Background: Microfragmented adipose tissue has been proposed for intra-articular treatment of knee osteoarthritis. There are little data comparing the outcomes of treatment between microfragmented adipose tissue and other biological treatments.
Purpose: To perform a systematic review and meta-analysis comparing microfragmented aspirated fat injections to other orthobiologics, hyaluronic acid, and corticosteroid injections for symptomatic knee osteoarthritis.
Study design: Systematic review and meta-analysis; Level of evidence, 2.
Methods: A systematic review of the literature was performed to identify pertinent publications in the MEDLINE, Embase, Scopus, and Google Scholar databases, including all level 1 to 3 studies from 2000 to 2023. Validated knee scores (visual analog scale [VAS] for pain, Knee injury and Osteoarthritis Outcome Score [KOOS], Lysholm, International Knee Documentation Committee) were included as outcome measures. Risk of bias was assessed using Cochrane tools. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess the quality of the body of evidence and the modified Coleman Methodology Score was used to assess study quality. Heterogeneity was assessed using χ2 and I2 statistics.
Results: Five studies were included in the analysis. One study had a high risk of bias; 4 studies had some risk of bias. The overall study quality was fair, and the certainty of evidence was low. The pooled estimate for VAS scores did not demonstrate significant differences at 3, 6, and 12 months. The pooled estimate for the KOOS Pain, Symptoms, Activities of Daily Living, Sport and Recreation, and Quality of Life subscales did not demonstrate significant differences at 3, 6, and 12 months.
Conclusion: The results of this systematic review and meta-analysis demonstrated that there were no statistically significant differences for both the clinical outcomes and pain scores between microfragmented adipose tissue and other orthobiologics for the treatment of knee osteoarthritis. However, modest study quality, some risk of bias, and low certainty of evidence reduce external validity, and these results must be viewed with some caution.
Background: Osteochondritis dissecans (OCD) lesions in the knee are most commonly found in the medial femoral condyle (MFC). However, a paucity of literature has explored the characteristics or morphology of patellar OCD lesions.
Purpose/hypothesis: The purpose of this study was to analyze patellar tracking and patellofemoral measurements of pediatric patients with patellar OCD compared with patients with MFC OCD. It was hypothesized that the patients with patellar OCD would demonstrate an increased bony sulcus angle, cartilaginous sulcus angle, and tibial tubercle-trochlear groove (TT-TG) distance compared with patients with MFC OCD.
Study design: Case series; Level of evidence, 3.
Methods: Patients aged ≤18 years diagnosed with either a patellar or MFC OCD lesion at a single tertiary care hospital between January 2016 and May 2023 were analyzed. Patients with a history of patellar instability were excluded. The Caton-Deschamps index, cartilaginous bony height, trochlear depth, patellar tilt, lateral patellar displacement, cartilaginous sulcus angle, bony sulcus angle, and TT-TG distance were assessed on magnetic resonance imaging (MRI). Patients were matched 1:2 based on sex and chronological age within 2 years between the patellar and MFC OCD groups.
Results: A total of 40 extremities in 34 patients with patellar OCD were matched to 80 extremities in 73 patients with MFC OCD. The mean age at the time of MRI was 14.1 ± 2.3 years, and 23% were female. Compared with patients with MFC OCD, patients with patellar OCD had a significantly greater TT-TG distance (11.55 ± 4.15 vs 13.35 ± 4.07 mm, respectively; P = .03). The cartilaginous sulcus angle (150.63°± 7.20° vs 128.09°± 14.07°, respectively; P < .001) and bony sulcus angle (144.70°± 7.78° vs 137.37°± 9.62°, respectively; P < .001) were higher in the patellar OCD group compared with the MFC OCD group. Of patients with patellar OCD, 40% had a TT-TG distance >15 mm, and of patients with MFC OCD, 20% had a TT-TG distance >15 mm. The patellar OCD group had 3.7 times the risk of having a patellar dislocation compared with the MFC OCD group.
Conclusion: An increased TT-TG distance and sulcus angle were associated with patellar OCD in pediatric patients. Patients with abnormal patellofemoral morphology who undergo treatment for a patellar OCD lesion may subsequently develop a patellar dislocation; in this study, patients with patellar OCD without a history of patellar dislocations demonstrated a nearly 4-fold higher dislocation rate compared with an age- and sex-matched group of patients with MFC OCD.
