Hss Journal最新文献

Background: The formation of a stable fibrin clot plays an important role in early tissue repair. Tranexamic acid (TXA), a potent fibrinolysis inhibitor, prevents fibrin clot dissolution.

Purpose: We sought to test the effect of intra-articular TXA administration on meniscus healing and articular cartilage status in a rabbit model.

Methods: Thirty-two rabbits underwent bilateral knee surgery with creation of a 1.5-mm circular defect in the anterior horn of the lateral meniscus and a 3-mm longitudinal tear with repair in the anterior horn of the medial meniscus. Twelve rabbits were used for an initial TXA dose determination study. Twenty rabbits were then injected with 50 mg/mL of TXA in the left knee while the right knee served as a control. Animals were sacrificed at 2-, 4-, and 8-week timepoints. Eight rabbits underwent biomechanical analysis. Semiquantitative histological analysis compared meniscal healing and articular cartilage between TXA-treated and control knees.

Results: Both circular defects of the lateral meniscus and longitudinal tear injuries of the medial meniscus showed no difference in healing across all timepoints. At 2 weeks post-surgery, TXA-treated knees exhibited reduced tibial articular cartilage structure compared to controls. By week 8, control knees had higher proteoglycan content in all femoral articular cartilage zones compared to TXA-treated knees. Biomechanical analysis was inconclusive.

Conclusion: This rabbit study found that TXA administration did not enhance healing following meniscus repair. Moreover, intra-articular TXA appeared to have exerted an adverse effect on articular cartilage, possibly due to the detrimental effects of persistent blood in a joint. Further studies will be critically important to determine the effect of TXA administration at various time points after surgical repair.

Background: Regenerative therapies are being studied for use in several orthopedic conditions, but as these approaches gain in popularity, insurance coverage denials have become a critical issue for patients, physicians, hospitals, and payers.

Purpose: We sought to analyze the references commercial payers use to support their policies denying coverage for orthopedic applications of mesenchymal stem cell (MSC) therapy.

Methods: We reviewed the policies regarding orthopedic applications of MSC therapy of the top 11 national commercial health insurance payers, 5 of which had publicly accessible policies. Supporting references were screened by title and/or abstract. Selected references were categorized by type of reference and reviewed for level of evidence (LOE), anatomic location under investigation, and type and source of MSC. Studies that were not LOE I or II were defined as low LOE. Finally, efficacy of the therapy was recorded in a binary fashion.

Results: To support denial of coverage for MSC use in orthopedics, the 5 insurance companies cited a majority of level IV evidence, despite available and pertinent level I and II studies on the subject. The knee was the most common anatomic location investigated and, along with the spine, the most likely to report favorable outcomes with MSC use. Primary journal articles and studies with higher LOE were more likely to report favorable outcomes than review articles or those with lower LOE.

Conclusion: This analysis of 5 commercial insurance payers' policies found that they substantiate their denial of coverage for MSC use in orthopedic applications primarily with low-level evidence. It also found that higher-level evidence, when cited, often points to the potential efficacy of MSCs.

Background: Body protection compound-157 (BPC-157) is a naturally occurring gastric peptide that promotes mucosal integrity and homeostasis. Preclinical studies show its potential for promoting healing in musculoskeletal injuries such as fractures, tendon ruptures, ligament tears, and muscle injuries. Despite lacking US Food and Drug Administration approval and its use being banned in professional sports, it is increasingly used by clinicians and athletes. Purpose: We sought to (1) provide a comprehensive synthesis of the BPC-157 literature from an orthopedic sports medicine perspective and (2) elucidate the mechanism of action, musculoskeletal effects, metabolism, and safety profile. Methods. We conducted a systematic review of English-language literature, published from database inception to June 3, 2024, from PubMed, Cochrane, and Embase. We searched PROSPERO to identify any current or unpublished reviews. Studies reporting BPC-157's mechanism, musculoskeletal outcomes, metabolism, and safety were included. Articles were screened in 3 phases by 2 reviewers. In cases of a disagreement between the 2 reviewers, blinding was removed, and eligibility was determined by group consensus, with a third author making the final decision. Results. A total of 544 articles from 1993 to 2024 were identified. After duplicates were removed, 36 studies were included (35 preclinical studies, 1 clinical study). The studies suggest that BPC-157 enhances growth hormone receptor expression and several pathways involved in cell growth and angiogenesis, while reducing inflammatory cytokines. In preclinical models, BPC-157 improved functional, structural, and biomechanical outcomes in muscle, tendon, ligament, and bony injuries. In a retrospective study of musculoskeletal pain following intraarticular injection of BPC-157 for unspecified chronic knee pain, 7 of 12 patients reported relief for >6 months. BPC-157 is metabolized in the liver, with a half-life of less than 30 minutes, and is cleared by the kidneys. Preclinical safety studies showed no adverse effects across several organ systems. No clinical safety data were found. Conclusion: This systematic review of level IV and level V studies suggests that BPC-157 shows promise for promoting recovery from musculoskeletal injuries. Adverse effects are possible due to unregulated manufacturing, contamination, or unknown clinical safety. We recommend that clinicians counsel athletes to understand their organizations' rules to remain compliant with medication/supplement safety and testing standards.

