Mark E. Cinque

A Call for Standardization in Platelet-rich Plasma Preparation Protocols and Composition Reporting: A Systematic Review of the Clinical Orthopaedic Literature

Background: Platelet-rich plasma (PRP) is a blood-derived preparation whose use has grown exponentially in orthopaedic practice. However, there remains an unclear understanding of the biological properties and effects of PRP on musculoskeletal healing. Heterogeneous processing methods, unstandardized nomenclature, and ambiguous classifications make comparison among studies challenging. A comprehensive assessment of orthopaedic clinical PRP trials is key to unraveling the biological complexity of PRP, while improving standardized communication. Toward this goal, we performed a systematic review of the PRP preparation protocols and PRP composition utilized in clinical trials for the treatment of musculoskeletal diseases. Methods: A systematic review of the literature was performed from 2006 to 2016. Inclusion criteria were human clinical trials, English-language literature, and manuscripts that reported on the use of PRP in musculoskeletal/orthopaedic conditions. Basic-science articles, editorials, surveys, special topics, letters to the editor, personal correspondence, and nonorthopaedic applications (including cosmetic use or dental application studies) were excluded. Results: A total of 105 studies (in 104 articles) met the inclusion criteria for analysis. Of these studies, only 11 (10%) provided comprehensive reporting that included a clear description of the preparation protocol that could be used by subsequent investigators to repeat the method. Only 17 studies (16%) provided quantitative metrics on the composition of the final PRP product. Conclusions: Reporting of PRP preparation protocols in clinical studies is highly inconsistent, and the majority of studies did not provide sufficient information to allow the protocol to be reproduced. Furthermore, the current reporting of PRP preparation and composition does not enable comparison of the PRP products being delivered to patients. A detailed, precise, and stepwise description of the PRP preparation protocol is required to allow comparison among studies and provide reproducibility.

Incidence and Detection of Meniscal Ramp Lesions on Magnetic Resonance Imaging in Patients With Anterior Cruciate Ligament Reconstruction

Background: Meniscal ramp lesions have been reported to be present in 9% to 17% of patients undergoing anterior cruciate ligament (ACL) reconstruction. Detection at the time of arthroscopy can be accomplished based on clinical suspicion and careful evaluation. Preoperative assessment via magnetic resonance imaging (MRI) has been reported to have a low sensitivity in identifying meniscal ramp lesions. Purpose: To investigate the incidence of meniscal ramp lesions in patients with ACL tears and the sensitivity of preoperative MRI for the detection of ramp lesions. Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent ACL reconstruction by a single surgeon between 2010 and 2016 were included in this study, and patients with medial meniscal ramp lesions found at the time of arthroscopy were identified. The sensitivity of MRI compared with the gold standard of arthroscopic evaluation was determined by review of the preoperative MRI musculoskeletal radiologist report, mimicking the clinical scenario. The incidence was calculated based on arthroscopic findings, and the potential secondary signs of meniscal ramp tears were evaluated on MRI. Results: In a consecutive series of 301 ACL reconstructions, 50 patients (33 male, 17 female) with a mean age of 29.6 years (range, 14-61 years) were diagnosed with a medial meniscal ramp lesion at arthroscopic evaluation (16.6% incidence). The sensitivity of MRI for ramp lesions was 48% based on the preoperative MRI report. A secondary finding of a posteromedial tibial bone bruise was identified on preoperative MRI in 36 of the 50 patients with ramp lesions in a retrospective MRI review by 2 orthopaedic surgeons. Conclusion: Medial meniscal ramp lesions were present in approximately 17% of 301 patients undergoing ACL reconstruction, and less than one-half were diagnosed on the preoperative MRI. A posteromedial tibial bone bruise was found to be a secondary sign of a ramp lesion in 72% of patients. Increased awareness of this potentially combined injury pattern is necessary, and careful intraoperative evaluation is required to identify all meniscal ramp tears.

Bone marrow aspirate concentrate for the treatment of osteochondral lesions of the talus: a systematic review of outcomes

BackgroundThe goal of this perform a systematic review on the outcomes of bone marrow aspirate concentrate (BMAC) for the treatment of chondral defects and osteoarthritis (OA) of the talus.ResultsThe systematic search performed identified 47 studies after duplicates were removed. After inclusion criteria were applied four studies were considered for insightful analysis for the treatment of focal chondral defects in the foot and ankle with the use of BMAC. Three studies were retrospective and one study was prospective in nature. One study was a comparative cohort study and three studies were case series.ConclusionsThis review denotes that there exists an overwhelming paucity of long-term data and high-level evidence supporting BMAC for the treatment of chondral defects. Nonetheless, the evidence available showed varying degrees of beneficial results of BMAC for the treatment of ankle cartilage defects. The limited literature presented in this review demonstrates the need for more advanced, comparative studies to further investigate the efficacy, safety and techniques for BMAC in the treatment of OLTs. The authors recommend that BMAC therapy should be performed with careful consideration until the application and target population for this treatment are established.

