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D'Souza RS, Her YF, Hussain N, Karri J, Schatman ME, Calodney AK, Lam C, Buchheit T, Boettcher BJ, Chang Chien GC, Pritzlaff SG, Centeno C, Shapiro SA, Klasova J, Grider JS, Hubbard R, Ege E, Johnson S, Epstein MH, Kubrova E, Ramadan ME, Moreira AM, Vardhan S, Eshraghi Y, Javed S, Abdullah NM, Christo PJ, Diwan S, Hassett LC, Sayed D, Deer TR. Evidence-Based Clinical Practice Guidelines on Regenerative Medicine Treatment for Chronic Pain: A Consensus Report from a Multispecialty Working Group. J Pain Res 2024; 17:2951-3001. [PMID: 39282657 PMCID: PMC11402349 DOI: 10.2147/jpr.s480559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 08/21/2024] [Indexed: 09/19/2024] Open
Abstract
Purpose Injectable biologics have not only been described and developed to treat dermal wounds, cardiovascular disease, and cancer, but have also been reported to treat chronic pain conditions. Despite emerging evidence supporting regenerative medicine therapy for pain, many aspects remain controversial. Methods The American Society of Pain and Neuroscience (ASPN) identified the educational need for an evidence-based guideline on regenerative medicine therapy for chronic pain. The executive board nominated experts spanning multiple specialties including anesthesiology, physical medicine and rehabilitation, and sports medicine based on expertise, publications, research, and clinical practice. A steering committee selected preliminary questions, which were reviewed and refined. Evidence was appraised using the United States Preventive Services Task Force (USPSTF) criteria for evidence level and degree of recommendation. Using a modified Delphi approach, consensus points were distributed to all collaborators and each collaborator voted on each point. If collaborators provided a decision of "disagree" or "abstain", they were invited to provide a rationale in a non-blinded fashion to the committee chair, who incorporated the respective comments and distributed revised versions to the committee until consensus was achieved. Results Sixteen questions were selected for guideline development. Questions that were addressed included type of injectable biologics and mechanism, evidence in treating chronic pain indications (eg, tendinopathy, muscular pathology, osteoarthritis, intervertebral disc disease, neuropathic pain), role in surgical augmentation, dosing, comparative efficacy between injectable biologics, peri-procedural practices to optimize therapeutic response and quality of injectate, federal regulations, and complications with mitigating strategies. Conclusion In well-selected individuals with certain chronic pain indications, use of injectable biologics may provide superior analgesia, functionality, and/or quality of life compared to conventional medical management or placebo. Future high-quality randomized clinical trials are warranted with implementation of minimum reporting standards, standardization of preparation protocols, investigation of dose-response associations, and comparative analysis between different injectable biologics.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yeng F Her
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Jay Karri
- Departments of Orthopedic Surgery and Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Christopher Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Thomas Buchheit
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Brennan J Boettcher
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | | | - Scott G Pritzlaff
- Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA
| | | | - Shane A Shapiro
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Johana Klasova
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jay S Grider
- Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Ryan Hubbard
- Department of Sports Medicine, Anderson Orthopedic Clinic, Arlington, VA, USA
| | - Eliana Ege
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Shelby Johnson
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Max H Epstein
- Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Eva Kubrova
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Mohamed Ehab Ramadan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alexandra Michelle Moreira
- Department of Physical Medicine & Rehabilitation, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Swarnima Vardhan
- Department of Internal Medicine, Yale New Haven Health - Bridgeport Hospital, Bridgeport, CT, USA
| | - Yashar Eshraghi
- Department of Anesthesiology & Critical Care Medicine, Ochsner Health System, New Orleans, LA, USA
| | - Saba Javed
- Department of Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Newaj M Abdullah
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Paul J Christo
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sudhir Diwan
- Department of Pain Medicine, Advanced Spine on Park Avenue, New York City, NY, USA
| | | | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Timothy R Deer
- Department of Anesthesiology and Pain Medicine, West Virginia University School of Medicine, Charleston, WV, USA
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Seeto AH, Wilson MD, McMeniman M, Astori IP. Severe mucoid degeneration of the anterior cruciate ligament (ACL) treated with conservative arthroscopic debridement and platelet-rich plasma (PRP) injection. BMJ Case Rep 2024; 17:e257217. [PMID: 38350698 PMCID: PMC10868321 DOI: 10.1136/bcr-2023-257217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Mucoid degeneration of the anterior cruciate ligament (ACL) can be treated with arthroscopic debridement, however, instability can ensue. Here, we present a fit and active woman in her 60s with severe mucoid degeneration of the ACL who underwent conservative arthroscopic debridement and treatment with intraligamentous administration of platelet-rich plasma (PRP). After 1 month, the patient demonstrated significant improvements in range of motion and pain symptoms, with nil resultant laxity. The patient was able to return to all recreational sporting activities and professional duties. Quantitative MRI conducted 6 months postoperatively revealed improved fibre orientation and formation of new parallel fibres. Compared with the preoperative scan, the mean grey value demonstrated darker pixel intensity with a smaller standard deviation (SD), potentially indicating a more uniform and less variable formation of ligamentous tissue. Therefore, PRP did not cause harm and was associated with benefit in combination with arthroscopic debridement.
