Image Guided Injection of Anterior Cruciate Ligament Tears with Autologous Bone Marrow Concentrate and Platelets: Midterm Analysis from A Randomized Controlled Trial

Background: There has been a recent emergence in the use of orthobiologics, including platelet-rich plasma (PRP) and bone marrow concentrate (BMC), in the treatment of various musculoskeletal conditions. The goal of this study was to determine if injection of BMC and platelet products into partial and full-thickness anterior cruciate ligament (ACL) tears can facilitate primary ligament healing in patients failing conservative care, resulting in improved outcomes compared to exercise therapy.Methods: Patients were randomized to either exercise therapy or percutaneous injection of autologous BMC with PRP and platelet lysate into the ACL under fluoroscopic guidance. Pain and function were assessed at baseline and at 1, 3, 6, 12, and 24 months. Baseline and 6-month post-treatment magnetic resonance imaging (MRI) were obtained to evaluate interval healing. Laxity was assessed using the Telos device.Results: There was significant improvement in functional outcomes in the BMC group, compared to base-line for LEFS at time points 3 up to 24 months s = 0.000000005), and significant improvement in pain in the BMC group at 6 (p = 0.00054), 12 (p = 0.00127), and 24 months (p = 0.002). There was no significant improvement in pain or function at any time point in the exercise therapy group. There was significant improvement in ACL MRI ImageJ quantitative assessment in the BMC group (p = 0.001) and no difference in the exercise group (p > 0.05). No serious adverse events were reported.Conclusion: Autologous BMC and platelet product injection into ACL tears improved patient function compared to exercise, observed through 24 months. Patients treated with BMC demonstrated quantitative improvements in post-treatment MRI scans suggestive of interval ligament healing.

Tissue Wrapping Augmentation for Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament reconstruction (ACLR) has become a popular surgery in orthopedic practice today, and the technique has evolved significantly over time. Surgical procedure, graft choice, and fixation systems have varied over the years. Nonetheless, several challenges like insufficient graft ligamentization, tunnel enlargement, and insufficient reestablishment of proprioception remain in ACLR. A vision of better graft healing and integration for improved outcomes after ACLR introduced the idea of the biological ACLR. Various techniques with growth factors, cellular therapies, or tissue augment have been researched with ACLR surgery for better integration and ligamentization. This review highlights the tissue wrappingmodalities currently being explored in biological ACLR.

Femoral Osteotomies for Osteonecrosis of the Femoral Head

Femoral osteotomy is performed for osteonecrosis of the femoral head to prevent the progression of collapse and promote the repair process by transposing the necrotic lesion to the nonweight-bearing portion. The purpose of this review article was to summarize the current knowledge on two types of femoral osteotomy: transtrochanteric anterior or posterior rotational osteotomy and transtrochanteric curved varus osteotomy, both of which are currently performed for osteonecrosis, mainly in Japan and Korea. Osteotomy can be expected to cure osteonecrosis, and no matter how much the durability of artificial joints improves, there will always be young patients for whom the procedure is indicated. We should continue to verify the results of this surgery and refine the techniques involved.

The Effect of Combined Bone Marrow Aspirate, Lipoaspirate, and Platelet Rich Plasma Injections on Pain, Function, and Perceived Change Amongst Individuals with Severe Knee Osteoarthritis

Background: Owing to a paucity of research on minimally processed orthobiologics, we sought to investi-gate the efficacy of minimally processed bone marrow aspirate (BMA) and fat graft with a leukocyte-rich, platelet-rich plasma (PRP) intra-articular injection series on pain, function, and global rating of change (GROC) among patients with severe knee osteoarthritis (OA).Methods: Thirty-one adults (23 females and 8 males, mean age 67 years) with clinical and radiographic evidence of knee OA (Kellgren–Lawrence ≥ 3) were included. During the initial visit, patients were exam-ined and administered the patient-specific functional scale (PSFS) and a numerical pain rating scale ranging from 0 to 10. Patients then underwent procedures to obtain 4–6 mL of PRP, a minimally processed 6 mL fat graft, and 10 mL of BMA. Patients returned twice over 6-week intervals for booster PRP injections. At each follow-up (F1 and F2), the GROC questionnaire and prior outcome measures were completed. Results: Patients returned at an average of 41 days for the second PRP (F1) and 90 days from initial visit for the third PRP injection (F2). Friedman Chi Square analysis indicated statistically significant improvements in pain (best and worst) and PSFS from initial to F1 and F2 (P ≤ 0.001). Post hoc Wilcoxon signed-ranks analysis with Bonferroni correction identified improvement from initial to F1 and F2, as well as F1–F2 for pain, PSFS, and GROC (P ≤ 0.013). Effect sizes ranged from r = 0.32 to 0.51. Change, based on established minimum clinically important differences, indicated pain, GROC, and PSFS met thresholds at F2. Conclusion: A minimally processed fat graft with BMA and a series of three PRP injections improved pain and function among individuals with severe knee OA who were previously recalcitrant to conservative care. Although results indicated significant improvement, clinically important change did not occur until F2. A one-arm design is a limitation of this study.

