Injured Soft Tissues Research Articles

Abstract 7: Nerve Growth Factor Derives From Pericytes And Smooth Muscle Cells After Extremity Trauma

Purpose: Neurotrophic factors like nerve growth factor (NGF) have been described in the literature as a crucial regulator in developmental biology and inflammation of musculoskeletal tissues. While extremity trauma has been shown to elicit re-engagement of developmental programs like NGF upregulation and invasion of new sensory nerve endings in a mature organism, the source of NGF has remained largely unknown. In a validated extremity trauma mouse model, we have previously demonstrated a significant attenuation of injury site re-innervation by sensory fibers following inhibiting of afferent neural signaling and NGF binding of its receptor TrkA. Given this significant impact of NGF on sensory reinnervation of injured soft tissues and downstream bone formation, we examined the source of NGF after extremity trauma using single cell transcriptomic and reporter proteomic technologies. Methods: A 30% dorsal burn and Achilles transection was performed. The tendon site tissues were harvested from baseline (t0) and day 3, 7, and 21 (n=3-4/group) after induction. Samples were prepared for library generation on a 10x Genomics Chromium Controller, sequenced on a Illumina HiSeq 4000, and analyzed with Cell Ranger Software for pre-processing and alignment to the mm10 genome. Downstream analyses including unsupervised clustering and canonical correlation analyses were performed with Seurat. Immunofluorescent (IF) labeling of cellular markers including αSMA was performed using NGF-eGFP reporter mice at baseline, and at 1,3 and 9 weeks after injury (n=2-3/group). Results: To localize cell specific Ngf expression from injured soft tissue, 9 cell clusters were defined across all timepoints: mesodermal (Prrx1) populations including Acta2+ pericyte/vascular smooth muscle (SMC) and Pdgfra+ mesenchymal cells, two Pecam1+ endothelium, and four inflammatory cell populations (mixed, B cell, T cell, and neutrophil). Ngf was found uniquely enriched in the pericyte/SMC cluster in a composite view. These pericytes/SMCs were found in increasing number and Ngf expression across timepoints, peaking at day 21. To further characterize this joint cluster (1273 cells), the pericyte/SMC cluster was isolated and blindly re-clustered to produce new sub-clusters, distinguishing Pdgfrb (platelet derived growth factor receptor beta)highPrrx1highAbcc9+ pericytes from Acta2highPln+Myh11high SMCs; an uncharacterized cluster with 24 cells was discarded from analysis. Of these two sub-clusters, vascular SMCs demonstrated the highest Ngf expression at baseline (mean normalized Ngf expression of 0.52 [in 41% of cells] vs 0.28 [in 23% of cells]. IF of NGF-eGFP reporter mice show robust NGF co-localization with αSMA+ SMCs. Conclusions: This is the first work characterizing the pericyte and vascular SMC as a major contributor to NGF signaling at an extremity injury site. The fine resolution defining the cellular source of NGF provides insight into potential mechanisms correlating nascent nerve and vascular growth given the intersection of these pathways at the level of pericytes and myofibroblastic SMCs that will inform future candidate therapeutics to improve extremity trauma healing and re-innervation.

Biomaterial-Based Scaffolds as Antibacterial Suture Materials.

Antibacterial scaffolds are highly desirable for the repair and reconstruction of injured soft tissues. However, the direct fabrication of scaffolds with excellent biocompatibility, flexibility, and antibacterial capacity remains a challenge, especially those based on biomaterials. In this study, we report the biomaterial-based antibacterial scaffolds based on regenerated silk fibroin, 2-hydroxypropyltrimethyl ammonium chloride chitosan, and bladder acellular matrix graft by blend and coaxial electrospinning. This approach eliminated the use of organic solvents and inorganic nanoparticles, ensuring greater clinical safety, mimicking physiological extracellular matrix structures, and the required softness for a suture material. Thus, the scaffold obtained in this study exhibited excellent biocompatibility, the required mechanical characteristics, and excellent antibacterial capacity. The rate of bacterial elimination of Staphylococcus aureus and Escherichia coli reached up to 99.5 and 98.3%, respectively. The scaffold design favored cell growth and proliferation and resulted in the significant promotion of repair and reconstruction of the urethra, indicating that it can be an ideal antibacterial suture material for soft tissue restoration.