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Affiliation(s)
- Alexander Henry Seeto
- Queensland Health, Brisbane, Queensland, Australia
- Griffith Centre of Biomedical and Rehabilitation Engineering (GCORE), Griffith University Faculty of Health, Gold Coast, Queensland, Australia
| | | | | | - Ivan Paul Astori
- Brisbane Orthopaedic and Sports Medicine Centre, Spring Hill, Queensland, Australia
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Milovanovic D, Vukman P, Gavrilovic D, Begovic N, Stijak L, Sreckovic S, Kadija M. The Influence of Platelet-Rich Fibrin on the Healing of Bone Defects after Harvesting Bone-Patellar Tendon-Bone Grafts. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:154. [PMID: 38256414 PMCID: PMC10820173 DOI: 10.3390/medicina60010154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024]
Abstract
Background and Objectives: A bone-patellar tendon-bone (BTB) autograft in anterior cruciate ligament reconstruction (ACLR) is still considered the gold standard among many orthopedic surgeons, despite anterior knee pain and kneeling pain being associated with bone defects at the harvest site. Bioregenerative products could be used to treat these defects, perhaps improving both the postoperative discomfort and the overall reconstruction. Materials and methods: During a year-long period, 40 patients were enrolled in a pilot study and divided into a study group, in which bone defects were filled with Vivostat® PRF (platelet-rich fibrin), and a standard group, in which bone defects were not filled. The main outcome was a decrease in the height and width of the bone defects, as determined by magnetic resonance imaging on the control exams during the one-year follow-up. The secondary outcomes included an evaluation of kneeling pain, measured with a visual analog scale (VAS), and an evaluation of the subjective knee scores. Results: The application of Vivostat® PRF resulted in a more statistically significant reduction in the width of the defect compared with that of the standard group, especially at 8 and 12 months post operation (p < 0.05). Eight months following the surgery, the study group's anterior knee pain intensity during kneeling was statistically considerably lower than that of the standard group (p < 0.05), and the statistical difference was even more obvious (p < 0.01) at the last follow-up. Each control examination saw a significant decrease in pain intensity in both the groups, with the values at each exam being lower than those from the prior exam (p < 0.01). A comparison of subjective functional test results 12 months post operation with the preoperative ones did not prove a statistically significant difference between the groups. Conclusions: The use of Vivostat® PRF reduces kneeling pain and accelerates the narrowing of bone defects after ACLR with a BTB graft, but without confirmation of its influence on the subjective knee score.
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Affiliation(s)
- Darko Milovanovic
- Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia; (P.V.); (M.K.)
- School of Medicine, University of Belgrade, Dr Subotica 8, 11000 Belgrade, Serbia; (N.B.)
| | - Petar Vukman
- Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia; (P.V.); (M.K.)
| | - Dusica Gavrilovic
- Institute for Oncology and Radiology of Serbia, Pasterova 14, 11000 Belgrade, Serbia
| | - Ninoslav Begovic
- School of Medicine, University of Belgrade, Dr Subotica 8, 11000 Belgrade, Serbia; (N.B.)
