Platelet-rich plasma for foot and ankle pathologies: A systematic review.
F Vannini, B Di Matteo, G Filardo, E Kon, M Marcacci, S Giannini
BACKGROUND: The aim of this article is to review systematically all the literature available on the clinical application of PRP for the treatment of foot and ankle pathologies, to understand its potential and best indications for clinical use.
METHODS: A systematic search of the PubMed database was performed. Research criteria were the following: (1) papers in the English language, (2) dealing with the clinical application of PRP for the treatment of orthopedic-related conditions affecting the foot and ankle district, (3) with I to IV level of evidence, and (4) reporting clinical results.
RESULTS: A total of 17 studies fulfilled the inclusion criteria. Nine papers dealt with Achilles tendon management, 2 articles with plantar fasciitis, 3 papers with talar osteochondral lesions, 2 with PRP application in total ankle replacement, and 1 article with PRP in foot and ankle fusions. The overall evaluation of the results reported does not clearly demonstrate the potential of PRP treatment in any of the specific fields of application.
CONCLUSIONS: Considering the literature currently available, no clear indications for using PRP in the foot and ankle district emerged.
LEVEL OF EVIDENCE: Level IV, systematic review of Level I, II, III and IV studies.
28 febrero 2014
General: células progenitoras subcondrales estimuladas con PRP. ¡Y funciona!
Human platelet-rich plasma induces chondrogenic differentiation of subchondral progenitor cells in polyglycolic acid-hyaluronan scaffolds.
Journal of Biomedical Materials Research. Part B, Applied Biomaterials 2013 November 26
Jan Philipp Krüger, Anna-Katharina Ketzmar, Michaela Endres, Axel Pruss, Alberto Siclari, Christian Kaps
Cartilage repair approaches may be improved by addition of human platelet-rich plasma (PRP) that increases chondrogenic differentiation of mesenchymal stem and progenitor cells. The aim of our study was to evaluate the effect of human PRP on the differentiation of multipotent human subchondral progenitor cells in resorbable polyglycolic acid-hyaluronan (PGA-HA) scaffolds. PGA-HA scaffolds were loaded with subchondral progenitor cells and stimulated with transforming growth factor-beta3 (TGFB3) or 5% PRP, whereas nonstimulated cultures served as controls. Chondrogenic differentiation was evaluated by real-time gene expression analysis of typical chondrogenic marker genes and by immunohistochemical staining of extracellular cartilage matrix molecules such as proteoglycans and collagen type II. TGFB3 and PRP induced the expression of chondrogenic marker genes collagen type II and IX, aggrecan, and cartilage oligomeric matrix protein in subchondral progenitor cells cultured in PGA-HA scaffolds compared with nonstimulated controls. Progenitor cells in PGA-HA scaffolds formed an extracellular matrix rich in proteoglycans and collagen type II on treatment with PRP, but to a lesser extent, than in cultures stimulated with TGFB3. The results suggest that PRP induces chondrogenic differentiation of progenitor cells in PGA-HA scaffolds and may be therefore beneficial in scaffold-assisted cartilage repair approaches involving stem and progenitor cells.
Jan Philipp Krüger, Anna-Katharina Ketzmar, Michaela Endres, Axel Pruss, Alberto Siclari, Christian Kaps
Cartilage repair approaches may be improved by addition of human platelet-rich plasma (PRP) that increases chondrogenic differentiation of mesenchymal stem and progenitor cells. The aim of our study was to evaluate the effect of human PRP on the differentiation of multipotent human subchondral progenitor cells in resorbable polyglycolic acid-hyaluronan (PGA-HA) scaffolds. PGA-HA scaffolds were loaded with subchondral progenitor cells and stimulated with transforming growth factor-beta3 (TGFB3) or 5% PRP, whereas nonstimulated cultures served as controls. Chondrogenic differentiation was evaluated by real-time gene expression analysis of typical chondrogenic marker genes and by immunohistochemical staining of extracellular cartilage matrix molecules such as proteoglycans and collagen type II. TGFB3 and PRP induced the expression of chondrogenic marker genes collagen type II and IX, aggrecan, and cartilage oligomeric matrix protein in subchondral progenitor cells cultured in PGA-HA scaffolds compared with nonstimulated controls. Progenitor cells in PGA-HA scaffolds formed an extracellular matrix rich in proteoglycans and collagen type II on treatment with PRP, but to a lesser extent, than in cultures stimulated with TGFB3. The results suggest that PRP induces chondrogenic differentiation of progenitor cells in PGA-HA scaffolds and may be therefore beneficial in scaffold-assisted cartilage repair approaches involving stem and progenitor cells.
27 febrero 2014
Hombro/Shoulder: tenodesis para revisar la lesión SLAP
The Efficacy of Biceps Tenodesis in the Treatment of Failed Superior Labral Anterior Posterior Repairs.
Am J Sports Med. 2014 Feb 11
McCormick F1, Nwachukwu B, Solomon D, Dewing C, Golijanin P, Gross DJ, Provencher MT.
Abstract
BACKGROUND:The incidence and arthroscopic treatment of superior labral anterior posterior (SLAP) tears have increased over the past decade. Recent evidence has identified factors associated with poor outcomes, including age, overhead activity, and concomitant rotator cuff tears. Biceps tenodesis has also been suggested as an alternative treatment to repair. Moreover, there are no studies demonstrating effective treatment strategies for failed type II SLAP repairs.
PURPOSE:To prospectively evaluate the surgical outcomes of biceps tenodesis for patients who undergo elected revision surgery after an arthroscopically repaired type II SLAP tear.