Etiology and Pathogenesis of Corticosteroid-Associated Osteonecrosis of the Femoral Head

Osteonecrosis of the femoral head (ONFH) is an intractable disease occurring at a relatively young age. The characteristic finding of ONFH – the femoral head collapse with severe hip pain – is observed in many cases, which frequently leads to further joint destruction, requiring surgical treatment. Among the associated factors of ONFH, majority of patients who require high-dose corticosteroid are still challenging due to inevitable therapeutic option regardless of poor prognosis. As a pathological mechanism, ONFH is defined as tissue necrosis in the femoral head region due to occlusion of the nutrient vessels; but the detailed micro-level processes leading to blood flow failure remains unclear. The elucidation of ONFH and the establishment of preventive therapy is desirable for these patients. Here, we discuss the etiology and pathogenesis of corticosteroid-associated ONFH by reviewing current literature.

12-Month Cohort Study to Investigate Changes in Patient-Reported Outcomes Pain after Intra-articular Injection of Micro-Fragmented Adipose Tissue for Knee Osteoarthritis

BackgroundTo evaluate changes in pain, function, and quality of life after treatment with injected micro-fragmented adipose tissue (MFAT) for knee osteoarthritis in a large cohort of individuals treated at multiple centers. MethodsOne hundred ten individuals were recruited from three private outpatient clinics. Participants had to be diagnosed with symptomatic knee OA (defined by persistent knee pain associated with clinical symptoms of OA and/ or classic imaging findings) and who had not received prior knee surgery or treatment with platelet-rich plasma, cortisone, or hyaluronic acid within the previous 6 weeks. Data from 120 knees were included in the analysis. Outcome measures included Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales (pain, symptoms, activities of daily living [ADL], sports and recreation, quality of life [QOL]) and an 11-point Numerical Rating Scale (NRS) for average knee pain over the past week. Outcomes were collected at baseline and 3, 6, and 12 months. ResultsSignificant increases and decreases in KOOS subscale and NRS scores were observed, respectively, in the cohort as a whole (p< .05). Lower BMI was associated with more significant improvements in pain, sports/recreation, and ADL KOOS subscale scores (p< .05). Greater age was associated with more significant improvements in symptoms and QOL subscale scores (p< .05). ConclusionsA single injection of MFAT improved pain, function, and QOL outcome measures up to 12 months in this cohort for more than half of the participants. Greater BMI and lower age negatively influenced outcomes. It is not known whether improvements continue after this timeframe or why many participants reported little-to-no improvement.

Safety and Efficacy of Mesenchymal Stromal Cells and Platelet-Rich Plasma for the Treatment of Moderately Advanced Post-Traumatic Arthritis of the Ankle