- Institute for Mother and Child Health Care of Serbia, Radoja Dakica 6-8, 11070 Belgrade, Serbia
| | - Lazar Stijak
- School of Medicine, University of Belgrade, Dr Subotica 8, 11000 Belgrade, Serbia; (N.B.)
| | - Svetlana Sreckovic
- Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia; (P.V.); (M.K.)
- School of Medicine, University of Belgrade, Dr Subotica 8, 11000 Belgrade, Serbia; (N.B.)
- Center for Anesthesiology and Resuscitation, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia
| | - Marko Kadija
- Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia; (P.V.); (M.K.)
- School of Medicine, University of Belgrade, Dr Subotica 8, 11000 Belgrade, Serbia; (N.B.)
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İPEK D, DÜNDAR A. Publication trends and global productivity about the anterior cruciate ligament: a bibliometric analysis between 1980-2021. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2023. [DOI: 10.32322/jhsm.1192190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Aim: Due to anatomic, biomechanical, kinematic, biological and clinical data obtained as a result of many studies related to treatment and rehabilitation of injuries to the anterior cruciate ligament (ACL), among the most studied anatomic structures in the human body, the literature is continuously being updated and improved. In this study, the aim was to holistically analyze scientific articles about the ACL published between 1980 and 2021 using a variety of statistical methods.
Material and Method: Articles published from 1980 to 2021 about the ACL were obtained from the Web of Science (WoS) database and analyzed using statistical methods and bibliometric approaches. To identify trend topics and global cooperation, and to complete citation analysis, network visualization maps were used. The exponential smoothing predictor was used to predict the number of articles that will be published in the next 5 years. Spearman’s correlation coefficient was used for correlation research.
Results: A total of 11,077 publications were identified. Of these publications, 9101 (82.1%) were articles. The top 3 countries contributing most to the literature were the USA (3894, 42.7%), Japan (879, 9.6%) and Germany (616, 6.7%). The top 3 active organizations were Pennsylvania Commonwealth System of Higher Education (n=468), University of Pittsburgh (440), and University of California system (279). The top 3 journals publishing most articles were the American Journal of Sports Medicine (n=1614), Knee Surgery Sports Traumatology Arthroscopy (1418), and Arthroscopy: The Journal of Arthroscopic and Related Surgery (915). The most effective journal according to mean number of citations per article was the Journal of Bone and Joint Surgery (average citation per document: 80.7). The most active author was Freddie H. Fu (n=278, from University of Pittsburgh).
Conclusion: In this comprehensive bibliometric research about the topic of ACL, with a trend toward increasing publication numbers in recent years, the summary information for 9101 articles published between 1980 and 2021 was shared. According to analysis results to determine trend topics, the keywords studied in recent years include return to sport, ACL injury, anterolateral ligament, pivot shift, quadriceps strength, KOOS, ACL tear, ACL repair, meniscal repair, knee ligaments, tibial slope, posterior tibial slope, return to play, adolescent, graft failure and lateral meniscus.
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Affiliation(s)
- Deniz İPEK
- hitit üniversitesi erol olçok eğitim ve araştırma
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Advanced Graft Development Approaches for ACL Reconstruction or Regeneration. Biomedicines 2023; 11:biomedicines11020507. [PMID: 36831043 PMCID: PMC9953332 DOI: 10.3390/biomedicines11020507] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/28/2023] [Accepted: 01/30/2023] [Indexed: 02/12/2023] Open
Abstract
The Anterior Cruciate Ligament (ACL) is one of the major knee ligaments, one which is greatly exposed to injuries. According to the British National Health Society, ACL tears represent around 40% of all knee injuries. The number of ACL injuries has increased rapidly over the past ten years, especially in people from 26-30 years of age. We present a brief background in currently used ACL treatment strategies with a description of surgical reconstruction techniques. According to the well-established method, the PubMed database was then analyzed to scaffold preparation methods and materials. The number of publications and clinical trials over the last almost 30 years were analyzed to determine trends in ACL graft development. Finally, we described selected ACL scaffold development publications of engineering, medical, and business interest. The systematic PubMed database analysis indicated a high interest in collagen for the purpose of ACL graft development, an increased interest in hybrid grafts, a numerical balance in the development of biodegradable and nonbiodegradable grafts, and a low number of clinical trials. The investigation of selected publications indicated that only a few suggest a real possibility of creating healthy tissue. At the same time, many of them focus on specific details and fundamental science. Grafts exhibit a wide range of mechanical properties, mostly because of polymer types and graft morphology. Moreover, most of the research ends at the in vitro stage, using non-certificated polymers, thus requiring a long time before the medical device can be placed on the market. In addition to scientific concerns, official regulations limit the immediate introduction of artificial grafts onto the market.