Abstract
BACKGROUND:The incidence and arthroscopic treatment of superior labral anterior posterior (SLAP) tears have increased over the past decade. Recent evidence has identified factors associated with poor outcomes, including age, overhead activity, and concomitant rotator cuff tears. Biceps tenodesis has also been suggested as an alternative treatment to repair. Moreover, there are no studies demonstrating effective treatment strategies for failed type II SLAP repairs.
PURPOSE:To prospectively evaluate the surgical outcomes of biceps tenodesis for patients who undergo elected revision surgery after an arthroscopically repaired type II SLAP tear.
STUDY DESIGN:Case series; Level of evidence, 4.
METHODS:After institutional review board approval, 46 patients who met failure criteria for an arthroscopically repaired type II SLAP tear elected to undergo open subpectoral tenodesis by 2 fellowship-trained surgeons from 2006 to 2010 at a tertiary care military treatment facility. Objective outcomes were preoperative and postoperative assessments with the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Western Ontario Shoulder Instability Index (WOSI) scores and an independent physical examination. Statistical analysis was performed via analysis of variance.
RESULTS:Of the 46 patients, 42 completed the study (91% follow-up rate). The mean age of the patients was 39.2 years, 85% were male, and the mean follow-up period was 3.5 years (range, 2.0-6.0 years). The rate of return to active duty and sports was 81%. There was a clinically and statistically significant improvement across all outcome assessments after revision surgery (preoperative mean scores: ASES = 68, SANE = 64, WOSI = 65; postoperative mean scores: ASES = 89, SANE = 84, WOSI = 81) (P < .0001) and shoulder range of motion (preoperative mean values: forward flexion = 135°, abduction = 125°; postoperative mean values: forward flexion = 155°, abduction = 155°) (P < .0001). There was 1 case of transient musculocutaneous nerve neurapraxia.
CONCLUSION:Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up. The majority of patients obtained good to excellent outcomes using validated measures with a significant improvement in range of motion.
METHODS:After institutional review board approval, 46 patients who met failure criteria for an arthroscopically repaired type II SLAP tear elected to undergo open subpectoral tenodesis by 2 fellowship-trained surgeons from 2006 to 2010 at a tertiary care military treatment facility. Objective outcomes were preoperative and postoperative assessments with the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Western Ontario Shoulder Instability Index (WOSI) scores and an independent physical examination. Statistical analysis was performed via analysis of variance.
RESULTS:Of the 46 patients, 42 completed the study (91% follow-up rate). The mean age of the patients was 39.2 years, 85% were male, and the mean follow-up period was 3.5 years (range, 2.0-6.0 years). The rate of return to active duty and sports was 81%. There was a clinically and statistically significant improvement across all outcome assessments after revision surgery (preoperative mean scores: ASES = 68, SANE = 64, WOSI = 65; postoperative mean scores: ASES = 89, SANE = 84, WOSI = 81) (P < .0001) and shoulder range of motion (preoperative mean values: forward flexion = 135°, abduction = 125°; postoperative mean values: forward flexion = 155°, abduction = 155°) (P < .0001). There was 1 case of transient musculocutaneous nerve neurapraxia.
CONCLUSION:Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up. The majority of patients obtained good to excellent outcomes using validated measures with a significant improvement in range of motion.
Codo/Elbow: PRP en la epicondilitis, no?
Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review.
de Vos RJ1, Windt J, Weir A.Br J Sports Med. 2014 Feb 2
Abstract
BACKGROUND:
Chronic lateral epicondylar tendinopathy is frequent in athletes, and platelet-rich plasma (PRP) is being used increasingly in its treatment.
OBJECTIVE:
To systematically review the literature on the efficacy of PRP injections for chronic lateral epicondylar tendinopathy.
METHODS:
The databases of PubMed, EMBASE, CINAHL, Medline OvidSP, Scopus, Google Scholar, Web of Science and Cochrane Library were searched in October 2013. Inclusion criteria were a clinical diagnosis of chronic lateral epicondylar tendinopathy, a randomised controlled trial, an intervention with a PRP injection and the outcome measures described in terms of pain and/or function. One author screened the search results and two authors independently assessed the study quality using the Physiotherapy Evidence Database (PEDro) score. A study was considered to be of high quality if its PEDro score was ≥6. A best evidence synthesis was used to identify the level of evidence.
RESULTS:
6 studies were included, of which four were considered to be of high quality. Three high-quality studies (75%) and two low-quality studies showed no significant benefit at the final follow-up measurement or predefined primary outcome score when compared with a control group. One high-quality study (25%) showed a beneficial effect of a PRP injection when compared with a corticosteroid injection (corticosteroid injections are harmful in tendinopathy). Based on the best evidence synthesis, there is strong evidence that PRP injections are not efficacious in chronic lateral epicondylar tendinopathy.
CONCLUSIONS:
There is strong evidence that PRP injections are not efficacious in the management of chronic lateral elbow tendinopathy.
Rodilla/Knee: qué hacemos con la lesión del cartílago
Trends in the Surgical Treatment of Articular Cartilage Lesions in the United States: An Analysis of a Large Private-Payer Database Over a Period of 8 Years
Frank McCormick, Joshua D. Harris, Geoffrey D. Abrams, Rachel Frank, Anil Gupta, Kristen Hussey, Hillary Wilson, Bernard Bach, Brian Coledomingo
Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 30, Issue 2 , Pages 222-226, February 2014
Purpose: The purpose of this study was to quantify the current trends in knee cartilage surgical techniques performed in the United States from 2004 through 2011 using a large private-payer database. A secondary objective was to identify salient demographic factors associated with these procedures.