Background: Lateral elbow pain, often attributed to lateral epicondylitis, presents diagnostic complexities. Lateral epicondylitis, or tennis elbow, is the most frequent cause of lateral elbow pain, but a differential diagnosis among all the potential causes of lateral elbow pain is not easy.
Purpose: To evaluate the rate of misdiagnoses in patients previously diagnosed with lateral epicondylitis, identify at-risk patient profiles, and determine sensitive clinical tests for a misdiagnosis.
Study design: Case series; Level of evidence, 4.
Methods: A prospective analysis was conducted on 189 consecutive patients with a previous diagnosis of lateral epicondylitis and failed nonoperative treatment. According to medical history and a physical examination, patients were preliminarily classified into the typical or atypical lateral epicondylitis group. Atypical epicondylitis was defined as one of the following: atypical lateral pain location, history of trauma, limited range of motion (ROM), elbow swelling, negative Cozen test finding, and physical examination findings suggesting a misdiagnosis. Patients in the atypical group were further investigated for a potential lateral epicondylitis misdiagnosis using magnetic resonance imaging, computed tomography, and/or analysis of intraoperative samples according to suspected underlying abnormalities. Univariate and logistic regression analyses were conducted to assess the risk of a misdiagnosis. A standardized diagnostic analysis was performed to evaluate the clinical tests used during the physical examination to identify misdiagnosed patients.
Results: A misdiagnosis occurred in 21 of 189 (11%) patients. The most common misdiagnoses were posterolateral elbow instability in 6 patients; radial nerve compression and inflammatory osteoarthritis in 3 patients each; and osteochondritis dissecans, posterolateral plica, and primary osteoarthritis in 2 patients each. The variables associated with a misdiagnosis were young age (≤30 years; odds ratio [OR], 66.90; P < .001), history of trauma (OR, 17.85; P = .0027), history of a limitation of ROM and/or mechanical symptoms (OR, 16.68; P = .0278), history of elbow swelling (OR, 14.32; P = .0032), and number of corticosteroid injections (OR, 2.00; P = .0007). Atypical lateral pain location highly predicted a misdiagnosis, with a sensitivity of 90.5%.
Conclusion: A misdiagnosis can occur in patients affected by longstanding lateral elbow pain. Young patients and patients with a history of elbow trauma, a limitation of ROM, swelling, corticosteroid injections, and atypical lateral pain should be highly suspected for a misdiagnosis.
Background: Muscle injuries often result in dysfunctional muscle repair and reduced muscle strength. While platelet-rich plasma (PRP) has emerged as a new treatment option in orthopaedics, its use for muscle injuries remains controversial.
Hypothesis: Encapsulating PRP within alginate hydrogels will achieve a localized and sustained release of growth factors at the site of the muscle injury, thereby enhancing skeletal muscle repair and reducing fibrosis.
Study design: Controlled laboratory study.
Methods: Bimodal blends of hydrogels were formulated using 1% oxidized high- and low-molecular weight alginate. There were 2 types of PRP prepared: leukocyte-rich PRP (L-PRP) and pure PRP (P-PRP). These PRP types were loaded onto 75L25H alginate hydrogels, and the release of TGF-β1 was quantified over time. A laceration injury was induced in mice, which was then treated with various agents: alginate only, L-PRP, L-PRP-loaded alginate (L-PRPA), P-PRP, and P-PRP-loaded alginate (P-PRPA). An additional 2 groups were formed: injury with no treatment and control with no treatment or injury.
Results: Our in vitro experiments showed that after an initial burst, TGF-β1 was released in a sustained manner for approximately 1 week after the encapsulation of both PRP preparations. The in vivo experiments showed that the groups treated with bolus injections of L-PRP or P-PRP did not show significant changes in the fibrotic area. However, the L-PRPA and P-PRPA groups demonstrated a 50% reduction in the fibrotic area (P < .05), resulting in a higher ratio of regenerating myofibers and higher levels of myogenic markers (myogenin and MyHC-emb) compared with all the other groups (P < .05). The L-PRPA group demonstrated significantly improved performance on the rotarod test; interestingly, this group also had more type I collagen than type III collagen.
Conclusion: The administration of L-PRP and P-PRP after a muscle injury did not reduce fibrosis. However, when loaded onto alginate hydrogels, they led to benefits, resulting in a smaller area of fibrosis and greater tissue regeneration.
Clinical relevance: The encapsulation of different preparations of PRP by alginate hydrogels was more effective in treating muscle lacerations than injections of PRP alone. This information is relevant for future clinical studies of PRP.