Clinical diagnostics of the shoulder’s soft tissue injures

Annotation. Our study is based on data of 444 patients with clinically, MRI diagnosed and then arthroscopically proved diagnosis of the shoulder’s soft tissue injures. Used the following diagnostic tests: “typical pain localization”, shoulder blade rhythm disturbance, “apprehension”, front driver test, compression rotary test, rear driver test, impedance test Nir, Hawkins, weaknesses of withdrawal, weakness of external rotation, “lift off”, “belly press”, “false paralysis”. We have described the most informative and simple clinical tests. Sensitivity and specificity for each clinical test were calculated. Sensitivity and specificity of these tests are statistically adjusted. It has been found that for clinical diagnostics of damage to the anterior-lower lip of the shoulder joint is more diagnostically attractive is the anterior driver test; for diagnosis of damage to the upper lip of the shoulder joint — compression-rotation test, preference is given to the rear “driver test”; for the diagnosis of subacromial conflict syndrome — a combination of two tests: Hawkins test and impingement test; for diagnosis of lesions of the supraspinatus muscle — test of weakness of the abduction; underarm muscle — test of weakness of external rotation; for the diagnosis of total damage to the rotator cuff (RС) — test “falling” hand; the specificity of “belly press” test is higher than the specificity of “Lift off” test when it is impossible to get your hand behind your back. Thus, tests of characteristic localization of pain and disturbance of the shoulder bladder rhythm are sufficient to suspect the patient of the pathology of the shoulder joint complex itself.

The utility of adding symptoms and signs to the management of injury-related pain

ObjectiveImproved pain assessment and management in the emergency department (ED) is warranted. We aimed to determine the impact on pain management, of adding symptoms and signs to pain assessment. Patients and methodsA single center before-and-after study was conducted, supplemented by an interrupted time series analysis. The intervention included the addition of clinical presentation (CP) of the injury and facial expression (FE) of the patient to pain assessment scales of patients with soft tissue injures. Pain intensity was categorized as: mild, moderate, and severe. We compared types of pain relief medications, use of strong opioids, and pain relief efficacy between pre and post intervention phases. ResultsBefore-and-after analysis revealed a significant reduction in the use of strong opioids. The adjusted relative ratio for the use of strong opioids in the post intervention phase was 0.63 (95% CI: 0.48–0.82). This reduction was mostly driven by less use of strong opioids in patients reporting severe pain (from 17.3%–7.9%) (P < 0.0001). A larger proportion of patients in the post intervention phase than in the pre intervention phase received weak opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) (27.4% vs 19.1%, P = 0.002), and a larger proportion did not receive any pain relief medication (19.8% vs 10.5%, p < 0.0001). The use of strong opioids increased with higher levels of FE and CP. Among patients with mild injury and reporting severe pain, the odds of receiving a strong opioid was nearly 9 times (OR = 8.9, 95% CI: 4.0–19.6) higher among those who were with an unrelaxed FE and showed pain behavior than those with relaxed FE. Interrupted time-series analysis showed that the mean ΔVAS (VAS score at entry minus VAS score at discharge) in the post intervention phase compared with the pre intervention phase was not statistically significant (P = 0.073). The use of strong opioids in the post intervention phase was significantly reduced (P = 0.017). ConclusionAdding symptoms and signs to pain assessment of patients admitted with soft tissue injuries decreased the use of strong opioids, without affecting pain relief efficacy.

