Olufemi R. Ayeni

Efficacy of autologous platelet-rich plasma use for orthopaedic indications: a meta-analysis.

BACKGROUND The recent emergence of autologous blood concentrates, such as platelet-rich plasma, as a treatment option for patients with orthopaedic injuries has led to an extensive debate about their clinical benefit. We conducted a systematic review and meta-analysis to determine the efficacy of autologous blood concentrates in decreasing pain and improving healing and function in patients with orthopaedic bone and soft-tissue injuries. METHODS We searched MEDLINE and Embase for randomized controlled trials or prospective cohort studies that compared autologous blood concentrates with a control therapy in patients with an orthopaedic injury. We identified additional studies by searching through the bibliographies of eligible studies as well as the archives of orthopaedic conferences and meetings. RESULTS Twenty-three randomized trials and ten prospective cohort studies were identified. There was a lack of consistency in outcome measures across all studies. In six randomized controlled trials (n = 358) and three prospective cohort studies (n = 88), the authors reported visual analog scale (VAS) scores when comparing platelet-rich plasma with a control therapy across injuries to the acromion, rotator cuff, lateral humeral epicondyle, anterior cruciate ligament, patella, tibia, and spine. The use of platelet-rich plasma provided no significant benefit up to (and including) twenty-four months across the randomized trials (standardized mean difference, -0.34; 95% confidence interval [CI], -0.75 to 0.06) or the prospective cohort studies (standardized mean difference, -0.20; 95% CI, -0.64 to 0.23). Both point estimates suggested a small trend favoring platelet-rich plasma, but the associated wide confidence intervals were consistent with nonsignificant effects. CONCLUSIONS The current literature is complicated by a lack of standardization of study protocols, platelet-separation techniques, and outcome measures. As a result, there is uncertainty about the evidence to support the increasing clinical use of platelet-rich plasma and autologous blood concentrates as a treatment modality for orthopaedic bone and soft-tissue injuries.

Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis

Background: Arthroscopic surgery for degenerative meniscal tears is a commonly performed procedure, yet the role of conservative treatment for these patients is unclear. This systematic review and meta-analysis evaluates the efficacy of arthroscopic meniscal débridement in patients with knee pain in the setting of mild or no concurrent osteoarthritis of the knee in comparison with nonoperative or sham treatments. Methods: We searched MEDLINE, Embase and the Cochrane databases for randomized controlled trials (RCTs) published from 1946 to Jan. 20, 2014. Two reviewers independently screened all titles and abstracts for eligibility. We assessed risk of bias for all included studies and pooled outcomes using a random-effects model. Outcomes (i.e., function and pain relief) were dichotomized to short-term (< 6 mo) and long-term (< 2 yr) data. Results: Seven RCTs (n = 805 patients) were included in this review. The pooled treatment effect of arthroscopic surgery did not show a significant or minimally important difference (MID) between treatment arms for long-term functional outcomes (standardized mean difference [SMD] 0.07, 95% confidence interval [CI] −0.10 to 0.23). Short-term functional outcomes between groups were significant but did not exceed the threshold for MID (SMD 0.25, 95% CI 0.02 to 0.48). Arthroscopic surgery did not result in a significant improvement in pain scores in the short term (mean difference [MD] 0.20, 95% CI −0.67 to 0.26) or in the long term (MD −0.06, 95% CI −0.28 to 0.15). Statistical heterogeneity was low to moderate for the outcomes. Interpretation: There is moderate evidence to suggest that there is no benefit to arthroscopic meniscal débridement for degenerative meniscal tears in comparison with nonoperative or sham treatments in middle-aged patients with mild or no concomitant osteoarthritis. A trial of nonoperative management should be the first-line treatment for such patients.

The Structure and Function of the Anterolateral Ligament of the Knee: A Systematic Review