Background: Rotator cuff tears (RCTs) can cause inflammation, muscle atrophy, and irreversible fatty infiltration, resulting in poor clinical outcomes. Effective therapeutic approaches to inhibit fatty infiltration in rotator cuff muscles remain limited.
Purpose: To identify pathways associated with fatty infiltration through RNA sequencing and to evaluate the therapeutic potential of the glycogen synthase kinase-3 (GSK-3) inhibitor CHIR99021 based on enrichment of the Akt/GSK-3 pathway identified by RNA sequencing.
Study design: Controlled laboratory study.
Methods: Supraspinatus muscle biopsy specimens from 6 patients with chronic full-thickness RCTs were analyzed by RNA sequencing. Fibro-adipogenic progenitors (FAPs) or C2C12 myoblasts were cultured with different doses of CHIR99021 to assess their effects on adipogenic or myogenic differentiation, respectively. RNA sequencing identified cellular pathways in FAPs treated with or without CHIR99021. A mouse RCT model was established by detaching the supraspinatus tendon, followed by treatment with or without CHIR99021 administered intraperitoneally. Muscle atrophy and fatty infiltration were assessed histologically and through gene expression analysis at 1 and 4 weeks after surgery.
Results: RNA sequencing analysis identified a marked upregulation of the Akt/GSK-3 signaling pathway specifically in patients' samples and FAPs with minimal fat accumulation. CHIR99021 suppressed adipogenic differentiation in FAPs and promoted myogenic differentiation in C2C12 cells. In the mouse RCT model, CHIR99021-treated mice exhibited reduced Oil Red O staining, a larger cross-sectional area, and less muscle weight loss in the supraspinatus muscle compared with the vehicle-treated mice. Gene expression analysis indicated increased myogenesis and reduced fatty infiltration at 1 and 4 weeks after surgery as well as increased expression levels of IL-6 and IL-15 in the CHIR99021 group compared with the control group at 1 week after surgery.
Conclusion: The Akt/GSK-3 pathway was enriched in supraspinatus muscle samples and FAPs with low fat accumulation, highlighting its potential as a therapeutic target. The GSK-3 inhibitor CHIR99021 was shown to alleviate fatty infiltration and muscle atrophy after RCTs in vitro and in vivo in a mouse model.
Clinical relevance: The GSK-3 inhibitor CHIR99021 shows potential for treating muscle degeneration after RCTs.
Background: Arthroscopic knee surgeries are among the most commonly performed orthopaedic surgeries, yet complications of these procedures are relatively understudied.
Purpose: To determine the rate of complications, reoperations, and readmissions for arthroscopic knee surgeries by procedure, patient characteristics, and physician fellowship training status using a large national database.
Study design: Cross-sectional study; Level of evidence, 3.
Methods: Data were collected from the American Board of Orthopaedic Surgery (ABOS) database for early-career orthopaedic surgeons taking the ABOS Part II Oral Examination between 2003 and 2022. We queried the type and frequency of complications, unexpected 90-day reoperations, and readmissions for patients undergoing sports medicine knee arthroscopy. Chi-square test and analysis of variance were used to determine the effect of fellowship training status, geographic region of practice, patient age, and patient sex on outcomes of interest.
Results: Of 138,823 knee arthroscopic procedures, 10,450 complications were self-reported, making for an overall complication rate of 7.53%. Unexpected 90-day reoperation and readmission rates were calculated to be 1.16% and 0.91%, respectively. Posterior cruciate ligament reconstruction had the highest complication rate (26.38%). Sports medicine fellowship-trained physicians had a significantly higher rate of complications (P < .001) compared with their non-sports medicine fellowship-trained peers (8.43% and 7.06%, respectively). Female patients had a higher complication rate (7.72%) than males (7.40%) (P = .02). Patients aged 20 to 29 had the highest rate of complications and reoperations (10.29% and 1.56%, respectively), whereas patients aged 70 to 79 had the highest rate of readmission (1.47%). Geographic regions of practice had significantly different complication and reoperation rates (P < .01). The rate of deep venous thrombus was 0.57%, and the rate of pulmonary embolism was 0.12%. Forty-two patients died, for an overall 0.03% mortality rate.
Conclusion: The overall rate of self-reported complications was 7.53%, and the 90-day rate of unexpected reoperation and unexpected readmission was 1.16% and 0.91%, respectively. Patient sex, patient age, sports medicine fellowship training status, and geographic region of practice all affected rates of complications, reoperations, and readmissions. Knee arthroscopy carries many risks of which patients should be aware before undergoing these procedures.