Synergistic therapy of magnetism-responsive hydrogel for soft tissue injuries

Soft tissue injury is very common and associated with pain, tissue swelling and even malformation if not treated on time. Treating methods include cryotherapy, electrical therapy, ultrasound therapy and anti-inflammatory drug, but none of them is completely satisfying. In this work, for a better therapeutic effect, drug therapy and pulsed electromagnetic field (PEMF) therapy were combined. We constructed a drug delivery system using the tetra-PEG/agar hydrogel (PA). By incorporating Fe3O4 NPs into the hydrogel network, a magnetism-responsive property was achieved in the system. The cytotoxicity and in vivo study showed a good biocompatibility of the PA/Fe3O4 hydrogel. A magnetism-controlled release was attained by the incorporation of Fe3O4. Finally, in vivo study showed a better performance of the DS-loaded PA/Fe3O4 compared with the commercially available DS ointment regarding the recovery of the injured soft tissue. Therefore, this magnetism-responsive hydrogel may represent a promising alternative to treat soft tissue injury.

Trauma-Induced Nanohydroxyapatite Deposition in Skeletal Muscle is Sufficient to Drive Heterotopic Ossification

Heterotopic ossification (HO), or the pathologic formation of bone within soft tissues, is a significant complication following severe injuries as it impairs joint motion and function leading to loss of the ability to perform activities of daily living and pain. While soft tissue injury is a prerequisite of developing HO, the exact molecular pathology leading to trauma-induced HO remains unknown. Through prior investigations aimed at identifying the causative factors of HO, it has been suggested that additional predisposing factors that favor ossification within the injured soft tissues environment are required. Considering that chondrocytes and osteoblasts initiate physiologic bone formation by depositing nanohydroxyapatite crystal into their extracellular environment, we investigated the hypothesis that deposition of nanohydroxyapatite within damaged skeletal muscle is likewise sufficient to predispose skeletal muscle to HO. Using a murine model genetically predisposed to nanohydroxyapatite deposition (ABCC6-deficient mice), we observed that following a focal muscle injury, nanohydroxyapatite was robustly deposited in a gene-dependent manner, yet resolved via macrophage-mediated regression over 28 days post injury. However, if macrophage-mediated regression was inhibited, we observed persistent nanohydroxyapatite that was sufficient to drive the formation of HO in 4/5 mice examined. Together, these results revealed a new paradigm by suggesting the persistent nanohydroxyapatite, referred to clinically as dystrophic calcification, and HO may be stages of a pathologic continuum, and not discrete events. As such, if confirmed clinically, these findings support the use of early therapeutic interventions aimed at preventing nanohydroxyapatite as a strategy to evade HO formation.

Four years of orthopaedic activities in Chinese Role 2 Hospital of eastern Mali peacekeeping area

IntroductionThe Chinese Role 2 Hospital (CHN-Role 2H) Medical Treatment Facility (MTF) was founded in July 2013 as part of the Chinese commitment to Multidimensional Integrated Stabilization Mission in Mali (MINUSMA)....

Optimal Management of the Patient With an Open Distal Femur Fracture

Open fractures of the distal femur present several challenges to the treating surgeon as well as the patient. Patients who sustain this injury are at risk for a variety of complications including nonunion, malunion, post-traumatic arthritis, limited function, need for multiple surgical procedures and in some cases, amputation. This article will review initial care of the injured patient, important facets of open fracture care, management of injured soft tissues, strategies for internal fixation in order to optimize outcomes and minimize complications. Additionally, management of nonunion and malunion of the distal femur, including the role for creation of anticipated nonunion following aggressive debridement of nonviable bone, are addressed.

A prospective study of delta frame as external fixator for open-distal tibial fractures

Distal tibial fractures pose a serious challenge to the orthopaedician because muscular coverage is very less and poorly vascularized [1]. It is further complicated by comminution, joint involvement, open fractures and high energy trauma [1]. The goals of management are proper care of the injured soft tissues, restoration of joint congruity, stable fixation [2]. Ankle spanning external fixation ie Delta frame has become the initial treatment of choice for complex tibial pilon fractures [3]. The ‘tripolar configuration’ allows facilitation of wound care, plastic procedures and good xray or CT images [4]. The Delta external fixator was found to be the most stable external fixator for treating not stable as type III according AO/OTA’s classification [5]. The IM nails often do not provide enough stability in distal tibial fractures and plating requires extensive soft tissue dissection [6]. External fixators can also be used in osteoporotic and unreconstructable comminuted metaphyseal fractures with poor bone stock [6]. However literature support is scanty, hence we decided to do the above study with an aim to analyze its results using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot score.