Methods: We performed a retrospective database review using a large private-payer medical record database within the PearlDiver database. The PearlDiver database is a publicly available, Health Insurance Portability and Accountability Act–compliant national database compiled from a collection of private insurer records. A search was performed for surgical techniques in cartilage palliation (chondroplasty), repair (microfracture/drilling), and restoration (arthroscopic osteochondral autograft, arthroscopic osteochondral allograft, autologous chondrocyte implantation, open osteochondral allograft, and open osteochondral autograft). The incidence, growth, and demographic factors associated with the surgical procedures were assessed.
Results: From 2004 through 2011, 198,876,000 patients were analyzed. A surgical procedure addressing a cartilage defect was performed in 1,959,007 patients, for a mean annual incidence of 90 surgeries per 10,000 patients. Across all cartilage procedures, there was a 5.0% annual incidence growth (palliative, 3.7%; repair, 0%; and restorative, 3.1%) (P = .027). Palliative techniques (chondroplasty) were more common (>2:1 ratio for repair [marrow-stimulation techniques] and 50:1 ratio for restoration [autologous chondrocyte implantation and osteochondral autograft and allograft]). Palliative surgical approaches were the most common technique, regardless of age, sex, or region.
Conclusions: Articular cartilage surgical procedures in the knee are common in the United States, with an annual incidence growth of 5%. Surgical techniques aimed at palliation are more common than cartilage repair and restoration techniques regardless of age, sex, or region.
Level of Evidence: Level IV, retrospective database analysis.
26 febrero 2014
Ciencia/Science: el profesor chiflado
Las cinco claves para identificar a un científico chiflado
2010 MAYO 26
tags: Escepticismo, Martin Gardner
por Luis Alfonso Gámez
Fuente: http://blogs.elcorreo.com/magonia/2010/05/26/la-cinco-claves-identificar-un-cientifico-chiflado/
El fallecido Martin Gardner retrata, en su obra Fad and fallacies in the name of science (Modas y falacias en el nombre de la ciencia. 1952), a “los modernos pseudocientíficos” como personajes que suelen permanecer al margen de los canales en los que se presentan y se someten a prueba las nuevas ideas, no mandan sus trabajos a revistas con revisión por pares, son ignorados por los científicos y sus sociedades, y, por eso, montan sus propias organizaciones y revistas. Y ofrece cinco claves que permiten identificar sin esfuerzo a un auténtico científico chiflado, a alguien que se cree su locura:
1. Se considera a sí mismo un genio.
2. Ve a sus colegas, sin excepción, como zopencos ignorantes. Todo el mundo está desfasado excepto él. Insulta frecuentemente a sus oponentes acusándoles de estupidez, deshonestidad y otros infames motivos. Si le ignoran, interpreta que lo hacen porque no pueden rebatir sus argumentos. Si sufre alguna represalia, ésta refuerza su ilusión de que está luchando contra sinvergüenzas. (…)
3. Cree que está siendo injustamente perseguido y discriminado. Las sociedades científicas no permiten que dé conferencias en ellas. Las revistas rechazan sus artículos e ignoran sus libros o encargan las recensiones a enemigos. Es todo parte de un miserable complot. Al chiflado nunca se le ocurre pensar que esa oposición puede deberse a errores en su trabajo. Está convencido de que la razón es el prejuicio ciego de la jerarquía establecida, los sumos sacerdotes de la ciencia que temen que se derrumbe la ortodoxia.
Se considera una víctima constante de graves calumnias y ataques no provocados. Se compara a sí mismo con Bruno, Galileo, Copérnico, Pasteur y otros grandes hombres perseguidos por sus herejías. (…) Llama repetidamente la atención sobre importantes descubrimientos científicos hechos por legos.
4. Suele centrar sus ataques en los científicos más importantes y las teorías más firmemente establecidas. Cuando Newton era el nombre de referencia en la física, los trabajos excéntricos de esa disciplina eran violentamente antinewtonianos. (…)
5. Tiene tendencia a escribir en una jerga compleja, en muchos casos usando términos y expresiones que él mismo ha acuñado. (…)”
2010 MAYO 26
tags: Escepticismo, Martin Gardner
por Luis Alfonso Gámez
Fuente: http://blogs.elcorreo.com/magonia/2010/05/26/la-cinco-claves-identificar-un-cientifico-chiflado/
El fallecido Martin Gardner retrata, en su obra Fad and fallacies in the name of science (Modas y falacias en el nombre de la ciencia. 1952), a “los modernos pseudocientíficos” como personajes que suelen permanecer al margen de los canales en los que se presentan y se someten a prueba las nuevas ideas, no mandan sus trabajos a revistas con revisión por pares, son ignorados por los científicos y sus sociedades, y, por eso, montan sus propias organizaciones y revistas. Y ofrece cinco claves que permiten identificar sin esfuerzo a un auténtico científico chiflado, a alguien que se cree su locura:
1. Se considera a sí mismo un genio.
2. Ve a sus colegas, sin excepción, como zopencos ignorantes. Todo el mundo está desfasado excepto él. Insulta frecuentemente a sus oponentes acusándoles de estupidez, deshonestidad y otros infames motivos. Si le ignoran, interpreta que lo hacen porque no pueden rebatir sus argumentos. Si sufre alguna represalia, ésta refuerza su ilusión de que está luchando contra sinvergüenzas. (…)
3. Cree que está siendo injustamente perseguido y discriminado. Las sociedades científicas no permiten que dé conferencias en ellas. Las revistas rechazan sus artículos e ignoran sus libros o encargan las recensiones a enemigos. Es todo parte de un miserable complot. Al chiflado nunca se le ocurre pensar que esa oposición puede deberse a errores en su trabajo. Está convencido de que la razón es el prejuicio ciego de la jerarquía establecida, los sumos sacerdotes de la ciencia que temen que se derrumbe la ortodoxia.
