A.J.H. Vochteloo

Concentrations of Blood Components in Commercial Platelet-Rich Plasma Separation Systems: A Review of the Literature:

Background: Platelet-rich plasma (PRP) has proven to be a very safe therapeutic option in the treatment of tendon, muscle, bone, and cartilage injuries. Currently, several commercial separation systems are available for the preparation of PRP. The concentrations of blood components in PRP among these separation systems vary substantially. Purpose: To systematically review and evaluate the differences between the concentrations of blood components in PRP produced by various PRP separation systems. Study Design: Systematic review. Methods: MEDLINE/PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE were searched for studies that compared the concentrations of blood components and growth factors in PRP between various separation systems and studies that reported on the concentrations of blood components and growth factors of single separation systems. The primary outcomes were platelet count, leukocyte count, and concentration of growth factors (eg, platelet-derived growth factor–AB [PDGF-AB], transforming growth factor–β1 [TGF-β1], and vascular endothelial growth factor [VEGF]). Furthermore, the preparation protocols and prices of the systems were compared. Results: There were 1079 studies found, of which 19 studies were selected for inclusion in this review. The concentrations of platelets and leukocytes in PRP differed largely between, and to a lesser extent within, the studied PRP separation systems. Additionally, large differences both between and within the studied PRP separation systems were found for all the growth factors. Furthermore, preparation protocols and prices varied widely between systems. Conclusion: There is a large heterogeneity between PRP separation systems regarding concentrations of platelets, leukocytes, and growth factors in PRP. The choice for the most appropriate type of PRP should be based on the specific clinical field of application. As the ideal concentrations of blood components and growth factors for the specific fields of application are yet to be determined for most of the fields, future research should focus on which type of PRP is most suitable for the specific field.

Smoking and morphology of calcific deposits affect the outcome of needle aspiration of calcific deposits (NACD) for calcific tendinitis of the rotator cuff

INTRODUCTION Although NACD has proven to be an effective minimal invasive treatment for calcific tendinitis of the rotator cuff, little is known about the factors associated with treatment failure or the need for multiple procedures. METHODS Patients with symptomatic calcific tendinitis who were treated by NACD were evaluated in a retrospective cohort study. Demographic details, medical history, sonographic and radiographic findings were collected from patient files. Failure of NACD was defined as the persistence of symptoms after a follow-up of at least six months. NACD procedures performed within six months after a previous NACD procedure were considered repeated procedures. Multivariate logistic regression analysis was used to determine factors associated with treatment failure and multiple procedures. RESULTS 431 patients (277 female; mean age 51.4±9.9 years) were included. Smoking (adjusted odds ratio (AOR): 1.7, 95% CI 1.0-2.7, p=0.04) was significantly associated with failure of NACD. Patients with Gärtner and Heyer (GH) type I calcific deposits were more likely to need multiple NACD procedures (AOR: 3.4, 95% CI 1.6-7.5, p<0.01) compared to patients with type III calcific deposits. Partial thickness rotator cuff tears were of no influence on the outcome of NACD or the number of treatments necessary. CONCLUSION Smoking almost doubled the chance of failure of NACD and the presence of GH type I calcific deposits significantly increased the chance of multiple procedures. Partial thickness rotator cuff tears did not seem to affect the outcome of NACD. Based on the findings in this study, the importance of quitting smoking should be emphasized prior to NACD and partial thickness rotator cuff tears should not be a reason to withhold patients NACD.

Needle aspiration of calcific deposits (NACD) for calcific tendinitis is safe and effective: Six months follow-up of clinical results and complications in a series of 431 patients

BACKGROUND Although needle aspiration of calcific deposits (NACD) has proven to be an effective treatment for calcific tendinitis of the rotator cuff (CTRC) in patients who are resistant to conservative treatment, little is known about the effectiveness of NACD in terms of complete relief of symptoms and the effectiveness of repeated NACD procedures. Furthermore, analyses of complications of the procedure in large series are scarce. METHODS 431 consecutive patients with symptomatic CTRC treated by NACD were included in this retrospective cohort study. Short-term effects were assessed at two weeks post-treatment by using an 11-point numeric rating scale (NRS). The six months outcome was determined on a dichotomous symptom scale (symptom free or persistence of symptoms). NACD procedures performed within six months of a previous NACD procedure were considered repeated procedures. All complications that occurred within six months of the NACD procedure were registered. RESULTS At two weeks post-treatment, a significant improvement of pain scores was noted (mean reduction of NRS: 4.4 points; p<0.001). 74% of patients had complete relief of symptoms at six months post-treatment. 143 (33.2%) patients required multiple treatments. These repeated procedures were equally effective as the primary procedure. Complications of the NACD procedure were seen in 31 (7.2%) patients: 21 patients (4.9%) developed a subacromial bursitis, seven patients (1.6%) a frozen shoulder and three patients (0.7%) developed a septic bursitis. CONCLUSION Needle aspiration of calcific deposits (NACD) is an effective treatment for calcific tendinitis of the rotator cuff in the majority of patients. Approximately one third of the patients will require multiple treatments, which were equally effective as the primary procedure. Based on this, patients should not be withheld a second or even a third treatment in case of persistent symptoms. Furthermore, NACD has a low complication rate, the risk of infection should, however, always be accounted for. LEVEL OF EVIDENCE Retrospective study, level IV.