PURPOSE The purpose of this systematic review was to evaluate the anatomic structure and function of the anterolateral ligament (ALL) of the knee. METHODS The Medline, Embase, and Cochrane databases were screened for all studies related to the ALL of the knee. Two reviewers independently reviewed all eligible articles and the references of these articles. Inclusion and exclusion criteria were applied to all searched studies. Quality assessment was completed for the included studies. RESULTS Nineteen studies were identified for final analysis. Pooled analysis identified the ALL in 430 of 449 knees (96%) examined. The ligament was found to originate from the region of the lateral femoral epicondyle and insert on the proximal tibia midway between the Gerdy tubercle and the fibular head. The ALL was found to be 34.1 to 41.5 mm in length, 5.1 to 8.3 mm in width above the lateral meniscus, and 8.9 to 11.2 mm in width below the lateral meniscus. By use of magnetic resonance imaging, the ALL was identified in 93% of knees examined (clinical, 64 of 70; cadaveric, 16 of 16). In one case study the ligament was clearly visualized by ultrasound examination. Histologic analysis across 3 studies showed characteristics consistent with ligamentous tissue. Though not shown in biomechanical studies, it is hypothesized that the ALL provides anterolateral stability to the knee, preventing anterolateral subluxation of the proximal tibia on the femur. One study identified a network of peripheral nerves, suggesting a proprioceptive function of the ALL. CONCLUSIONS This systematic review shows the ALL to be a distinct structure with a consistent origin and insertion sites. The ALL is an extra-articular structure with a clear course from the lateral femoral epicondyle region, running anteroinferiorly, to the proximal tibia at a site midway between the Gerdy tubercle and the head of the fibula. The function of this ligament is theorized to provide anterolateral knee stability. LEVEL OF EVIDENCE Level IV, systematic review of cadaveric and imaging studies.

Femoral neck fracture after arthroscopic management of femoroacetabular impingement: a case report.

Ganz and colleagues recently identified femoroacetabular impingement as the predominant cause of labral tears in nondysplastic hips1. Structural abnormalities of the hip can limit motion and result in repetitive impact of the proximal part of the femoral neck against the acetabular labrum and adjacent cartilage. Osseous impingement as a result of a decrease in femoral head-neck offset or an aspherical femoral head is termed cam impingement. On the acetabular side, pincer impingement results from various degrees of overgrowth of the osseous acetabulum and excessive acetabular retroversion2. Pincer impingement can be subdivided into coxa profunda or protrusio, anterosuperior overcoverage, and true acetabular retroversion. Regardless of whether arthroscopic or open techniques are employed, the goal of surgical treatment of femoroacetabular impingement is a complete decompression of the impingement from the pathologic osseous anatomy. Recent work with a cadaveric model by Mardones et al. suggested that up to 30% of the diameter of the femoral neck can be resected to restore neck offset without increasing the risk of postoperative fracture3. We present a case of a nondisplaced, iatrogenic femoral neck fracture sustained after arthroscopic osteoplasty for the treatment of femoroacetabular impingement. This case provides a sentinel reminder to hip surgeons that femoral neck fracture can occur after a modest osteoplasty done for the treatment of cam impingement and warrants consideration of a period of protected weight-bearing postoperatively. The patient was informed that data concerning the case would be submitted for publication, and he consented. A fifty-one-year-old man presented with a three-year history of insidious-onset, increasingly intense anterior right groin pain, exacerbated by standing from a seated position or by playing golf. The patient had completed a trial of nonsteroidal anti-inflammatory medications and physical therapy without relief of symptoms. An intra-articular injection of corticosteroids provided excellent but transient …

Consistency of Reported Outcomes After Arthroscopic Management of Femoroacetabular Impingement

PURPOSE The purpose of this systematic review is to evaluate the consistency of the reporting of clinical and radiographic outcomes after arthroscopic management of femoroacetabular impingement (FAI). METHODS Two databases (Medline and EMBASE) were screened for clinical studies involving the arthroscopic management of FAI. A full-text review of eligible studies was conducted, and the references were searched. Inclusion and exclusion criteria were applied to the searched studies, and a quality assessment was completed for included studies. RESULTS We identified 29 eligible studies involving 2,816 patients. There was a lack of consensus with regard to reported outcomes (clinical and radiographic) after arthroscopic treatment of FAI. Clinical outcomes reported include the Harris Hip Score (45%) and the Non-Arthritic Hip Scale (28%), range of motion (34%), pain scores (24%), and patient satisfaction (28%). The most commonly reported radiographic outcomes included the alpha angle (38%), head-neck offset (14%), and degenerative changes (21%). CONCLUSIONS There is significant variation in reported clinical and radiographic outcomes after arthroscopic treatment of FAI. This study highlights the need for consistent outcome reporting after arthroscopic FAI surgery. LEVEL OF EVIDENCE Level IV, systematic review of Level II, III, and IV studies.