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Zhang S, Wen A, Li S, Yao W, Liu C, Lin Z, Jin Z, Chen J, Hua Y, Chen S, Li Y. Radial Extracorporeal Shock Wave Therapy Enhances Graft Maturation at 2-Year Follow-up After ACL Reconstruction: A Randomized Controlled Trial. Orthop J Sports Med 2023; 10:23259671221116340. [PMID: 36760537 PMCID: PMC9902647 DOI: 10.1177/23259671221116340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/16/2022] [Indexed: 02/05/2023] Open
Abstract
Background Graft maturation is an important prognostic factor for hamstring autograft anterior cruciate ligament reconstruction (ACLR). It remains unclear whether extracorporeal shock wave therapy (ESWT) can promote graft healing after ACLR. Purpose To evaluate the therapeutic and graft maturation effects of ESWT in hamstring autograft ACLR. Study Design Randomized controlled trial; Level of evidence, 1. Methods Between May 18, 2019, and September 20, 2019, we randomly assigned 30 patients who met study inclusion criteria to 2 groups. Patients in the control group followed a 5-week advanced rehabilitation training program (30 minutes/session, 5 times/week) starting at 3 months postoperatively. In the ESWT group, together with the 5-week advanced rehabilitation training, radial ESWT was applied once a week for 5 weeks. Functional scores (Lysholm, International Knee Documentation Committee, and Tegner scores), KT-1000 arthrometer knee laxity measurement, and magnetic resonance imaging scans were assessed at 3 months (baseline), 6 months, and 24 months postoperatively. To evaluate graft maturation, we assessed the graft signal-to-noise quotients (SNQs) of the tibial, intra-articular, and femoral sides on magnetic resonance imaging scans. Data were compared between the ESWT and control groups. Results In total, 26 patients (13 with ESWT, 13 controls) were assessed. There were no significant between-group differences on any assessment at baseline, and no significant within-group or between-group differences were found in knee laxity at any point. At 24-month follow-up, the ESWT group had significantly higher Lysholm and Tegner scores compared with the controls (P = .012 and .017, respectively). Regarding graft maturation, at 6-month follow-up, the SNQ of the tibial intraosseous graft was significantly lower in the ESWT group versus controls (P = .006), but no differences were detected at the femoral intraosseous graft (P = .321) or the intra-articular graft (P = .314). At 24-month follow-up, the SNQs of the femoral intraosseous graft and intra-articular graft were significantly lower in the ESWT group versus controls (P = .020 and .044, respectively) but no difference was found at the tibial intraosseous graft (P = .579). Conclusion Both enhanced graft maturation and improved functional scores at 24-month follow-up were seen in patients who received radial ESWT during rehabilitation after hamstring autograft ACLR. Registration ChiCTR1900022853 (Chinese Clinical Trial Registry).
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Affiliation(s)
- Shurong Zhang
- Department of Sports Medicine, Huashan Hospital, Fudan University,
Shanghai, China
| | - Aizhen Wen
- Department of Sports Medicine, Huashan Hospital, Fudan University,
Shanghai, China.,Department of Sport Rehabilitation, Shanghai University of Sport,
Shanghai, China
| | - Shengkun Li
- Department of Sports Medicine, Huashan Hospital, Fudan University,
Shanghai, China
| | - Wei Yao
- Department of Sports Medicine, Huashan Hospital, Fudan University,
Shanghai, China
| | - Chang Liu
- Department of Sports Medicine, Huashan Hospital, Fudan University,
Shanghai, China
| | - Zifan Lin
- Department of Sports Medicine, Huashan Hospital, Fudan University,
Shanghai, China
| | - