutic and pharmacological treatment underwent 3 SW sessions at 72-h intervals, each consisting of 4000 shocks emitted by a MiniLith SL1 Storz electromagnetic generator. An energy flux density (EFD) of 0.035 or 0.09 mJ/mm2 was used, depending on how well the patient endured the pain during the treatment. Satisfactory results were observed in 76.7% of the cases (23 pts) at the 2-month follow-up (FU) visit, and in 80% (24 pts) at the 6-month FU visit. The therapeutic effects of SW were caused by decreasing pain. The significant improvements we obtained bear witness to the potential value of SW therapy in the management of CRPS. (E-mail: angelanotarnicola@yahoo.it) [Copyright &y& Elsevier]

Abstract: In soccer players, lower extremity stress fractures are common injuries and are the result of repetitive use damage that exceeds the intrinsic ability of the bone to repair itself. They may be treated conservatively but this may cause long-term complications, such as delayed union, muscle atrophy and chronic pain. Stress fractures that fail to respond to this management require surgical treatment, which is also not without risks and complications. Extracorporeal shock wave therapy (ESWT) has been used successfully on fracture complications, such as delayed union and nonunion. As such, we want to examine ESWT in the management of stress fractures. In this article, we present a retrospective study of 10 athletes affected by chronic stress fractures of the fifth metatarsus and tibia that received three to four sessions of low-middle energy ESWT. At the follow-up (8 wk on average), the clinical and radiography results were excellent and enabled all players to gradually return to sports activities. These reports show that ESWT is a noninvasive and effective treatment for resistant stress fractures in soccer players. (E-mail: b.moretti@ortop2.uniba.it (B.M.), angelanotarnicola@yahoo.it (A.N.)) [Copyright &y& Elsevier]

Summary: Hydatidosis is a rare parasitic disease caused by the Echinococcus tapeworm, which only occasionally affects the musculoskeletal tissues. In this article we describe the case of a patient who underwent a total hip replacement procedure for a pathological fracture of the femur neck. At the next histological examination it was shown to be a consequence of secondary bone hydatidosis. This clinical case is exceptional in that the infection spread to the cotyloid and femoral prosthesis components and, in the following years, caused repeated episodes of joint dislocation. [ABSTRACT FROM AUTHOR]

Abstract: Myositis ossificans (MO) is a fairly common evolution in sports activity and can be due to direct trauma or to repeated micro-injuries. The traditional therapeutic approach relies on a variety of treatments, such as physical therapy but evidence of their proven clinical efficacy is lacking. The latest therapeutic option is surgical removal but this is a demolitive procedure and is frequently associated with a significant loss of functional integrity. There are few articles in literature about the treatment of post-traumatic MO, and none on extracorporeal shock wave therapy (ESWT). We illustrate a case series of 24 sportsmen treated with three sessions of electro-hydraulic shockwave therapy and an associated rehabilitation program. Only a partial reduction of the ossification was observed in the X-ray images but all the patients showed signs of functional improvement immediately after therapy. Two months after the therapy, a normal range of motion and no signs of weakness were observed. Three months after treatment, 87.5% of patients resumed regular sports activities. (E-mail: angelanotarnicola@yahoo.it) [Copyright &y& Elsevier]

Abstract: The extracorporeal shock wave therapy (ESWT) is an extensively applied treatment for musculoskeletal disorders because it promotes bone repair. The aim of this study was to evaluate the direct effect of ESWT on murine osteoblasts to clarify the cellular mechanism that leads to the induction of osteogenesis. Osteoblasts in culture flasks were treated with ESWT pulses (500 impulses of 0.05 mJ/mm2) generated by an electromagnetic device. Using western blot analysis 3h after ESWT, an increased expression of Bax was found, indicating a fast pro-apoptotic effect of treatment on some of the osteoblasts. Activation of the cyclin E2/CDK2 is the complex that regulates the G1-S transition and is essential for cell proliferation. It was evident 24 to 72h after treatment, indicating a proliferative stimulus. A decreased expression of osteoprotegerin (OPG) and receptor activator NF kappa B ligand (RANKL) 24 and 48h after ESW, followed by a later increase of OPG, paired with a much smaller increase of RANKL, was evident by real-time polymerase chain reaction (PCR). The decreased RANKL/OPG ratio suggests inhibition of osteoclastogenesis. We can conclude that ESWT induces bone repair through the proliferation and differentiation of osteoblasts and the reduction of their secretion of pro-osteoclastogenic factors. (E-mail: angelanotarnicola@yahoo.it) [Copyright &y& Elsevier]

Sclerostin, negative regulator of bone formation, has been originally known as an osteocyte product. Recently, it has been also detected in hypertrophic chondrocytes, distinctive cells of avascular cartilage which is invaded by capillaries and then replaced by vascularized bone. Thus, we hypothesized that sclerostin, in addition to its role already known, may exert an angiogenic activity. We first proved that sclerostin increased the proliferation of human umbilical vein endothelial cells (HUVECs), and next, by using the chicken chorioallantoic membrane (CAM) in vivo assay, we demonstrated that it exerts an angiogenic activity similar to that of vascular endothelial growth factor (VEGF). This last finding was reinforced by several in vitro approaches. Indeed, we showed that sclerostin induced the formation of a network of anastomosing tubules, a significant increase in the percentage of tubule number, total tubule length and number of junctions, as well as the ability of sclerostin-stimulated HUVECs to organize capillary-like structures and closed-meshes similar to VEGF. The angiogenic response elicited by the protein may be due to the binding to its receptor, LRP6, which is highly expressed at mRNA and protein levels by sclerostin treated HUVECs and through the production of two well-known pro-angiogenic cytokines, VEGF and placental growth factor (PlGF). Finally, we demonstrated that sclerostin was also responsible for the recruitment of osteoclasts and their circulating monocyte progenitors. Overall, these findings showed for the first time the new angiogenic in vitro role of sclerostin which could be also considered as a novel molecule in angiogenesis-osteogenesis coupling. [ABSTRACT FROM AUTHOR]

Abstract: Primary musculoskeletal hydatidosis is less frequent than hydatidosis of the parenchymal organs. This localization has been little studied and so there is little information in the literature on the subsequent disease evolution. We present a case of primary hydatidosis of the abductor muscle that came to medical attention very late. After complete surgical removal of the huge mass, a secondary bone localization developed, causing a femoral pertrochanteric pathological fracture. The case described is exceptional in view of both the localization and the great size of the primary multi-lobed muscle hydatid cyst. We underline the difficulties of diagnosis and treatment of both the primary muscle localization and the secondary bone recurrence. [ABSTRACT FROM AUTHOR]