Cartilage Restoration of the Knee A Systematic Review and Meta-Analysis of Level 1 Studies

Background: Focal cartilage defects of the knee are a substantial cause of pain and disability in active patients. There has been an emergence of randomized controlled trials evaluating surgical techniques to manage such injuries, including marrow stimulation (MS), autologous chondrocyte implantation (ACI), and osteochondral autograft transfer (OAT). Purpose: A meta-analysis was conducted to determine if any single technique provides superior clinical results at intermediate follow-up. Study Design: Systematic review and meta-analysis of randomized controlled trials. Methods: The MEDLINE, EMBASE, and Cochrane Library databases were systematically searched and supplemented with manual searches of PubMed and reference lists. Eligible studies consisted exclusively of randomized controlled trials comparing MS, ACI, or OAT techniques in patients with focal cartilage defects of the knee. The primary outcome of interest was function (Lysholm score, International Knee Documentation Committee score, Knee Osteoarthritis Outcome Score) and pain at 24 months postoperatively. A meta-analysis using standardized mean differences was performed to provide a pooled estimate of effect comparing treatments. Results: A total of 12 eligible randomized trials with a cumulative sample size of 765 patients (62% males) and a mean (±SD) lesion size of 3.9 ± 1.3 cm2 were included in this review. There were 5 trials comparing ACI with MS, 3 comparing ACI with OAT, and 3 evaluating different generations of ACI. In a pooled analysis comparing ACI with MS, there was no difference in outcomes at 24-month follow-up for function (standardized mean difference, 0.47 [95% CI, –0.19 to 1.13]; P = .16) or pain (standardized mean difference, –0.13 [95% CI, –0.39 to 0.13]; P = .33). The comparisons of ACI to OAT or between different generations of ACI were not amenable to pooled analysis. Overall, 5 of the 6 trials concluded that there was no significant difference in functional outcomes between ACI and OAT or between generations of ACI. Conclusion: There is no significant difference between MS, ACI, and OAT in improving function and pain at intermediate-term follow-up. Further randomized trials with long-term outcomes are warranted.

Surgical Indications for Arthroscopic Management of Femoroacetabular Impingement

PURPOSE The clinical literature was systematically reviewed to determine the consistently reported indications for arthroscopic management of femoroacetabular impingement (FAI). METHODS Two databases (Medline and EMBASE) were screened for clinical studies involving the arthroscopic surgical management of FAI. A full-text review of eligible studies was conducted, and the references were searched. Articles published from 1980 until June 2011 were included, and the inclusion criteria were as follows: studies of human patients of all ages and genders with FAI, studies with a minimum of 6 months of patient follow-up, and studies reporting clinical outcome data. A quality assessment of the included articles was conducted. RESULTS We included 20 articles in this review, involving a total of 1,368 patients. We identified a lack of consensus on clinical and radiographic indications for the arthroscopic management of FAI. The indications varied from a positive impingement sign (45%) and symptoms or pain for more than 6 months (35%) to a series of positive special tests (25%). Commonly reported radiographic indicators for arthroscopic FAI management included the following: results from a computed tomography scan or magnetic resonance imaging (60%), cam or pincer lesions evident on anteroposterior and/or lateral radiographs (50%), loss of sphericity of the femoral neck (30%), acetabular retroversion (30%), magnetic resonance arthrography (25%), reduction in head-neck offset (25%), an alpha angle greater than 50° (25%), and coxa profunda (25%). CONCLUSIONS We found that there was great inconsistency among the indications for arthroscopic management of FAI. Clinical and radiographic indices remain largely unvalidated. This review highlights the need for more consistent reporting of surgical indications for the arthroscopic management of FAI. Future research should explore what combination of clinical and radiographic indications should be best used to determine arthroscopic FAI management. LEVEL OF EVIDENCE Level IV, systematic review of Level II to IV studies.

Arthroscopy Up to Date: Hip Femoroacetabular Impingement

PURPOSE To provide a comprehensive review and summary of the research published in Arthroscopy: The Journal of Arthroscopic and Related Surgery and The American Journal of Sports Medicine (AJSM) related to hip arthroscopy for femoroacetabular impingement (FAI). METHODS A comprehensive review was conducted in duplicate of Arthroscopy and AJSM from February 2012 to February 2015 for all articles related to FAI, and a quality assessment was completed for all included studies. Clinical outcomes were dichotomized into short-term (<6 months) and midterm (<24 months) outcomes, and values were pooled when possible. RESULTS We identified 60 studies in Arthroscopy and 44 studies in AJSM, primarily from North America (78.8%), that predominantly assessed clinical outcomes after arthroscopic hip surgery (46.1%). Seventy-one percent of Arthroscopy studies and 20.5% of AJSM studies were Level IV evidence. The modified Harris Hip Score (mHHS) was used by 81.5% of included studies. Pooled weighted mean mHHS values after arthroscopic surgery for FAI showed improvements at the midterm from 60.5 points (range, 56.6 to 83.6 points) to 80.5 points (range, 72.1 to 98.0 points) out of a possible 100 points. Pooled weighted outcomes for labral repair showed mean mHHS improvements from 63.8 points (range, 62.5 to 69.0 points) preoperatively to 86.9 points (range, 85.5 to 89.9 points) up to 24 months postoperatively. CONCLUSIONS This comprehensive review of research published in Arthroscopy and AJSM over the past 3 years identified a number of key findings. Arthroscopic intervention results in improvements in functional outcomes at both the short-term and midterm for patients with symptomatic FAI in the absence of significant existing degenerative changes. Labral repair may result in improvements over labral debridement. The most commonly used outcome score was the mHHS for objective assessment of surgical success. There is a need for continued focus on improvement of methodologic quality and reporting of research pertaining to FAI. LEVEL OF EVIDENCE Level IV, systematic review of Level IV studies.