Background: Hip arthroscopy is a valuable tool through which intra- and extra-articular hip pathologies may be addressed, with the goal of improving pain and function while preventing osteoarthritis progression. Little data are available regarding the effect of social determinants of health on hip arthroscopy outcomes.
Purpose: To determine if a patient's lived environment is associated with better or worse postoperative outcomes using the area deprivation index (ADI).
Study design: Cohort study; Level of evidence, 3.
Methods: Patients undergoing hip arthroscopy between January 1, 2015, and June 30, 2022, at a single institution were identified using Current Procedural Terminology codes. Patients' zip codes were utilized to identify ADI measures. Patients were divided into quartiles of ADI, and the most deprived (ADIHigh) and least deprived (ADILow) quartiles were compared. Pre- and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores for the Pain Interference (PI), Physical Function (PF), and Depression domains were obtained. For the PF and PI domains, the minimal clinically important difference (MCID) was defined using an anchor-based approach using previously established cutoffs. For the Depression domain, the MCID was defined using a distribution-based approach and calculated as one-half of the standard deviation of the preoperative PROMIS score. Multivariable logistic regression models were estimated to characterize the association of the ADI with MCID attainment along PROMIS domains.
Results: A total of 170 patients were included in the analysis of the ADIHigh (n = 85) and ADILow (n = 85) cohorts. Age, body mass index, smoking status, and race did not significantly vary between groups. No significant differences in MCID attainment were observed at any time point in the PF, PI, or Depression domains. However, the ADIHigh cohort had higher mean PI (worse) scores compared with the ADILow cohort at the preoperative, 1-year, and final follow-up (mean, 2.52 years) time points. In multivariable logistic regression analyses, ADI was not associated with the odds of MCID attainment.
Conclusion: For patients undergoing hip arthroscopy, increased social disadvantage measured by the ADI was not associated with the odds of MCID attainment in any PROMIS domain. This information provides guidance for care providers, researchers, and policymakers to seek and identify other mechanisms that may affect outcomes after hip arthroscopy.
Background: Recent biomechanical evidence for adjustable suture anchor (ASA)-based posterior medial meniscus root (PMMR) fixation has shown promising results compared with conventional transtibial pull-out repair (TPOR). However, ASA fixation has not been evaluated in human tissue to 100,000 cycles.
Hypothesis: ASA repair would lead to increased primary fixation strength and less cyclic displacement than conventional TPORs.
Study design: Controlled laboratory study.
Methods: A total of 32 human medial menisci were used, 8 of which were intact specimens and served as native controls. For the others, PMMR tears were created and repaired using 3 different techniques (n = 8 group). Two conventional PMMR repairs were prepared consisting of two No. 2 simple sutures (TSS) and two No. 2 sutures in a Mason-Allen (MA) configuration, all tied over a cortical button. The knotless ASA repair was fixed in MA with repair sutures tensioned at 120 N (MA-120). The repairs' initial force, stiffness, and relief displacement from the tensioned state toward repair unloading (2 N) were measured after fixation. All repair constructs were loaded for 100,000 cycles, with displacement and stiffness measured, and finally were pulled to failure.
Results: The TPORs demonstrated similar primary fixation and cyclic loading behavior except for initial cyclic displacement (cycle 10). The ASA repair provided a higher initial repair load (P < .001) and stiffness (P < .001) with relief displacement similar to conventional TPORs. Lower initial cyclic displacement (P < .011; cycle 10) with overall higher repair stiffness (P < .011) resulted in significantly lower displacement (P < .001) throughout testing for ASA repair. Although both TPORs were completely loose after 100,000 cycles, the ASA repair achieved near-native dynamic meniscal stabilization. The TSS repair had lower overall ultimate load (P < .001) and ultimate stiffness (P < .023) compared with the ASA repair. All repairs had lower ultimate stiffness and loads than the native meniscus (P < .001).
Conclusion: The ASA repair resulted in improved primary PMMR fixation that was stiffer with less cyclic displacement than conventional TPORs and approached that of the human meniscal function after 100,000 load cycles in a cadaveric model. However, all repair techniques had lower ultimate strength than the native human PMMR.
Clinical relevance: Knotless ASA meniscus root fixation resulted in higher tissue compression and less displacement in a cadaveric model; however, future clinical series with surveillance imaging will define the overall significance of healing rates.
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