A theory of damage and self-regenerating materials

A new type of material is postulated that is self-regenerating in the context of damage processes. The theory is built mathematically within the framework of continuum damage mechanics. The mathematical formulation is both systematic and consistent. For the generation of such a pure material, use is made of a new form of the damage variable that is suitable for this purpose. The main characteristic of the postulated self-regenerating material is that it undergoes a process of re-integration and re-assembly upon further loading. The damage process is reversed, and full recovery of damage is achieved once a certain level of loading is reached. This process is also characterized by strengthening of the elastic modulus until the original virgin material is recovered. The formulation is described precisely both mathematically and graphically. It is understood that this material is hypothetical at the present time, but it is hoped that future progress in manufacturing will make the realization of this new material a reality. It is anticipated that the presented theory lays the groundwork for the analysis and design of a new class of materials termed self-regeneration material. Some earlier materials that may fit this description were introduced in the last 20 years as self-healing materials that have the structurally incorporated ability to repair damage caused by mechanical damage. A final section is added to show how the theory of self-regenerating materials as presented here can be applied to the healing of injured soft tissue. It is shown that one single equation can represent both the inflammation phase along with the regeneration/remodeling phase of injured soft tissue. Furthermore, this governing equation is characterized by two parameters that can be varied to fit experimental data, namely the integer exponent and the control parameter.

Anthropological analysis of projectile trauma to the bony regions of the trunk

Ballistics literature often focuses on soft tissue injures and projectile trauma to the cranium. Minimal details on the bony characteristics of projectile trauma to the thorax/abdomen regions have been published. This study aims to analyse projectile trauma to the bony trunk region including the ribs, vertebrae, scapula, sternum and the hip bone to form a better understanding of the characteristics and biomechanics of skeletal trauma caused by a projectile and contribute to the existing database on skeletal trauma caused by projectiles. Fourteen cases of documented projectile trauma to the bony regions of the trunk from the Hamman-Todd Human Osteological Collection at the Cleveland Natural History Museum, Ohio were analysed. Of the 14 individuals with gunshot wounds examined, 40 wounds occurred to the bones. Twenty-four injuries to the ribs, 1 ilium, 11 vertebrae, 3 scapulae, and 1 sternum. Fracture patterns, heaving and bevelling can be used to determine the direction of travel of the projectile which can be evident on the ribs, sternum, scapula and ilium. It is critical to understand the wounding patterns associated with projectile trauma to the torso region as this is often targeted, due to being the centre of mass.

Role of MRI in a Series of Cases with Biceps Injuries of the Shoulder.

Dislocation and injury of the biceps is associated with acute and chronic trauma, degenerative changes, repetitive microtrauma, or injuries associated with recurrent and neglected cases of shoulder dislocation. The cases of displaced biceps injuries are relatively rare (only 1/6th of all rotator cuff injuries). The dislocation of biceps is manifested with pain and restriction of movements. The X-ray shoulder is not of much help in this condition barring for ruling out the fractures of humerus and scapula. Ultrasound is an important tool in the dislocation and shows empty bicipital groove which raises the suspicion of the soft tissue injures. Ultrasound is a problem solving tool when the equivocal findings in MRI (Magnetic Resonance Imaging) in other muscular injuries also. MRI is the modality of choice in these conditions. The bone and anatomy is better visualised on the T1WI images and the pathology is better visualised on the PDFS (Proton Density Fat Saturation) and the STIR (Short Tau Inversion Recovery) images. The role of Non Contrast Computed Tomography (NCCT) is important in associated suspicious bony abnormalities as highlighted in the article. The biceps region is a hidden area and challenging on arthroscopy due to poor visualisation of the extra-articular tendon part. MRI study helps the orthopaedicians for better management of the hidden areas. This series highlights the role of each modality in the diagnosis and management of the biceps lesions.