Quantitative and Qualitative Analysis of the Medial Patellar Ligaments: An Anatomic and Radiographic Study

Background: The qualitative and quantitative anatomy of the medial patellar stabilizers has been reported; however, a quantitative analysis of the anatomic and radiographic attachments of all 4 ligaments relative to anatomic and osseous landmarks, as well as to one another, has yet to be performed. Purpose: To perform a qualitative and quantitative anatomic and radiographic evaluation of the medial patellofemoral ligament (MPFL), medial patellotibial ligament (MPTL), medial patellomeniscal ligament (MPML), and medial quadriceps tendon femoral ligament (MQTFL) attachment sites, with attention to their relationship to pertinent osseous and soft tissue landmarks. Study Design: Descriptive laboratory study. Methods: Ten nonpaired fresh-frozen human cadaveric knees were dissected, and the MPFL, MPTL, MPML, and MQTFL were identified. A coordinate measuring device quantified the attachment areas of each structure and its relationship to pertinent bony landmarks. Radiographic analysis was performed through ligament attachment sites and relevant anatomic structures to assess their locations relative to pertinent bony landmarks. Results: Four separate medial patellar ligaments were identified in all specimens. The center of the MPFL attachments was 14.3 mm proximal and 2.1 mm posterior to the medial epicondyle and 8.3 mm distal and 2.7 mm anterior to the adductor tubercle on the femur and 8.9 mm distal and 19.9 mm medial to the superior pole on the patella. The MQTFL had a mean insertion length of 29.3 mm on the medial aspect of the distal quadriceps tendon. The MPTL and MPML shared a common patellar insertion and were 9.1 mm proximal and 15.4 mm medial to the inferior pole. The MPTL attachment inserted on a newly identified bony ridge, which was located 5.0 mm distal to the joint line. The orientation angles of the MPTL and MPML with respect to the patellar tendon were 8.3° and 22.7°, respectively. Conclusion: The most important findings of this study were the correlative anatomy of 4 distinct medial patellar ligaments (MPFL, MPTL, MPML, MQTFL), as well as the identification of a bony ridge on the medial proximal tibia that consistently served as the attachment site for the MPTL. The quantitative and radiographic measurements, while comparable with current literature, detailed the meniscal insertion of the MPML and defined a patellar insertion of the MPTL and the MPML as a single attachment. The data allow for reproducible landmarks to be established from previously known bony and soft tissue structures. Clinical Relevance: The findings of this study provide the anatomic foundation needed for an improved understanding of the role of medial-sided patellar restraints. This will help to further refine injury patterns and/or soft tissue deficiencies that result in lateral patellar instability, which can then be addressed with an anatomic-based reconstruction or repair technique and potentially lead to improved outcomes.

Two-Tunnel Transtibial Repair of Radial Meniscus Tears Produces Comparable Results to Inside-Out Repair of Vertical Meniscus Tears:

Background: Radial meniscus tears disrupt the circumferential fibers and thereby compromise meniscus integrity. Historically, radial tears were often treated with meniscectomy because of an incomplete understanding of the biomechanical consequences of these tears, limited information regarding the biomechanical performance of repair, and the technical difficulty associated with repair. There is a paucity of studies on the outcomes of the repair of radial meniscus tears. Purpose/Hypothesis: The purpose was to determine the outcomes of 2-tunnel transtibial repair of radial meniscus tears and compare these results to the outcomes of patients who underwent the repair of vertical meniscus tears with a minimum of 2-year follow-up. The hypothesis was that radial and vertical meniscus tear repair outcomes were comparable. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent 2-tunnel transtibial pullout repair for a radial meniscus tear were included in this study and compared with patients who underwent inside-out repair for a vertical meniscus tear. Subjective questionnaires were administered preoperatively and at a minimum of 2-year follow-up, including the Lysholm score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Short Form–12 (SF-12) physical component summary (PCS), the Tegner activity scale, and patient satisfaction. Analysis of covariance was used to compare postoperative outcome scores between the meniscus repair groups while accounting for baseline scores. Adjusted mean effects relative to the radial repair group were reported with 95% CIs. Results: Twenty-seven patients who underwent 2-tunnel transtibial pullout repair for radial meniscus tears and 33 patients who underwent inside-out repair for vertical meniscus tears were available for follow-up at a mean of 3.5 years (range, 2.0-5.4 years). No preoperative outcome score significantly differed between the groups. There were no significant group differences for any of the 2-year postoperative outcome scores. Relative to the vertical repair group, the radial repair group exhibited an adjusted mean of −0.2 (95% CI, −5.4 to 4.9), −0.6 (95% CI, −6.6 to 5.5), and 5.1 (95% CI, −3.9 to 14.0) points on the SF-12 PCS, WOMAC, and Lysholm scores, respectively. Conclusion: The 2-tunnel transtibial pullout technique for the repair of radial meniscus tears produces similar clinical outcomes when compared with the repair of vertical meniscus tears at a mean 3.5 years’ follow-up.

Biological treatment of the knee with platelet-rich plasma or bone marrow aspirate concentrates

ABSTRACT — Knee pathologies including focal cartilage injuries, osteoarthritis (OA), and ligament injuries are common. The poor regeneration and healing potential of cartilage has led to the search for other treatment modalities with improved healing capacity. Furthermore, with an increasing elderly population that desires to remain active, the burden of knee pathologies is expected to increase. Increased sports participation and the desire to return to activities faster is also demanding more effective and minimally invasive treatment options. Thus, the use of biologic agents in the treatment of knee pathologies has emerged as a potential option. Despite the increasing use of biologic agents for knee pathology, there are conflicting results on the efficacy of these products. Furthermore, strong data supporting the optimal preparation methods and composition for widely used biologic agents, such as platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC), largely remain absent from the literature. This review presents the literature on the most commonly employed biologic agents for the different knee pathologies.

Return to Sport and Performance After Anterior Cruciate Ligament Reconstruction in National Football League Linemen

Background: Tears of the anterior cruciate ligament (ACL) are common in the National Football League (NFL). The impact of these injuries on the careers of NFL linemen is unknown. Purpose: To define the percentage of NFL linemen who return to sport (RTS) after ACL reconstruction, the mean time to RTS, and the impact on performance compared with matched controls. Study Design: Cohort study; Level of evidence, 3. Methods: Data on NFL offensive and defensive linemen who sustained an ACL tear and underwent ACL reconstruction between 1980 and 2015 were analyzed. Players were identified through NFL team websites, publicly available injury reports, player profiles, and press releases. Demographics and mean in-game performance data preinjury and post–ACL reconstruction were recorded. A player was deemed to have returned to sport if he played in at least 1 NFL game after his ACL reconstruction. A healthy control group was selected to compare in-game performance data and was matched with the study group on several parameters. Results: Overall, 73 NFL linemen met the inclusion criteria; 47 (64.3%) returned to play after ACL reconstruction (62.5% of offensive linemen, 65.9% of defensive linemen). All offensive linemen successfully returned to play the season after injury. No difference existed in number of seasons, total number of games played, mean number of games played, or mean number of games started per season when offensive linemen who RTS after ACL reconstruction were compared with matched controls (all P > .05). Among defensive linemen who RTS, most returned the season after injury (88.9%). There was no difference between defensive linemen who RTS after ACL reconstruction and matched controls in any performance metrics as an average over the remainder of their career (all P > .05). However, NFL defensive linemen who tore their ACL played fewer total seasons than matched controls (P = .020). Conclusion: Overall, 64.3% of NFL offensive and defensive linemen who undergo ACL reconstruction returned to play. Linemen who RTS do so at a high level, with no difference in in-game performance or career duration when compared with matched controls.

Bone Marrow Aspirate Concentrate Harvesting and Processing Technique

Bone marrow obtained by iliac crest aspiration is a common source for harvesting mesenchymal stem cells, other progenitor cells, and associated cytokine/growth factors. Recent studies have reported good to excellent outcomes with the use of bone marrow aspirate concentrate (BMAC) for pain relief in the treatment of focal chondral lesions and osteoarthritis of the knee. However, the harvesting and processing technique are crucial to achieve satisfactory results. Several studies have examined outcomes after BMAC injection, with encouraging results, but there is a lack of consensus in terms of the frequency of injection, the amount of BMAC that is injected, and the timing of BMAC injections. The purpose of this Technical Note was to describe a standardized bone marrow aspiration harvesting technique and processing method.