Background: Long-term use of corticosteroids is a known risk factor for various bone diseases. Corticosteroids disrupt the balance between oxidative and glycolytic energy metabolism, increase oxidative stress and reactive oxygen species (ROS) associated with prolongation of inflammation, cell apoptosis, deficits in mesenchymal stem cells (MSCs), and osteoclast differentiation. Metformin, a drug for diabetes, has antioxidant properties by inhibiting nicotinamide adenine dinucleotide phosphate oxidase, which promotes the production of ROS.

Purpose: We sought to evaluate the effects of corticosteroid and metformin administration on MSCs in vitro.

Methods: Primary bone marrow MSCs were collected from 20 mice. We evaluated prednisolone's effects on cell proliferation, oxidative stress, osteogenic differentiation, and mineralization, followed by metformin's effect on corticosteroid-induced reduction in bone formation. Metformin (1, 10, 100 µM) was tested with prednisolone 3 ng/mL. Cytokines were assessed by Luminex.

Results: Prednisolone at 3 ng/mL significantly reduced cell proliferation, while 10 µM metformin restored it. Prednisolone increased oxidative stress and was reversed by metformin in a concentration-dependent manner, particularly at 100 µM. Osteogenic differentiation and mineralization were significantly impaired with prednisolone but improved with metformin at 10 and 100 µM. As for inflammatory cytokines, interleukin-1β (IL-1β) expression was increased by prednisolone administration and suppressed by metformin. Conversely, IL-6 and monocyte chemotactic protein-1 were suppressed by prednisolone.

Conclusion: This in vitro study found that corticosteroid-associated decrease in osteogenic potential of murine MSCs was associated with elevated oxidative stress that can be alleviated by metformin; further studies are needed to validate these findings in vivo and with human-derived MSCs.

Background: Minimally invasive surgery (MIS) has shown the potential in reducing surgical site infection (SSI); however, its impact on instrumented lumbar fusion procedures remains unclear. Purpose: We sought to investigate the difference in SSI rates for open, mini-open, and MIS techniques in patients who underwent posterior lumbar instrumented fusions. Methods: We conducted a retrospective review of all patients at a single academic institution who underwent instrumented 1- or 2-level posterior lumbar fusion between January 2019 and June 2022. Cases were allocated to 1 of 3 mutually exclusive surgical cohorts (MIS, mini, or open). SSIs were diagnosed based on the National Healthcare Safety Network criteria. Results: A total of 1352 patients were reviewed for a total of 1382 lumbar fusion operations included in this study. The mean age was 61.5 ± 12.8 years, and the mean body mass index was 28.7 ± 5.67 kg/m². The largest cohort was open (39.3%, 543), followed by mini (33.1%, 458) and MIS (27.6%, 381). Thirteen patients (0.94%) developed an SSI. There were no statistically significant differences in the infection rates between the cohorts; SSI rates were MIS (0.3%, 1), mini (1.1%, 5), and open (1.3%, 7). Twelve (92%) of the patients with an SSI underwent a subsequent irrigation and debridement procedure; on average, this occurred 42.2 ± 25 days postoperatively. Conclusions: This retrospective review found that 0.94% of patients developed an SSI following a 1- or 2-level posterior lumbar instrumented fusion. Although the observed SSI rate in the open cohort was 4 times higher than in the MIS cohort, the sample sizes were insufficient to determine statistically significant differences between the 3 surgical approaches. Nonetheless, our data suggests that all 3 techniques evaluated had exceptionally low infection rates.

Introduction: There is little literature reporting on the efficacy of bone marrow aspirate concentrate (BMAC) in conjunction with hip arthroscopy.

Purpose: We sought to systematically review the literature on BMAC use following hip arthroscopy, in particular, whether its use results in improved patient-reported outcome measures (PROMs).

Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed when querying PubMed, Cochrane Central Register of Controlled Trials, and Scopus in January 2023. Articles were included if they reported on pre- and postoperative outcomes for patients undergoing hip arthroscopy with concomitant BMAC and were written in English.

Results: Five articles were included in the review. A total of 252 hips undergoing BMAC and hip arthroscopy performed between 2010 and 2020 were evaluated. The average age of patients in the studies ranged between 32.8 and 48.5 years. All studies reported improved postoperative PROM scores compared to preoperative outcome scores after BMAC and hip arthroscopy. Two studies reported survivorship of 100% and 85.7%. All 5 studies conducted a subanalysis between BMAC and hip arthroscopy and a control group. Three studies reported superior outcomes in the BMAC and hip arthroscopy group, while another study reported findings that trended toward favoring the BMAC and hip arthroscopy group but that did not reach statistical significance.

Conclusion: BMAC may improve outcomes in patients undergoing hip arthroscopy. However, due to the small sample size and lack of standardized control groups, the results of this systematic review are inconclusive.