Se considera una víctima constante de graves calumnias y ataques no provocados. Se compara a sí mismo con Bruno, Galileo, Copérnico, Pasteur y otros grandes hombres perseguidos por sus herejías. (…) Llama repetidamente la atención sobre importantes descubrimientos científicos hechos por legos.
4. Suele centrar sus ataques en los científicos más importantes y las teorías más firmemente establecidas. Cuando Newton era el nombre de referencia en la física, los trabajos excéntricos de esa disciplina eran violentamente antinewtonianos. (…)
5. Tiene tendencia a escribir en una jerga compleja, en muchos casos usando términos y expresiones que él mismo ha acuñado. (…)”
Cadera/Hip: 30 artroscopias para ser bueno?
The Learning Curve for Hip Arthroscopy: A Systematic Review
Arthroscopy: The Journal of Arthroscopic & Related Surgery
Publication date: March 2014
Source:Arthroscopy: The Journal of Arthroscopic & Related Surgery, Volume 30, Issue 3
Author(s): Daniel J. Hoppe , Darren de SA , Nicole Simunovic , Mohit Bhandari , Marc R. Safran , Christopher M. Larson , Olufemi R. Ayeni
Purpose
The learning curve for hip arthroscopy is consistently characterized as “steep.” The purpose of this systematic review was to (1) identify the various learning curves reported in the literature, (2) examine the evidence supporting these curves, and (3) determine whether this evidence supports an accepted number of cases needed to achieve proficiency.
Methods
The electronic databases Embase and Medline were screened for any clinical studies reporting learning curves in hip arthroscopy. Two reviewers conducted a full-text review of eligible studies and a hand search of conference proceedings and reference sections of the included articles. Inclusion/exclusion criteria were applied, and a quality assessment was completed for each included article. Descriptive statistics were compiled.
Results
We identified 6 studies with a total of 1,063 patients. Studies grouped surgical cases into “early” versus “late” in a surgeon's experience, with 30 cases being the most common cutoff used. Most of these studies used descriptive statistics and operative time and complication rates as measures of competence. Five of 6 studies showed improvement in these measures between early and late experience, but only one study proposed a bona fide curve.
Conclusions
This review shows that when 30 cases was used as the cutoff point to differentiate between early and late cases in a surgeon's experience, there were significant reductions in operative time and complication rates. However, there was insufficient evidence to quantify the learning curve and validate 30, or any number of cases, as the point at which the learning curve plateaus. As a result, this number should be interpreted with caution.
Level of Evidence
Level IV, systematic review of Level IV studies.
Rodilla/Knee: componente rotuliano sí/no
Increased patellofemoral pressure after TKA: an in vitro study.
Knee Surgery, Sports Traumatology, Arthroscopy: 2014, 22 (3): 500-8Ulf G Leichtle, Markus Wünschel, Carmen I Leichtle, Otto Müller, Philipp Kohler, Nikolaus Wülker, Andrea Lorenz
PURPOSE: Considering the discrepant results of the recent biomechanical studies, the purpose of this study was to simulate dynamic muscle-loaded knee flexion with a large number of specimens and to analyse the influence of total knee arthroplasty (TKA) without and with patellar resurfacing on the patellofemoral pressure distribution.
METHODS: In 22 cadaver knee specimens, dynamic muscle-loaded knee flexion (15°-90°) was simulated with a specially developed knee simulator applying variable muscle forces on the quadriceps muscles to maintain a constant ankle force. Patellofemoral pressures were measured with flexible, pressure-sensitive sensor foils (TEKSCAN) and patellofemoral offset with an ultrasound motion-tracking system (ZEBRIS). Measurements were taken on the native knee, after total knee arthroplasty and after patellar resurfacing. Correct positioning of the patellar implant was examined radiologically.
RESULTS: The maximal patellofemoral peak pressure partly increased from the native knee to the knee with TKA with intact patella (35°-90°, p < 0.012) and highly increased (twofold to threefold) after patellar resurfacing (20°-90°, p < 0.001). Concurrently, the patellofemoral contact area decreased and changed from a wide area distribution in the native knee, to a punctate area after TKA with intact patella and a line-shaped area after patellar resurfacing. Patellar resurfacing led to no increase in patellar thickness and patellofemoral offset.
CONCLUSIONS: Despite correct implantation of the patellar implants and largely unchanged patellofemoral offset, a highly significant increase in pressure after patellar resurfacing was measured. Therefore, from a biomechanical point of view, the preservation of the native patella seems reasonable if there is no higher grade patellar cartilage damage.
25 febrero 2014
Deporte/Sport: edema medular en corredores
Bone Marrow Edema Lesions in the Professional Runner.
American Journal of Sports Medicine 2014 February 20Peter R Kornaat, Samuel K Van de Velde
BACKGROUND:The clinical significance of an incidental finding of bone marrow edema (BME) on MRI in professional runners is poorly understood.
PURPOSE:To investigate the prevalence and clinical and radiological progression of BME lesions in professional runners who consider themselves to be asymptomatic. STUDY DESIGN:Case series; Level of evidence, 4.
METHODS:Sixteen athletes (13 men and 3 women; mean age, 22.9 ± 2.7 years) were recruited from the Dutch National Committee middle-distance and long-distance running selection. All athletes had been injury free for the year before the study. Magnetic resonance imaging scans were obtained before the start of the season and at the end of the season. Both pubic bones, hips, knees, and ankles were scanned in a single session. Preseason and postseason Lysholm scores were obtained.