Neck of Femur Fracture in a Patient with a Chronic Osteomyelitis of the Ipsilateral Foot

This case report describes a successful two-stage treatment in a 75-year-old male with a displaced neck of femur fracture, also suffering from an active chronic osteomyelitis of the ipsilateral calcaneus. In our case, a below-knee amputation was performed first, followed by total hip arthroplasty two weeks later. At 15-month follow-up, full recovery of the prefracture level of activities of daily living without significant impairment was obtained. Only a few cases of total hip arthroplasty in amputees have been published, but the indication for surgery was mainly traumatic or advanced osteoarthritis. Treating patients with this type of comorbidities is challenging; therapeutic dilemmas can be major. The management in cases like these requires a thorough evaluation and a clear surgical and medical treatment plan, preferably conducted by a multidisciplinary orthogeriatric team.

Successful Treatment of a 15-Year-Old Nonunion of a Midshaft Clavicle Fracture Causing Brachial Plexus Compression

A 49-year-old man with a 15-year-old nonunion of a midshaft clavicle fracture suffered from progressive tingling in his entire arm and fingers for two years, due to irritation of the brachial plexus in the costoclavicular space, especially upon elevation of the arm. After open reduction and internal plate fixation, all symptoms were resolved and complete consolidation of the fracture was achieved at one-year follow-up. This case demonstrates two things: brachial plexus compression can occur even many years after a nonunion of a clavicle fracture and union can be still achieved, even in a longstanding nonunion.

Removal of restrictions following primary THA with posterolateral approach does not increase the risk of early dislocation

Sir—We read with great interest the article in this issue of Acta Orthopedica by Gromov et al. (2015). We want to congratulate the authors on their very interesting and clinically relevant paper and we would like to make some comments. Firstly, as stated by Gromov et al. the reported overall incidence rates of dislocation range from less than 1% to 15%. However, with an anterolateral approach dislocation rate ranged from 0% to 0.6% (Ververeli et al. 2009, Talbot et al. 2012). It is debatable whether the higher dislocation rate, around 3% within 3 months, found by Gromov et al. can be explained solely by the type of surgical approach, since a meta-analysis (Kwon et al. 2006) revealed similar dislocation rates associated for the anterolateral, direct lateral, and posterior approaches with soft tissue repair (0.70%, 0.43%, and 1.0%). Secondly, the authors made a distinction between avoidable and unavoidable dislocations and state that the risk of dislocations that could possibly have been avoided if mobilization restrictions had been observed was similar in both groups, indicating that dislocations due to undesirable movement do occur despite having restrictions. When looking into detail, among the unavoidable dislocations are the so-called “unknown mechanisms” and ‘other’ (getting dressed, moving in bed, lifting a leg) (Table 4). However, in our opinion one could also state that these might as well have to be added to the ‘avoidable’ dislocation group. When doings so, the actual number of avoidable dislocations would triple which in turn could have major impact on the results and conclusions drawn. Thirdly, in order to draw valid conclusions from studies investigating the impact of (reduced) restrictions after hip replacement it is important to objectify the compliance of patients with prescribed or removed restrictions. Without knowledge about compliance with reduced restrictions in the different study arms it is difficult to relate dislocation rates to effectiveness of postoperative protocols as postulated in the current study. Finally, in our view the use of patient reported outcomes on perceived burden in terms of psychological distress (anxiety, mental preoccupation) and functional limitations of postoperative restrictions during the rehabilitation is desirable. In that way we will be able to know which restrictions have the highest impact on patients, which restrictions can safely be abandoned and which strategies achieve the highest patient compliance.