Background: For orthopedic oncology patients who are poor candidates for open spine surgery, minimally invasive radiofrequency ablation and cementoplasty (RFA/C) is becoming increasingly popular for managing osteolytic vertebral metastases. Purpose: We sought to characterize long-term changes in vertebral body radiographical parameters and potential risk of adjacent fractures occurring. Methods: A single-institution, retrospective study of all patients receiving RFA/C for osteolytic thoracic or lumbar vertebral body metastases from 2017 to 2023 was conducted. Vertebral body integrity was assessed by column height changes (anterior, middle, and posterior 1/3), local vertebral angle, and indirect bone mass assessment (at 3, 6, 12, and 24 months postoperatively). The latter was assessed via Hounsfield unit (HU) changes on axial computed tomography. Adjacent vertebral fractures were defined as within 3 vertebral levels above or below index site. Treatment history including radiation therapy was tracked. Results: A total of 54 vertebral levels (26 patients; mean age 59.8 ± 19.0 years; 18 females) were included (mean follow-up 15.8 ± 13.8 months). HU (bone mass proxy) stabilized after RFA/C. Except for middle column height increasing at 3 months, no column height or local angle deformity changes were detected. Adjacent fracture occurred in 4 patients (15.4%); all 4 demonstrated systemic cancer progression. Conclusions: Our findings suggest that RFA/C may provide effective long-term stabilization of the index site that is maintained for at least 1 year postoperatively. All patients who experienced an adjacent fracture occurrence demonstrated radiographic evidence of cancer progression surrounding the treatment sites that appeared unrelated to the procedure itself.

Background: Prior studies have suggested a possible association between eczema and postoperative surgical site infections (SSI) following anterior cruciate ligament reconstruction (ACL-R), presumably due to higher rates of staphylococcal colonization in patients with eczema. Purpose:We sought to determine if patients with a history of eczema are at an increased risk for postoperative SSI following ACL-R, medial patellofemoral ligament reconstruction (MPFL-R), and/or knee arthroscopy. Methods:We conducted a retrospective matched case-control study of patients aged 5 to 25 years who underwent ACL-R, MPFL-R, and/or knee arthroscopy from February 1, 2016 to February 8, 2023 at a single tertiary care facility. Cases of postoperative infection were identified as those requiring surgical irrigation and debridement (I&D) and/or postoperative oral antibiotics or had a documented visit for postoperative infection with an infectious disease specialist within 6 months of the indexed procedure. Cases and controls were matched 1:2 based on sex, age ±1 year, body mass index ±1 kg/m², and primary Current Procedural Terminology code. Preoperative diagnosis of eczema and postoperative diagnosis of infection were compared between cases and controls. Results:Three hundred patients were analyzed (mean age 18.2 ± 3.8 years); 4% of both cases and controls had a history of eczema. Patients with postoperative SSI did not have greater odds of having an eczema diagnosis preoperatively compared to matched controls. Overall, 32% of cases required an I&D procedure; these patients did not have greater odds of having an eczema diagnosis preoperatively compared to matched controls. Conclusion:This retrospective matched case-control study suggests that a prior or current diagnosis of eczema is not associated with SSI following ACL-R, MPFL-R, or knee arthroscopy in patients aged 5 to 25 years. Level of Evidence: Level III: Case-Control Study.

Background: Far-lateral lumbar disk herniation (FLLDH) poses a surgical challenge given the difficulty in visualizing the pathology with traditional techniques. Endoscopic microdiscectomy is a novel technique for the treatment of FLLDH with decreased soft tissue disruption. Purposes: We sought to compare the efficacy of tubular versus endoscopic microdiscectomy for FLLDH. Methods: A retrospective cohort study was performed that included patients undergoing uniportal endoscopic or tubular decompression for FLLDH over a 5-year period. The primary outcome was patient-reported outcome measures (PROMs). Secondary outcomes included operative time, intraoperative radiation, length of stay (LOS), and reoperation/complication rates. Comparisons between non-paired continuous variables were done with a 2-tailed independent sample t-test. Categorical variables were compared with a χ² or a Fisher exact test. Significance was assumed at P < .05. Results: We identified 135 patients, 64 having undergone endoscopic and 71 tubular microdiscectomy. There were no differences in operative times (67.7 vs 68.2 minutes) or LOS (945.5 vs 911.1 minutes). Endoscopic microdiscectomy was associated with increased total fluoroscopy time (105.92 vs 34.66 seconds) and intraoperative radiation dose (33.68 vs 19.12 mGy). Postoperatively, both groups had statistically significant improvements in all PROMs at early and late follow-up. There was no difference in the magnitude of improvement or the rate of postoperative complications/reoperations between the groups. Conclusion: This retrospective review found that endoscopic microdiscectomy and tubular decompression were effective techniques for the treatment of FLLDH, showing significant improvement in postoperative PROMs and no differences in postoperative complications. However, endoscopic microdiscectomy is associated with increased intraoperative radiation exposure.