Background: Orthobiologics such as mesenchymal stromal cells and platelet-rich plasma are intensely being investigated as treatment options for osteoarthritis. The purpose of this retrospective case series is to evaluate the safety, adverse events, long-term outcomes, and efficacy of bone marrow concentrate (BMC) combined with platelet-rich plasma (PRP) to treat moderate to advanced Kellgren-Lawrence (KL3-4) post-traumatic ankle osteoarthritis.Methods: Study population at final follow-up included 19 patients with 22 treated ankles with post-traumatic ankle osteoarthritis with a mean duration of symptoms of 56 months before treatment with ultrasound-guided intra-articular injection of BMC and PRP. Patients were followed prospectively from the time of treatment for a mean of 2.6 years at final follow-up. Pre and post Foot and Ankle Disability (FADI) scores were tabulated to assess outcomes, and 7 patients also completed the FADI sports module. Total nucleated cell counts were obtained on all treated patients and Mishra Type 3A PRP was utilized.Results: A total of 19 of 22 ankles treated showed improvement in their FADI scores. Thirteen of the 19 who had improved FADI scores patients reached MCID (P = .17). Three of the six patients who did not reach MCID eventually underwent ankle arthrodesis. The average patient age was 56 years old. There was no correlation between the history of previous surgery, KL grade, sex, or age in terms of outcomes. Seven patients completed the sports module of the FADI, and none reached MCID. Patients with a shorter duration of symptoms had higher post-FADI scores reaching MCID (P < .001). The three patients who underwent arthrodesis had the longest duration of symptoms of 84, 84, and 120 months. No adverse effects were reported in the study group. Total nucleated cell count (TNCC) did not correlate with outcomes in this group, and there was no correlation of TNCC based on age and sex.Conclusion: BMC combined with PRP is a safe treatment option for patients with moderate to advanced ankle arthritis and can provide functional pain relief for a sustained period and delay or possibly obviate the need for future ankle arthrodesis. A shorter duration of symptoms may lead to improved outcomes.

Orthobiologics: Filling the Gaps in Current Orthopaedic Surgical Treatment

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Combat COVID-19 with Exercise and Vitamin D Supplementation

COVID-19 is a raging pandemic with cases, hospitalizations and deaths surging. Prevention has focused to date on mask wearing, social distancing, and the development of vaccines. Novel mitigation strategies, however, are needed to combat the pandemic optimally.There was an epidemic of inactivity in 2020 partially because of government recommendations to stay indoors and the mandated closure of gyms. Vitamin D deficiency is also a common worldwide problem, especially for persons of color. These two issues are contributing to the severity of the pandemic and should be addressed.

Average Level Of Evidence Of Papers Published In Six Orthopedic Journals

Background An assessment of the average level of evidence (LOE) of clinical research papers in peer reviewed orthopedic surgery journals has not previously been published. In this paper we report on the average LOE of papers published in six of the top English language orthopedic surgery journals. Methods Six well established orthopedic journals were identified by using the Google Scholar H5 Journal Index. We selected 6 of the top ten journals identified by the Index. The six journals that were evaluated for this project were as follows: The American Journal Of Sports Medicine (AJSM); Clinical Orthopedics and Related Research (CORR); Journal of Bone and Joint Surgery (JBJS); Knee Surgery, Sports, Traumatology, Arthroscopy (KSSTA); Journal of Arthroscopy (Arthros.); and the Journal of Shoulder and Elbow Surgery (JSES). Thirteen consecutive monthly issues (July, 2018 - July, 2019) of each journal were evaluated for the LOE of each clinical paper. The assigned LOE was used if published, or the level of evidence was assigned by the senior author (DAB) if one was not listed. For each journal, the overall mean LOE along with the variance and standard deviation was calculated with all confidence intervals set at 95%. Summary data was statistically analyzed to provide an overall mean LOE for the 6 journals evaluated. Results For AJSM, we evaluated 246 clinical research articles that had an average LOE of 2.96 +/- 0.16. For CORR, we evaluated 155 papers that had an average LOE of 2.83 +/- 0.19. For JBJS, we evaluated 164 papers that had an average LOE of 3.04 +/- 0.13. For KSSTA, we evaluated 402 papers that had an average LOE of 3.05 +/- 0.16. For Arthros. we evaluated 226 papers that had an average LOE of 3.19 +/- 0.10. For JSES, we evaluated 237 papers that had an average LOE of 3.25 +/- 0.13. In summary, for the 1425 clinical research papers published in 98 issues of 6 of the top orthopedic journals, we found the average Level Of Evidence to be 3.05 +/- 0.16. Conclusions The goal of scientific study design is to prove or disprove a hypothesis while minimizing bias and errors. The gold standard for therapeutic studies has been a double blind, randomized controlled trial (RCT). However, it is not possible or feasible for every clinical study to have a blinded RCT design. Additionally, clinically relevant and actionable data can come from studies that are not RCTs. In a medical discipline like orthopedics many interventions are invasive, making controlled trials or blinded trials unethical or technically not practical. Our analysis of over 1400 peer reviewed publications in one year in 6 of the top English language orthopedic journals reveals that the average level of evidence deemed worthy of publication is level 3. In terms of the most common study design, the average published clinical study in these orthopedic journals was a case-control study.