The Heel Height Test: A Novel Tool for the Detection of Combined Anterior Cruciate Ligament and Fibular Collateral Ligament Tears

PURPOSE To determine the exact value of side-to-side difference (SSD) in heel height that was associated with combined anterior cruciate ligament (ACL) and fibular collateral ligament (FCL) tears (compared with an isolated ACL tear) and determine the clinical utility of heel height SSD in the assessment of this injury pattern. METHODS Two patient groups were identified: (1) patients with isolated ACL tears and (2) patients with combined ACL-FCL tears but without additional collateral or cruciate ligament injuries. Determination of the amount of the heel height SSD was determined during the outpatient clinic visit. Receiver operator characteristic curves were used to evaluate the accuracy of diagnostic tests by plotting the true-positive (sensitivity) rate against the false-positive (1-specificity) rate at various thresholds. In addition, magnetic resonance imaging (MRI) reports were reviewed to calculate the sensitivity of MRI for the detection of FCL injury. MRI sensitivity was then compared with the sensitivity of the heel height examination. RESULTS One hundred and fifty-eight patients (71 men, 87 women) in the isolated ACL tear patient group and 117 patients (60 men, 57 women) in the combined ACL-FCL tear patient group were reviewed. A 3-cm or greater SSD was found in 13 of the 158 (8.2%) isolated ACL tear patients and 84 of the 117 (72%) ACL-FCL tear patients. The sensitivity, specificity, positive predictive value, and negative predictive value of the heel height test were 72%, 92%, 86%, and 86%, respectively. The area under the receiver operator characteristic curve was found to be 0.876. After review of all preoperative MRI musculoskeletal radiology reports for patients in the ACL-FCL patient group, a sensitivity of 48% was found. CONCLUSIONS The clinical heel height test resulted in high sensitivity and excellent specificity for the diagnosis of combined ACL-FCL tears compared with the sensitivity and specificity of the MRI detection of FCL injury. The information presented in the current study will improve diagnostic ability through a simple physical examination and avoid missed injuries that are known to compromise surgical outcomes. LEVEL OF EVIDENCE Level III, cross-sectional.

Clinical Outcomes and Failure Rates of Osteochondral Allograft Transplantation in the Knee: A Systematic Review:

Background: Cartilage lesions are a significant cause of morbidity and impaired knee function; however, cartilage repair procedures have failed to reproduce native cartilage to date. Thus, osteochondral allograft (OCA) transplantation represents a 1-step procedure to repair large chondral defects without the donor site morbidity of osteochondral autograft transplantation. Purpose: To perform a systematic review of clinical outcomes and failure rates after OCA transplantation in the knee at a minimum mean 2 years’ follow-up. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature regarding the existing evidence for clinical outcomes and failure rates of OCA transplantation in the knee joint was performed using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE from studies published between 1980 and 2017. Inclusion criteria were as follows: clinical outcomes and failure rates of OCAs for the treatment of chondral defects in the knee joint, English language, mean follow-up of 2 years and minimum follow-up of 18 months, minimum study size of 20 patients, and human studies. The methodological quality of each study was assessed using a modified version of the Coleman methodology score. Results: The systematic search identified 19 studies with a total of 1036 patients. The mean 5-year survival rate across the studies included in this review was 86.7% (range, 64.1%-100.0%), while the mean 10-year survival rate was 78.7% (range, 39.0%-93.0%). The mean survival rate was 72.8% at 15 years (range, 55.8%-84.0%) and 67.5% at 20 years (range, 66.0%-69.0%). The weighted mean patient age was 31.5 years (range, 10-82 years), and the weighted mean follow-up was 8.7 years (range, 2-32 years). The following outcome measures showed significant improvement from preoperatively to postoperatively: d’Aubigné-Postel, International Knee Documentation Committee, Knee Society function, and Lysholm scores. The weighted mean reoperation rate was 30.2% (range, 0%-63%). The weighted mean failure rate was 18.2% (range, 0%-31%). Of note, revision cases, patellar lesions, and bipolar lesions demonstrated worse survival rates. Conclusion: Improved patient-reported outcomes can be expected after OCA transplantation, with a survival rate of 78.7% at 10 years. Revision cases, patellar lesions, and bipolar lesions were associated with worse survival rates; therefore, utilization of the most appropriate index cartilage restoration procedure and proper patient selection are key to improving results.