Indications and Outcomes for Microfracture as an Adjunct to Hip Arthroscopy for Treatment of Chondral Defects in Patients With Femoroacetabular Impingement: A Systematic Review.

PURPOSE To evaluate the indications, preoperative workup outcomes, and postoperative rehabilitation of patients with femoroacetabular impingement (FAI) receiving microfracture as an adjunct to hip arthroscopy for chondral defects. METHODS The electronic databases MEDLINE, EMBASE, and PubMed were searched and screened in duplicate for studies involving patients with FAI treated arthroscopically with microfracture of the hip for chondral defects either solely or as an adjunct to hip arthroscopy. Data regarding indications, investigations, outcomes, and postoperative rehabilitation were abstracted from eligible studies. The references of included studies were additionally searched, and descriptive statistics are provided. RESULTS There were 12 studies included in this review, involving 267 patients. With the exception of a single, one-patient case report, 11 of the 12 studies reported positive outcomes after hip arthroscopy with microfracture. Only 0.7% of the total patients experienced a complication, and 1.1% required further surgery on the basis of outcomes evaluated at a mean follow-up of 29.5 (range, 4 to 60) months across the studies. Eight of 12 studies discussed the preoperative workup of these patients, with X-rays and magnetic resonance imaging being the most common preoperative imaging used. There was little reported on weight-bearing status during postoperative rehabilitation. CONCLUSIONS The outcomes reported in the literature after hip arthroscopy with microfracture for chondral defects are, in general, positive, with a very low percentage of patients requiring further surgery or experiencing complications. The most common indication used in the literature for microfracture is a full-thickness, focal chondral defect (Outerbridge grade IV). The vast majority of literature recommends limited weight bearing after microfracture; however, there was significant variation among the specific rehabilitation protocols used. More research is needed to explore what indications and postoperative rehabilitation result in the best outcomes for patients. LEVEL OF EVIDENCE Level IV, systematic review of Level II, III, and IV studies.

Femoroacetabular Impingement: Have We Hit a Global Tipping Point in Diagnosis and Treatment? Results From the InterNational Femoroacetabular Impingement Optimal Care Update Survey (IN FOCUS).

PURPOSE This international survey was conducted to assess the perceptions of orthopaedic surgeons regarding the diagnosis and management of femoroacetabular impingement (FAI) as well as to explore the current demographic characteristics of surgeons performing FAI surgery. METHODS A survey was developed using previous literature, focus groups, and a sample-to-redundancy strategy. The survey contained 46 questions and was e-mailed to national orthopaedic associations and orthopaedic sports medicine societies for member responses. Members were contacted on multiple occasions to increase the response rate. RESULTS Nine hundred orthopaedic surgeons from 20 national and international organizations completed the survey. Surgeons responded across 6 continents, 58.2% from developed nations, with 35.4% having sports fellowship training. North American and European surgeons reported significantly greater exposure to hip arthroscopy during residency and fellowship training in comparison to international respondents (48.0% and 44.5% respectively, v 25.6%; P < .001). Surgeons performing a higher volume of FAI surgery (> 100 cases per year) were significantly more likely to have practiced for more than 20 years (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.01 to 3.63), to be practicing at an academic hospital (OR, 2.25; 95% CI, 1.22 to 4.15), and to have formal arthroscopy training (OR, 46.17; 95% CI, 20.28 to 105.15). High-volume surgeons were over two-fold more likely to practice in North America and Europe (OR, 2.26; 95% CI, 1.08 to 4.72). CONCLUSIONS The exponential rise in the diagnosis and surgical management of FAI appears to be driven largely by experienced surgeons in developed nations. Significant variability exists regarding the diagnosis and management of FAI. Our analysis suggests that although FAI management is early in the innovation cycle, we are at a tipping point toward wider uptake and use.