Videoassisted thoracoscopic fixation of floating rib fragments

We examined the results of videoassisted thoracoscopic fixation of floating rib fractures in 16 patients with blunt chest traumas. The method, which was used, was described by K.G. Zhestkov and improved by the authors of this article. Indications for ribs fixation were prolapse of ribs fragments into the pleural cavity with the lung injury (7 patients) and functionally significant abnormal mobility of multiple rib fractures (9 patients). It is shown that the proposed method of videoassisted thoracoscopic ribs fixation at pathological mobility can reliably stabilize the chest wall without wide dissection of injured soft tissue.

Evaluation of Hybrid External Fixator for Tibial Plateau Fractures: A Prospective Study

Background: Tibial plateau fracture is one of the common injuries encountered in our daily clinical practice. The goals of management of these peri-articular fractures are restoration of joint congruity by anatomic reduction of the articular fragments, stable fixation of fragments, early joint movements, care of injured soft tissues and prevention of fracture related, surrounding soft tissue and wound related complications. Though open reduction and internal fixation is preferred in the current day practice for such fractures, they are associated with a variety of complications leading to poor outcome. Ligamentotaxis and percutaneous fixation has been advocated by many authors to improve the results and to minimize the risk of serious complications. The aim of the present study is to evaluate and assess the results of closed reduction and hybrid external fixator application in the management of tibial plateau fractures. Materials and methods: Study included 28 patients with Schatzker type II and above closed tibial plateau fractures treated by Hybrid external fixator by the same team of surgeons on a tertiary care center following relevant investigations and assessment. Patients were followed up at regular intervals and finally evaluated clinically and radiologically at the end of one year. Conclusion: Our study highlighted the success of indirect reduction and hybrid external fixation application as the definitive method for the management of tibial plateau fractures. It minimizes the risk of soft tissue damage and reduces the incidence of serious complications with good fracture union and functional outcome in patients. Keywords: Hybrid external fixator, Tibial plateau fracture, Schatzker

A Rare case of bear attack on the face and the treatment in a tertiary hospital in Central Nepal

This case report presents a case of wild bear attack in the central region of Nepal causing extensive maxillofacial injuries and its management. The patient suffered bilateral comminuted midface fractures with extensive soft tissue lacerations. Management included multidisciplinary approach including maxillofacial surgeons, ENT surgeons and cosmetic surgeon to realign the injured soft tissue and bone to pre injury state. Outcome was satisfactory given the initial presentation of patient.JCMS Nepal. 2015; 11(2):31-33

Low-intensity pulsed ultrasound rescues insufficient salivary secretion in autoimmune sialadenitis.