RESULTS:Fourteen of the 16 athletes had BME lesions before the start of the season (45 BME lesions in total). Most BME lesions (69%; 31/45) were located in the ankle joint and foot. More than half of the lesions (58%; 26/45) fluctuated during the season, with new lesions occurring (20%; 9/45) and old lesions disappearing (22%; 10/45). The few clinical complaints that occurred throughout the season were not related to the presence of BME lesions.
CONCLUSION:Almost all asymptomatic athletes showed BME lesions, with more than half of the lesions fluctuating during the season. These data suggest that the incidental finding of a BME lesion on MRI of professional runners should not immediately be related to clinical complaints or lead to an altered training program.
Rodilla/Knee: PRP para la rodilla del saltador
Are Multiple Platelet-Rich Plasma Injections Useful for Treatment of Chronic Patellar Tendinopathy in Athletes?: A Prospective Study.
Am J Sports Med. 2014 Feb 11. [Epub ahead of print]Charousset C1, Zaoui A, Bellaiche L, Bouyer B.
Abstract
BACKGROUND:Chronic patellar tendinopathy (PT) is one of the most common overuse knee disorders. Platelet-rich plasma (PRP) appears to be a reliable nonoperative therapy for chronic PT.
PURPOSE:To evaluate clinical and radiological outcomes of 3 consecutive ultrasound (US)-guided PRP injections for the treatment of chronic PT in athletes.
STUDY DESIGN:Case series; Level of evidence, 4.
METHODS:A total of 28 athletes (17 professional, 11 semiprofessional) with chronic PT refractory to nonoperative management were prospectively included for US-guided pure PRP injections into the site of the tendinopathy. The same treating physician at a single institution performed 3 consecutive injections 1 week apart, with the same PRP preparation used. All patients underwent clinical evaluation, including the Victorian Institute of Sport Assessment-Patella (VISA-P) score, visual analog scales (VAS) for pain, and Lysholm knee scale before surgery and after return to practice sports. Tendon healing was assessed with MRI at 1 and 3 months after the procedure.
RESULTS:The VISA-P, VAS, and Lysholm scores all significantly improved at the 2-year follow-up. The average preprocedure VISA-P, VAS, and Lysholm scores improved from 39 to 94 (P < .001), 7 to 0.8 (P < .0001), and 60 to 96 (P < .001), respectively, at the 2-year follow-up. Twenty-one of the 28 athletes returned to their presymptom sporting level at 3 months (range, 2-6 months) after the procedure. Follow-up MRI assessment showed improved structural integrity of the tendon at 3 months after the procedure and complete return to normal structural integrity of the tendon in 16 patients (57%). Seven patients did not recover their presymptom sporting level (among them, 6 were considered treatment failures): 3 patients returned to sport at a lesser level, 1 patient changed his sport activity (for other reasons), and 3 needed surgical intervention.
CONCLUSION:In this study, application of 3 consecutive US-guided PRP injections significantly improved symptoms and function in athletes with chronic PT and allowed fast recovery to their presymptom sporting level. The PRP treatment permitted a return to a normal architecture of the tendon as assessed by MRI.
Rodilla/Knee: faltan pruebas para usar PRP en la ligamentoplastia
Use of platelet rich plasma in knee ligament surgery
David Figueroa P, Francisco Figueroa B, Ahumada P Ximena, Rafael Calvo R, Alex Vaisman BRevista Médica de Chile 2013, 141 (10): 1315-20
Platelet Rich Plasma (PRP) is used in musculoskeletal lesion surgery, including muscle, bone, tendons and ligaments. PRP might accelerate the healing process and the integration of the graft, allowing an earlier return to sports activities of patients. PRP is obtained from autologous blood, which is centrifuged, obtaining platelet and supposedly growth factor concentrations three to five times higher than those of regular blood. The clinical results of studies performed in Chile and elsewhere on PRP use in knee anterior cruciate ligament (ACL) reconstruction have been variable. Therefore, there is not enough evidence to support or deny the usefulness of PRP in ACL reconstructions.
Rodilla/Knee: artrosis y combinar PRP con ácido hialurónico
Knee osteoarthritis: hyaluronic acid, platelet-rich plasma or both in association?
Expert Opinion on Biological Therapy 2014 February 17Isabel Andia, Michele Abate
Introduction: Bidirectional interactions between cells and fluidic surroundings regulate cellular functions and maintain tissue or organ architecture. Accordingly, the synovial fluid is the primary source of environmental signals and determines to a great extent the molecular interactions within the joint capsule, both in homeostasis and pathology.
Areas covered: We provided an update on hyaluronic acid (HA) and platelet-rich plasma (PRP) concepts necessary to build the rationale for creating a combined treatment. The information is based on a PubMed search using the terms 'platelet-rich plasma', 'hyaluronic acid', 'knee pathology', 'knee osteoarthritis' (OA).
Expert opinion: In OA, a deleterious fluidic microenvironment is established, with presence of HA fragments, catabolic enzymes and inflammatory molecules. The central concept underlying intra-articular injection is to modify deleterious fluidic microenvironments. PRP administration has shown pain remission and function improvement, but less than half of the patients showed clinically significant improvement. PRP exceeds HA, the comparator used in PRP clinical trials, albeit both HA and PRP alleviate symptoms in mild-to-moderate OA patients. Combining PRP and HA may benefit from their dissimilar biological mechanisms and help in controlling delivery and presentation of signaling molecules. Three armed randomized studies, using both HA and PRP as comparators, will provide information about the impact of this approach.
Rodilla/Knee: lca y reintervención al poco tiempo
Abstract
Risk Factors of Subsequent Operations After Primary Anterior Cruciate Ligament Reconstruction.
