Jaskarndip Chahal

The Role of Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: A Systematic Review With Quantitative Synthesis

PURPOSE Despite the theoretic basis and interest in using platelet-rich plasma (PRP) to improve the potential for rotator cuff healing, there remains ongoing controversy regarding its clinical efficacy. The objective of this systematic review was to identify and summarize the available evidence to compare the efficacy of arthroscopic rotator cuff repair in patients with full-thickness rotator cuff tears who were concomitantly treated with PRP. METHODS We searched the Cochrane Central Register of Controlled Trials, Medline, Embase, and PubMed for eligible studies. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed using a random effects model to arrive at summary estimates of treatment effect with associated 95% confidence intervals. RESULTS Five studies (2 randomized and 3 nonrandomized with comparative control groups) met the inclusion criteria, with a total of 261 patients. Methodologic quality was uniformly sound as assessed by the Detsky scale and Newcastle-Ottawa Scale. Quantitative synthesis of all 5 studies showed that there was no statistically significant difference in the overall rate of rotator cuff retear between patients treated with PRP and those treated without PRP (risk ratio, 0.77; 95% confidence interval, 0.48 to 1.23). There were also no differences in the pooled Constant score; Simple Shoulder Test score; American Shoulder and Elbow Surgeons score; University of California, Los Angeles shoulder score; or Single Assessment Numeric Evaluation score. CONCLUSIONS PRP does not have an effect on overall retear rates or shoulder-specific outcomes after arthroscopic rotator cuff repair. Additional well-designed randomized trials are needed to corroborate these findings. LEVEL OF EVIDENCE Level III, systematic review of Level I, II, and III studies.

The efficacy of platelet-rich plasma in the treatment of symptomatic knee osteoarthritis: a systematic review with quantitative synthesis.

PURPOSE The purpose of this systematic review was to synthesize the available Level I and Level II literature on platelet-rich plasma (PRP) as a therapeutic intervention in the management of symptomatic knee osteoarthritis (OA). METHODS A systematic review of Medline, Embase, Cochrane Central Register of Controlled Trials, PubMed, and www.clinicaltrials.gov was performed to identify all randomized controlled trials and prospective cohort studies that evaluated the clinical efficacy of PRP versus a control injection for knee OA. A random-effects model was used to evaluate the therapeutic effect of PRP at 24 weeks by use of validated outcome measures (Western Ontario and McMaster Universities Arthritis Index, visual analog scale for pain, International Knee Documentation Committee Subjective Knee Evaluation Form, and overall patient satisfaction). RESULTS Six Level I and II studies satisfied our inclusion criteria (4 randomized controlled trials and 2 prospective nonrandomized studies). A total of 577 patients were included, with 264 patients (45.8%) in the treatment group (PRP) and 313 patients (54.2%) in the control group (hyaluronic acid [HA] or normal saline solution [NS]). The mean age of patients receiving PRP was 56.1 years (51.5% male patients) compared with 57.1 years (49.5% male patients) for the group receiving HA or NS. Pooled results using the Western Ontario and McMaster Universities Arthritis Index scale (4 studies) showed that PRP was significantly better than HA or NS injections (mean difference, -18.0 [95% confidence interval, -28.8 to -8.3]; P < .001). Similarly, the International Knee Documentation Committee scores (3 studies) favored PRP as a treatment modality (mean difference, 7.9 [95% confidence interval, 3.7 to 12.1]; P < .001). There was no difference in the pooled results for visual analog scale score or overall patient satisfaction. Adverse events occurred more frequently in patients treated with PRP than in those treated with HA/placebo (8.4% v 3.8%, P = .002). CONCLUSIONS As compared with HA or NS injection, multiple sequential intra-articular PRP injections may have beneficial effects in the treatment of adult patients with mild to moderate knee OA at approximately 6 months. There appears to be an increased incidence of nonspecific adverse events among patients treated with PRP. LEVEL OF EVIDENCE Level II, systematic review of Level I and II studies.

How to set the bar in competency-based medical education: standard setting after an Objective Structured Clinical Examination (OSCE)