IntroductionLow-intensity pulsed ultrasound (LIPUS) has been known to promote bone healing by nonthermal effects. In recent studies, LIPUS has been shown to reduce inflammation in injured soft tissues. Xerostomia is one of the most common symptoms in Sjögren syndrome (SS). It is caused by a decrease in the quantity or quality of saliva. The successful treatment of xerostomia is still difficult to achieve and often unsatisfactory. The aim of this study is to clarify the therapeutic effects of LIPUS on xerostomia in SS.MethodsHuman salivary gland acinar (NS-SV-AC) and ductal (NS-SV-DC) cells were cultured with or without tumor necrosis factor-α (TNF-α; 10 ng/ml) before LIPUS or sham exposure. The pulsed ultrasound signal was transmitted at a frequency of 1.5 MHz or 3 MHz with a spatial average intensity of 30 mW/cm2 and a pulse rate of 20 %. Cell number, net fluid secretion rate, and expression of aquaporin 5 (AQP5) and TNF-α were subsequently analyzed. Inhibitory effects of LIPUS on the nuclear factor κB (NF-κB) pathway were determined by Western blot analysis. The effectiveness of LIPUS in recovering salivary secretion was also examined in a MRL/MpJ/lpr/lpr (MRL/lpr) mouse model of SS with autoimmune sialadenitis.ResultsTNF-α stimulation of NS-SV-AC and NS-SV-DC cells resulted in a significant decrease in cell number and net fluid secretion rate (p < 0.01), whereas LIPUS treatment abolished them (p < 0.05). The expression changes of AQP5 and TNF-α were also inhibited in LIPUS treatment by blocking the NF-κB pathway. Furthermore, we found that mRNA expression of A20, a negative feedback regulator, was significantly increased by LIPUS treatment after TNF-α or interleukin 1β stimulation (NS-SV-AC, p < 0.01; NS-SV-DC, p < 0.05). In vivo LIPUS exposure to MRL/lpr mice exhibited a significant increase in both salivary flow and AQP5 expression by reducing inflammation in salivary glands (p < 0.01).ConclusionsThese results suggest that LIPUS upregulates expression of AQP5 and inhibits TNF-α production. Thus, LIPUS may restore secretion by inflamed salivary glands. It may synergistically activate negative feedback of NF-κB signaling in response to inflammatory stimulation. Collectively, LIPUS might be a new strategic therapy for xerostomia in autoimmune sialadenitis with SS.Electronic supplementary materialThe online version of this article (doi:10.1186/s13075-015-0798-8) contains supplementary material, which is available to authorized users.

Videoassisted Thoracoscopic Fixation of Floating Rib Fractures

We examined the results of videoassisted thoracoscopic fixation of floating rib fractures in 16 patients with blunt chest traumas. The method, which was used, was described by K.G. Zhestkov and improved by the authors of this article. Indications for ribs fixation were prolapse of ribs fragments into the pleural cavity with the lung injury (7 patients) and functionally significant abnormal mobility of multiple rib fractures (9 patients). It is shown that the proposed method of videoassisted thoracoscopic ribs fixation at pathological mobility can reliably stabilize the chest wall without wide dissection of injured soft tissue.

Early Characterization of Blast-related Heterotopic Ossification in a Rat Model.

Heterotopic ossification (HO) affects the majority of combat-related lower extremity wounds involving severe fracture and amputation. Defining the timing of early osteogenic-related genes may help identify candidate prophylactic agents and guide the timing of prophylactic therapy after blast and other combat-related extremity injuries. Using a recently developed animal model of combat-related HO, we sought to determine (1) the timing of early chondrogenesis, cartilage formation, and radiographic ectopic bone development; and (2) the early cartilage and bone-related gene and protein patterns in traumatized soft tissue. We used an established rat HO model consisting of blast exposure, controlled femur fracture, crush injury, and transfemoral amputation through the zone of injury. Postoperatively, rats were euthanized on Days 3 to 28. We assessed evidence of early ectopic bone formation by micro-CT and histology and performed proteomic and gene expression analysis. All rats showed radiographic evidence of HO within 28 days. Key chondrogenic (collagen type I alpha 1 [COL1α1], p = 0.016) and osteogenic-related genes (Runt-related transcription factor 2 [RUNX-2], p = 0.029; osteoclacin [OCN], p = 0.032; phosphate-regulating neutral endopeptidase, X-linked [PHEX], p = 0.0290, and POU domain class 5 transcription factor [POU5F], p = 0.016) and proteins (Noggin [NOG], p = 0.04, OCN, p = 0.02, RUNX- 2, p = 0.04, and substance P-1 [SP-1], p = 0.01) in the injured soft tissue, normalized to the contralateral limb and/or sham-treated naïve rats, increased on Days 3 to 14 postinjury. By 14 days, foci of hypertrophic chondrocytes, hyaline cartilage, and woven bone were present in the soft tissue surrounding the amputation site. We found that genes that regulate early chondrogenic and osteogenic signaling and bone development (COL1α1, RUNX-2, OCN, PHEX, and POU5F1) are induced early during the tissue reparative/healing phase in a rat model simulating a combat-related extremity injury. The ability to correlate molecular events with histologic and morphologic changes will assist researchers and clinicians to understand HO and hence formulate therapeutic interventions.