American Journal of Sports Medicine 2013 December 17
Rick P Csintalan, Maria C S Inacio, Tadashi T Funahashi, Gregory B Maletis
BACKGROUND:The incidence of nonrevision reoperations after anterior cruciate ligament reconstruction (ACLR) is less commonly studied and quantified.
PURPOSE:To describe the incidence of short-term reoperations after primary ACLR for the 4 most common procedures and to evaluate the risk factors associated with these reoperations. STUDY
DESIGN:Cohort study; Level of evidence, 3.
METHODS:Patients who underwent ACLRs and were enrolled in an ACLR registry between February 2005 and September 2011 were evaluated. First reoperations after primary ACLR performed for the 4 most common procedures (meniscal procedures, cartilage procedures, hardware removal procedures, and arthrofibrosis procedures) were the primary end points of the study. Patient, surgical, surgeon, and hospital risk factors associated with reoperations were evaluated, and Cox regression models were employed. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported.
RESULTS:A total of 14,522 ACLRs were identified. The patients had a mean age of 29.4 ± 11.5 years and were mostly male (63.3%) and white (48.3%). The mean follow-up was 1.9 ± 1.5 years (range, 0-6.7 years), and the median time to reoperation was 301 days (interquartile range, 172-515 days). The reoperation rate per 100 person-years of follow-up was 1.1 for meniscal reoperations, 0.3 for cartilage reoperations, 0.4 for hardware removal reoperations, and 0.4 for arthrofibrosis reoperations. Meniscal repair at the index ACLR was a significant risk factor for subsequent meniscal procedures (HR, 4.19; 95% CI, 3.10-5.67). Sports medicine fellowship training of the surgeon (HR, 2.17; 95% CI, 1.01-4.62) and older patient age (≤17 vs ≥26 years) (HR, 0.32; 95% CI, 0.12-0.81) were significant risk factors for cartilage reoperations. Use of allografts (HR, 1.90; 95% CI, 1.10-3.30) and female sex (HR, 1.75; 95% CI, 1.16-2.64) were risk factors for hardware removal reoperations. Female sex (HR, 2.48; 95% CI, 1.66-3.71) and prior surgery (HR, 3.02; 95% CI, 1.39-6.53) were risk factors for subsequent surgery for arthrofibrosis.
CONCLUSION:Overall short-term reoperation rates after ACLR are relatively low. Risk factors for subsequent surgery vary depending on the type of surgery evaluated. Some of the risk factors observed for reoperations include previous meniscal repair, female sex, allografts, prior surgery, older patient age, and being operated on by a sports medicine fellowship-trained surgeon
Rodilla/Knee: Ligamentoplastia lca y cuándo acaba en PTR
The risk of knee arthroplasty following cruciate ligament reconstruction: a population-based matched cohort study.
Journal of Bone and Joint Surgery. American Volume 2014 January 1, 96 (1): 2-10
Timothy Leroux, Darrell Ogilvie-Harris, Tim Dwyer, Jaskarndip Chahal, Rajiv Gandhi, Nizar Mahomed, David Wasserstein
BACKGROUND: Evidence regarding the risk of end-stage osteoarthritis following cruciate ligament reconstruction is based upon small sample sizes and radiographic, rather than clinical, criteria. The goals of this study were to determine the risk of knee arthroplasty, a surrogate for end-stage osteoarthritis, following cruciate ligament reconstruction, and to identify patient, provider, and surgical factors that influence knee arthroplasty risk.
METHODS: Using administrative databases, we identified all patients who were sixteen to sixty years of age and had undergone cruciate ligament reconstruction in Ontario from July 1993 to March 2008. Case patients were matched by demographic variables to five individuals without knee injury from the general population of Ontario, Canada, who had not undergone previous knee surgery, including cruciate ligament reconstruction. The main outcome was knee arthroplasty. Kaplan-Meier survival curves were generated for both cohorts. A Cox proportional hazards model determined those factors that influenced knee arthroplasty risk.
RESULTS: We identified 30,301 eligible patients who had undergone cruciate ligament reconstruction; of these patients, 30,277 were matched to 151,362 individuals from the general population; the median patient age was twenty-eight years and 65% of the patients were male. Primary anterior cruciate ligament reconstruction accounted for >98% of index cases. During the follow-up period, there was a significant difference (p < 0.001) between matched case and control cohorts with respect to the number of patients who underwent knee arthroplasty during the study period; in the matched case cohort, 209 patients underwent knee arthroplasty (event rate, 0.68 of 1000 person-years), and in the control cohort, 125 patients underwent knee arthroplasty (event rate, 0.10 of 1000 person-years). Moreover, fifteen years after cruciate ligament reconstruction (case cohort) or study enrollment (control cohort), there was a significant difference (p < 0.001) in the cumulative incidence of knee arthroplasty between the case cohort (1.4%) and the control cohort (0.2%). Age of fifty years or more (hazard ratio, 37.28; p < 0.001), female sex (hazard ratio, 1.58; p = 0.001), comorbidity score of ≥5 points (hazard ratio, 5.91; p = 0.002), surgeon annual volume of cruciate ligament reconstruction of twelve or fewer cases per year (hazard ratio, 2.53; p < 0.001), and cruciate ligament reconstruction undertaken in university-affiliated hospitals (hazard ratio, 1.51, p = 0.008) increased the odds of knee arthroplasty; however, male sex (hazard ratio, 0.63; p = 0.001) and patient age of less than twenty years (hazard ratio, 0.07; p = 0.009) were protective. Concurrent meniscal repair or debridement did not increase arthroscopy risk.
CONCLUSIONS: After fifteen years, the cumulative incidence of knee arthroplasty following cruciate ligament reconstruction was low (1.4%); however, it was seven times greater than the cumulative incidence of knee arthroplasty among matched control patients from the general population (0.2%). Older age, female sex, higher comorbidity, low surgeon annual volume of cruciate ligament reconstruction, and cruciate ligament reconstruction performed in a university-affiliated hospital were factors that increased knee arthroplasty risk.