BackgroundThe goal of the Objective Structured Clinical Examination (OSCE) in Competency-based Medical Education (CBME) is to establish a minimal level of competence. The purpose of this study was to 1) to determine the credibility and acceptability of the modified Angoff method of standard setting in the setting of CBME, using the Borderline Group (BG) method and the Borderline Regression (BLR) method as a reference standard; 2) to determine if it is feasible to set different standards for junior and senior residents, and 3) to determine the desired characteristics of the judges applying the modified Angoff method.MethodsThe results of a previous OSCE study (21 junior residents, 18 senior residents, and six fellows) were used. Three groups of judges performed the modified Angoff method for both junior and senior residents: 1) sports medicine surgeons, 2) non-sports medicine orthopedic surgeons, and 3) sports fellows. Judges defined a borderline resident as a resident performing at a level between competent and a novice at each station. For each checklist item, the judges answered yes or no for “will the borderline/advanced beginner examinee respond correctly to this item?” The pass mark was calculated by averaging the scores. This pass mark was compared to that created using both the BG and the BLR methods.ResultsA paired t-test showed that all examiner groups expected senior residents to get significantly higher percentage of checklist items correct compared to junior residents (all stations p < 0.001). There were no significant differences due to judge type. For senior residents, there were no significant differences between the cut scores determined by the modified Angoff method and the BG/BLR method. For junior residents, the cut scores determined by the modified Angoff method were lower than the cut scores determined by the BG/BLR Method (all p < 0.01).ConclusionThe results of this study show that the modified Angoff method is an acceptable method of setting different pass marks for senior and junior residents. The use of this method enables both senior and junior residents to sit the same OSCE, preferable in the regular assessment environment of CBME.

The clinical status of cartilage tissue regeneration in humans

PURPOSE To provide a comprehensive overview of the basic science and clinical evidence behind cartilage regeneration techniques as they relate to surgical management of chondral lesions in humans. METHODS A descriptive review of current literature. RESULTS Articular cartilage defects are common in orthopedic practice, with current treatments yielding acceptable short-term but inconsistent long-term results. Tissue engineering techniques are being employed with aims of repopulating a cartilage defect with hyaline cartilage containing living chondrocytes with hopes of improving clinical outcomes. Cartilage tissue engineering broadly involves the use of three components: cell source, biomaterial/membranes, and/or growth stimulators, either alone or in any combination. Tissue engineering principles are currently being applied to clinical medicine in the form of autologous chondrocyte implantation (ACI) or similar techniques. Despite refinements in technique, current literature fails to support a clinical benefit of ACI over older techniques such as microfracture except perhaps for larger (>4 cm) lesions. Modern ACI techniques may be associated with lower operative revision rates. The notion that ACI-like procedures produce hyaline-like cartilage in humans remains unsupported by high-quality clinical research. CONCLUSIONS Many of the advancements in tissue engineering have yet to be applied in a clinical setting. While basic science has refined orthopedic management of chondral lesions, available evidence does not conclude the superiority of modern tissue engineering methods over other techniques in improving clinical symptoms or restoring native joint mechanics. It is hoped further research will optimize ease of cell harvest and growth, enhanced cartilage production, and improve cost-effectiveness of medical intervention.

Epidemiology of Primary Anterior Shoulder Dislocation Requiring Closed Reduction in Ontario, Canada

Background: There is a lack of high-quality population-based literature describing the epidemiology of primary anterior shoulder dislocation. Purpose: To (1) calculate the incidence density rate (IDR) of primary anterior shoulder dislocation requiring closed reduction (CR; “index event”) in the general population and demographic subgroups, and (2) determine the rate of and risk factors for repeat shoulder CR. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: All patients who underwent shoulder CR by a physician in Ontario between April 2002 and September 2010 were identified with administrative databases. Exclusion criteria included age <16 and >70 years, posterior dislocation, and prior shoulder dislocation or surgery. Index event IDR was calculated for all populations/subgroups, and IDR comparisons were made. Repeat shoulder CR was sought until September 2012. Risk factors for repeat shoulder CR were identified with a Prentice, Williams, and Peterson proportional hazards model. Results: There were 20,719 persons (median age, 35 years; 74.3% male) who underwent a shoulder CR after a primary anterior shoulder dislocation (23.1/100,000 person-years). The IDR was highest among young males (98.3/100,000 person-years). A total of 3940 (19%) patients underwent repeat shoulder CR after a median of 0.9 years, of which 41.7% were ≤20 years of age. Less than two-thirds of all first repeat shoulder CR events occurred within 2 years; in fact, 95% occurred within 5 years. The risk of repeat shoulder CR was lowest if the primary reduction had been performed by an orthopaedic surgeon (hazard ratio [HR], 0.76; 95% CI: 0.64, 0.90; P = .002) or was associated with a humeral tuberosity fracture (HR, 0.71; CI, 0.53, 0.95; P = .02). Older age (HR, 0.97; CI, 0.97, 0.98; P < .0001) and higher medical comorbidity score (HR, 0.92; CI, 0.87, 0.98; P = .009) were also protective. Risk was highest among males (HR, 1.26; CI, 1.16, 1.36; P < .0001) and patients from low-income neighborhoods (HR, 1.23; CI, 1.13, 1.34; P < .0001). Conclusion: Young male patients have the highest incidence of primary anterior shoulder dislocation requiring CR and the greatest risk of repeat shoulder CR. Patient, provider, and injury factors all influence repeat shoulder CR risk. A comprehensive understanding of the epidemiology of primary anterior shoulder dislocation will aid management decisions and injury prevention initiatives.