Is the use of STABHA™ for supplementation of damaged extracellular matrix of soft tissues in the musculoskeletal system an effective treatment of acute injuries and tendinopathies?

Viscosupplementation, or the intra articular administration of hyaluronic acid in order to stabilise synovial fluid chemistry and improve its functional quality, is now a popular therapeutic method whose efficacy, based on numerous published studies, makes it not only a form of symptomatic treatment, but also, to a considerable extent, a cause-oriented treatment. However, a possibly controversial aspect of this therapy is the use of “intra articular hyaluronate” in the treatment of post-traumatic or inflammatory soft-tissue lesions in in the musculoskeletal system. Inappropriate administration of this dosage form to the area of the injured soft tissue (Achilles tendon, periarticular tendon of tarsal joint or knee, tennis elbow, tendinopathy within the rotator cuff, etc.) may not only lead to a failure to achieve the desired therapeutic effect but can even increase the severity of the symptoms, including a rupture of the frayed tendon. The role and importance of hyaluronate in the process of natural regeneration of damaged soft tissue has been demonstrated unequivocally and beyond any doubt. Subsequent research aimed to produce forms of hyaluronic acid that would be characterised by a greater influence and support of the regeneration processes in musculoskeletal soft tissue after an acute or chronic injury, as well as to develop the technology to produce a formulation which would be biocompatible, efficient and adapted to the treatment of ligament and tendon injuries. Following administration, such formulation would also need to be identified by the body as a naturally produced hyaluronate, which plays an essential role in the repair of damaged tissue, beginning with the bleeding phase and involving in all phases of the healing process, as has been demonstrated in numerous scientific studies. The development of a technology for producing hyaluronic acid known as STABHA™ (Soft Tissue Adapted Biocompatible Hyaluronic Acid) in 2008 proved to be a significant achievement in this area. The therapeutic efficacy of STABHA™-containing preparations has been documented in many clinical trials with patients treated for common musculoskeletal disorders and injuries, such as talocrural sprain, so called tennis elbow or rotator cuff tendinopathy. This paper, based on the available literature and the authors’ clinical experience, reviews the therapeutic efficacy of preparations containing STABHA™ used in the treatment of acute and chronic musculoskeletal soft-tissue injuries to enable the reader to make decisions regarding the use of this form of treatment in clinical practice.

A comparison of the epidemiology of ice hockey injuries between male and female youth in Canada.

Hockey is played by youth across Canada, and its popularity has increased dramatically among females in the past decade. Despite this, there has been little epidemiological research comparing the injury patterns of young female and male hockey players. To describe and compare injuries sustained by female and male youth hockey players using the Canadian Hospitals Injury Reporting and Prevention Program database. In the present cross-sectional, retrospective comparison study, the Canadian Hospitals Injury Reporting and Prevention Program database was used to identify all hockey-related injuries sustained by children seven to 17.5 years of age over a 15-year period (January 1995 to December 2009). Exclusion criteria included paid professional players and children with injuries sustained while playing road hockey. Inclusion criteria were met by 33,233 children (2637 [7.9%] females and 30,596 [92.1%] males). Compared with males, females reported proportionately more soft tissue injuries (39.8% versus 32.6%; P<0.01) and sprains/strains (21.1% versus 17.6%; P<0.01). Males experienced more fractures (27.1% versus 18.2%; P<0.01) and were most often injured through body checking (42.8% versus 25.7%; P<0.01). Females showed a trend toward increased concussion with age, and were most often injured through collisions (28.6% versus 24.6%; P<0.01). Compared with males, female hockey players sustained proportionately more soft tissue injures and sprains/strains, and showed a trend toward concussions in late adolecence. Males experienced more fractures, shoulder injuries and injuries due to body checking. Further research is required to identify risk factors for injury in female youth hockey players and to target injury prevention.