23 febrero 2014
Hombro/Shoulder: derrame peribicipital y lesiones asociadas
Associations of sonographic abnormalities of the shoulder with various grades of biceps peritendinous effusion (BPE).
Authors: Chang KVChen WSWang TGHung CYChien KL
Source: Ultrasound Med Biol 2014 Feb; 40(2):313-21.
INTRODUCTION
Bicipital peritendinous effusion (BPE), a common ultrasonographic finding of the long head of the biceps tendon, may be associated with shoulder joint derangement, but supporting evidence from large-scale studies is lacking.
The aim of this cross-sectional study was to determine the strength of the association between BPE and sonographic abnormalities of the shoulder joint.
METHODS
We reviewed the sonographic reports of patients with suspected shoulder disorders investigated ultrasonographically between January 2011 and January 2012. BPE was graded according to its measured thickness as absent (<1 mm), mild (1-2 mm), moderate (2-3 mm) or severe (>3 mm). The associations between BPE and sonographic abnormalities were examined using multinomial logistic regression adjusted for age, gender, affected side and clinical diagnosis of frozen shoulder.
RESULTS
The prevalence rates of absent, mild, moderate and severe BPE among the 907 shoulders examined were 64.1%, 17.8%, 10.4% and 7.7%, respectively. Frozen shoulder was associated with mild BPE (relative risk [RR] vs. participants without BPE = 1.83, 95% confidence interval [CI] = 1.28-2.50). Sonographic findings of biceps tendinopathy, subdeltoid bursitis and full-thickness tears of the supraspinatus tendon were significantly associated with the entire spectrum of BPE, whereas subscapularis tendon tears were significantly associated with moderate (RR = 2.47, 95% CI = 1.29-4.69) and severe (RR = 3.11, 95% CI = 1.51-6.33) BPE. Severe BPE was associated with articular-sided partial-thickness tears of the supraspinatus tendon (RR = 14.32, 95% CI = 4.30-34.35), posterior recess effusion (RR, 7.98, 95% CI = 1.44-34.93) and biceps medial subluxation (RR = 7.25, 95% CI = 1.90-22.33).
CONCLUSION
Our study indicates that BPE is related to various shoulder abnormalities and that the strengths of these associations depend on the severity of BPE. Clinicians encountering BPE should grade its severity and be alert for hidden lesions of the shoulder joint.
Hombro/Shoulder: tenodesis con o sin hardware
Ultrasound and clinical evaluation of soft-tissue versus hardware biceps tenodesis: is hardware tenodesis worth the cost?
Authors: Elkousy H Romero JA Edwards TB Gartsman GM O'Connor DP
Source: Am J. Orthop. 2014 Feb; 43(2):62-5.
INTRODUCTION
This study assesses the failure rate of soft-tissue versus hardware fixation of biceps tenodesis by ultrasound to determine if the expense of a hardware tenodesis technique is warranted.
METHODS
Seventy-two patients that underwent arthroscopic biceps tenodesis over a 3-year period were evaluated using postoperative ultrasonography and clinical examination. The tenodesis technique employed was either a soft-tissue technique with sutures or an interference screw technique using hardware based on surgeon preference.
RESULTS
Patient age was 57.9 years on average with ultrasound and clinical examination done at an average of 9.3 months postoperatively. Thirty-one patients had a hardware technique and 41 a soft-tissue technique. Overall, 67.7% of biceps tenodesis done with hardware were intact, compared with 75.6% for the soft-tissue technique by ultrasound (P = .46). Clinical evaluation indicated that 80.7% of hardware techniques and 78% of soft-tissue techniques were intact. Average material cost to the hospital for the hardware technique was $514.32, compared with $32.05 for the soft-tissue technique.
CONCLUSION
Biceps tenodesis success, as determined by clinical deformity and ultrasound, was not improved using hardware as compared to soft-tissue techniques. Soft-tissue techniques are equally efficacious and more cost effective than hardware techniques.
Rodilla/Knee: ¿microfracturas por artroscopia?
Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis.
Mithoefer K1, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR.
Am J Sports Med. 2009 Oct;37(10):2053-63.
Abstract
BACKGROUND:
Despite the popularity of microfracture as a first-line treatment for articular cartilage defects in the knee, systematic information on its clinical efficacy for articular cartilage repair and long-term improvement of knee function is not available.
HYPOTHESIS:
Systematic analysis of the existing clinical literature of microfracture in the knee can improve the understanding of the advantages and limitations of this cartilage repair technique and can help to optimize its indications and clinical outcomes.
STUDY DESIGN:
Systematic review.
METHODS:
A comprehensive literature search was performed using established search engines (MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials) to identify original human studies of articular cartilage repair with microfracture. Modified Coleman Methodology Scores were used to analyze the quality of the existing studies. Clinical efficacy of articular cartilage repair was evaluated by systematic analysis of short- and long-term functional outcome scores, macroscopic and microscopic repair cartilage quality, and findings of postoperative magnetic resonance imaging.
RESULTS:
Twenty-eight studies describing 3122 patients were included in the review. The average follow-up was 41 months, with only 5 studies reporting follow-up of 5 years or more. Six studies were randomized controlled trials and the mean Coleman Methodology Score was 58 (range, 22-97). Microfracture effectively improved knee function in all studies during the first 24 months after microfracture, but the reports on durability of the initial functional improvement were conflicting. Several factors were identified that affected clinical outcome. Defect fill on magnetic resonance imaging was highly variable and correlated with functional outcome. Macroscopic repair cartilage quality positively affected long-term failure rate, while the influence of histologic repair tissue quality remained inconclusive.