An Evidenced-Based Examination of the Epidemiology and Outcomes of Traumatic Rotator Cuff Tears

PURPOSE The purpose of this study was to systematically review the literature to better define the epidemiology, mechanism of injury, tear characteristics, outcomes, and healing of traumatic rotator cuff tears. A secondary goal was to determine if sufficient evidence exists to recommend early surgical repair in traumatic rotator cuff tears. METHODS An independent systematic review was conducted of evidence Levels I to IV. A literature search of PubMed, Medline, Embase, and Cochrane Collaboration of Systematic Reviews was conducted, with 3 reviewers assessing studies for inclusion, methodology of individual study, and extracted data. RESULTS Nine studies met the inclusion and exclusion criteria. Average patient age was 54.7 (34 to 61) years, and reported mean time to surgical intervention, 66 days (3 to 48 weeks) from the time of injury. The most common mechanism of injury was fall onto an outstretched arm. Supraspinatus was involved in 84% of tears, and infraspinatus was torn in 39% of shoulders. Subscapularis tears were present in 78% of injuries. Tear size was <3 cm in 22%, 3 to 5 cm in 36%, and >5 cm in 42%. Average active forward elevation improved from 81° to 150° postoperatively. The weighted mean postoperative UCLA score was 30, and the Constant score was 77. CONCLUSIONS Traumatic rotator cuff tears are more likely to occur in relatively young (age 54.7), largely male patients who suffer a fall or trauma to an abducted, externally rotated arm. These tears are typically large and involve the subscapularis, and repair results in acceptable results. However, insufficient data prevent a firm recommendation for early surgical repair. LEVEL OF EVIDENCE Level IV, systematic review Levels III and IV studies.

Risk Factors for Recurrent Anterior Cruciate Ligament Reconstruction

Background: Anterior cruciate ligament reconstruction (ACLR) is routinely performed for symptomatic instability. Although it is a common procedure, there remain differences in surgical technique. Hospital administrative records in a public health care system were used to investigate the effect of patient, provider, and surgical factors on the risk of revision ACLR. Purpose: To define the rate and risk factors for ACL reoperation in Ontario, Canada, including both ipsilateral revision and contralateral primary procedures. Study Design: Cohort study; Level of evidence, 3. Methods: All primary elective ACLR procedures performed in Ontario (July 2003 to March 2008) in patients aged 15 to 60 years were identified via physician billing and hospital databases. Revision and contralateral ACLR were sought until January 2012. Patient factors (age, sex, comorbidity, income quintile, length of index hospital admission), provider factors (surgeon volume, academic hospital status), and surgical factors (allograft vs autograft; fixation type [screw, button, staple]; concomitant operative procedures) were used as covariates in a Cox proportional hazards survivorship model to generate hazard ratios (HRs) with confidence intervals (CIs) (α = .05). Kaplan-Meier survivorship curves with ACL revision as the end point were generated. Results: A total of 12,967 ACLR procedures with a mean follow-up of 5.2 years were eligible for study using preset criteria. The revision rate was 2.6% (mean ± SD, 2.91 ± 1.71 years to revision). The rate of primary contralateral ACLR was 4.6% (mean, 2.95 ± 1.81 years). In the Cox model, younger age (15-19 years) (HR, 2.1; 95% CI, 1.5-2.9; P < .001), ACLR performed at an academic hospital (HR, 1.6; 95% CI, 1.2-2.1; P < .001), and the use of allograft (HR, 1.7; 95% CI, 1.1-2.6; P = .02) significantly increased the risk of revision ACLR. Only younger age (HR, 2.1; 95% CI, 1.6-2.7; P < .001) was associated with an increased risk of contralateral ACLR. Conclusion: Contralateral ACLR was more frequent than revision ACLR in this population, while both surgical procedures were most common in patients younger than 20 years. Academic hospital status, but not surgeon volume, as well as the use of allograft also increased the risk for revision ACLR.

The role of subacromial decompression in patients undergoing arthroscopic repair of full-thickness tears of the rotator cuff: a systematic review and meta-analysis.

PURPOSE The purpose of this study was to determine the efficacy of arthroscopic repair of full-thickness rotator cuff tears with and without subacromial decompression. METHODS We searched the Cochrane Central Register of Controlled Trials (third quarter of 2011), Medline (1948 to week 1 of September 2011), and Embase (1980 to week 37 of 2011) for eligible randomized controlled trials. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed by use of a random effects and relative risk model with computation of 95% confidence intervals. RESULTS We included 4 randomized trials and 373 patients. Methodologic quality was variable as assessed by the CLEAR NPT (Checklist to Evaluate a Report of a Non-pharmacological Trial) tool. One trial showed that there was no difference in disease-specific quality of life (Western Ontario Rotator Cuff questionnaire) between the 2 treatment groups. A meta-analysis of shoulder-specific outcome measures (American Shoulder and Elbow Surgeons or Constant scores) or the rate of reoperation between patients treated with subacromial decompression and those treated without it also showed no statistically significant differences. CONCLUSIONS On the basis of the currently available literature, there is no statistically significant difference in subjective outcome after arthroscopic rotator cuff repair with or without acromioplasty at intermediate follow-up. LEVEL OF EVIDENCE Level I, systematic review of Level I studies.