CONCLUSION:
This systematic analysis shows that microfracture provides effective short-term functional improvement of knee function but insufficient data are available on its long-term results. Shortcomings of the technique include limited hyaline repair tissue, variable repair cartilage volume, and possible functional deterioration. The quality of the currently available data on micro-fracture is still limited by the variability of results and study designs. Further well-designed studies are needed to determine the long-term efficacy of microfracture and to define its specific clinical indications compared to other cartilage repair techniques.
Pie/Foot: fascitis plantar y plasma rico en plaquetas
Platelet-rich Plasma and Plantar Fasciitis.
Sports Medicine & Arthroscopy Review, 21(4):220-224, 2013
Monto RR
Abstract:
Plantar fasciitis is the most common cause of heel pain and can prove difficult to treat in its most chronic and severe forms. Advanced cases of plantar fasciitis are often associated with ankle stiffness, heel spurs, and other conditions and can lead to extensive physical disability and financial loss. Most available traditional treatments, including orthoses, nonsteroidal anti-inflammatory drugs, and steroid injections have a paucity of supportive clinical evidence. More invasive treatments, ranging from corticosteroid and botulinum-A toxin injections to shockwave therapy and plantar fasciotomy, have demonstrated varying clinical success in severe cases but carry the potential for serious complication and permanent disability. Platelet-rich plasma has recently been demonstrated to be helpful in managing chronic severe tendinopathies when other techniques have failed. This review examines the pathophysiology, diagnostic options, nonoperative treatment modalities, and surgical options currently used for plantar fasciitis. It also focuses on the clinical rationale and available evidence for using autologous platelet-rich plasma to treat severe refractory chronic plantar fasciitis.
Plantar fasciitis is the most common cause of heel pain and can prove difficult to treat in its most chronic and severe forms. Advanced cases of plantar fasciitis are often associated with ankle stiffness, heel spurs, and other conditions and can lead to extensive physical disability and financial loss. Most available traditional treatments, including orthoses, nonsteroidal anti-inflammatory drugs, and steroid injections have a paucity of supportive clinical evidence. More invasive treatments, ranging from corticosteroid and botulinum-A toxin injections to shockwave therapy and plantar fasciotomy, have demonstrated varying clinical success in severe cases but carry the potential for serious complication and permanent disability. Platelet-rich plasma has recently been demonstrated to be helpful in managing chronic severe tendinopathies when other techniques have failed. This review examines the pathophysiology, diagnostic options, nonoperative treatment modalities, and surgical options currently used for plantar fasciitis. It also focuses on the clinical rationale and available evidence for using autologous platelet-rich plasma to treat severe refractory chronic plantar fasciitis.
22 febrero 2014
Técnicas/Trauma: Ojo al tornillo bloqueado
Mechanical Effects of Off-Axis Insertion of Locking Screws - Should we do it?
Journal of Orthopaedic Trauma, Publish Ahead of Print():-, 2014
Cartner JL, Petteys T, Tornetta P
Objectives: The purposes of this study were to evaluate the cantilevered bending strength and failure modes of locking screws inserted at various angles in a plate with fully circumferential threaded holes. As an additional measure, the amount of screw head prominence at these angles was also assessed.
Methods: Standard 3.5 mm locking screws were inserted into round fully circumferential threaded holes through a standard straight 3.5 mm locking plate at various angles. The achieved angle of insertion and its prominence protruding from the far-bone side of the plate was measured using an optical luminescence technique. Each screw was then loaded at a constant rate until failure in a cantilevered bending scenario. The maximum cantilevered bending strength was measured and the moment at failure was calculated.
Results: There was a positive correlation between increasing insertion angle and increasing prominence; a higher screw insertion angle yielded greater prominence. Prominence values ranged from negligible up to 2 mm. As screw insertion angle increased, the bending moment at failure decreased. Screws inserted to 3-degrees or below primarily failed via screw deformation at the minor diameter below the head, whereas screws inserted to greater than 3-degrees primarily failed via locking mechanism disengagement.
Conclusions: These findings indicate that cross-threading may not be biomechanically advantageous and change screw mode of failure. Based on these findings, screws inserted to 3-degrees or higher would reduce the bending moment at failure to approximately 50% of an orthogonally inserted screw.
Cartner JL, Petteys T, Tornetta P
Objectives: The purposes of this study were to evaluate the cantilevered bending strength and failure modes of locking screws inserted at various angles in a plate with fully circumferential threaded holes. As an additional measure, the amount of screw head prominence at these angles was also assessed.
Methods: Standard 3.5 mm locking screws were inserted into round fully circumferential threaded holes through a standard straight 3.5 mm locking plate at various angles. The achieved angle of insertion and its prominence protruding from the far-bone side of the plate was measured using an optical luminescence technique. Each screw was then loaded at a constant rate until failure in a cantilevered bending scenario. The maximum cantilevered bending strength was measured and the moment at failure was calculated.
Results: There was a positive correlation between increasing insertion angle and increasing prominence; a higher screw insertion angle yielded greater prominence. Prominence values ranged from negligible up to 2 mm. As screw insertion angle increased, the bending moment at failure decreased. Screws inserted to 3-degrees or below primarily failed via screw deformation at the minor diameter below the head, whereas screws inserted to greater than 3-degrees primarily failed via locking mechanism disengagement.
Conclusions: These findings indicate that cross-threading may not be biomechanically advantageous and change screw mode of failure. Based on these findings, screws inserted to 3-degrees or higher would reduce the bending moment at failure to approximately 50% of an orthogonally inserted screw.
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