Risk factors for Recurrent Anterior Cruciate Ligament Reconstruction: A Population Study in Ontario, Canada with 5-year Follow-up.

Objectives: Anterior cruciate ligament reconstruction (ACLR) is routinely performed to treat symptomatic instability. Despite being a common procedure, significant variation persists in technique and graft choice. How patient, provider and surgical factors influence the risk of revision or contralateral primary ACLR has not been investigated using administrative data. The goal of our study was to define the rate and risk factors for ACL re-operation in Ontario. Methods: All primary elective ACLR performed in Ontario, Canada from July 2003 to March 2008 in patients aged 15 to 60 years were identified via billing, diagnosis and procedural databases. The main outcomes were revision and contralateral ACLR, sought until January 2012. Patient factors (age, gender, co-morbidity, income quintile, and length of index hospital admission), provider factors (surgeon volume, academic hospital status) and surgical factors (allograft vs. autograft; fixation: screw, button, staple; concomitant operative procedures) were used as covariates in a Cox Proportional Hazards survivorship model to generate Hazard Ratios (HR) with confidence intervals (alpha 0.05). Kaplan-Meier survivorship curves to revision were generated. Results: A total of 12,967 ACLR with a mean follow-up of 5.2 years were identified. The revision rate was 2.6% [after a median 2.72 years (interquartile range 1.38, 4.11)]. The rate of primary contralateral ACLR was 4.6% [after a median 2.71 years (interquartile range 1.49, 4.22)]. In the Cox model, younger age [15-19 years; HR=2.1 (95% CI: 1.5-2.9), p<0.001], ACLR performed at an academic hospital [HR=1.6 (95% CI: 1.2-2.1), p<0.001] and the use of allograft [HR=1.7 (95% CI: 1.1-2.6), p=0.02] significantly increased the risk of revision ACLR. The K-M curves to revision ACLR for allograft and autograft demonstrated equivalent survivorship for approximately 3 years, after which allograft ACLR were more commonly revised (Figure 1). Only younger age [15-19 years; HR=2.1, (95% CI: 1.6-2.7), p<0.001] was associated with an increased risk of contralateral ACLR. Conclusion: Contralateral ACLR was more frequent than revision ACLR in this population, while both re-operations were significantly more common in patients <20 years old. Academic hospital status but not surgeon volume, and the use of allograft also increased the risk of revision ACLR. Late failure of allograft ACLR is a novel finding.

Anatomic Bankart Repair Compared With Nonoperative Treatment and/or Arthroscopic Lavage for First-Time Traumatic Shoulder Dislocation

PURPOSE The objective of this systematic review was to determine the efficacy of anatomic Bankart repair in patients with a first-time shoulder dislocation compared with either arthroscopic lavage or traditional sling immobilization. METHODS We searched the Cochrane Central Register of Controlled Trials, Medline, Embase, CINAHL, Web of Science, LILACS, and a clinical trials registry for ongoing and completed randomized or quasi-randomized controlled trials comparing anatomic Bankart repair with either rehabilitation or arthroscopic lavage. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed by use of a random-effects model, and risk ratio (RR) and 95% confidence intervals (CIs) were computed. RESULTS We included 3 randomized trials and 1 quasi-randomized trial comprising 228 patients. Of the included trials, 2 compared anatomic Bankart repair with sling immobilization whereas 2 compared Bankart repair with arthroscopic lavage. A meta-analysis of all 4 trials showed that the rate of recurrent instability was significantly lower among participants undergoing anatomic Bankart repair compared with those undergoing either immobilization or arthroscopic lavage (RR, 0.18; 95% CI, 0.10 to 0.33). Subgroup analysis showed that this effect persisted when Bankart repair was compared with arthroscopic lavage alone (2 studies) (RR, 0.14; 95% CI, 0.06 to 0.31) or sling immobilization alone (2 studies) (RR, 0.26; 95% CI, 0.10 to 0.67). Western Ontario Shoulder Instability scores were better with anatomic Bankart repair compared with either arthroscopic lavage or immobilization (2 studies) (mean difference, -232; 95% CI, -317 to -146). CONCLUSIONS There is evidence to suggest treatment of young patients with a first-time shoulder dislocation with anatomic Bankart repair with the goal of lowering the rate of recurrent instability over the long-term and improving short-term quality of life. LEVEL OF EVIDENCE Level II, systematic review of Level I and II studies.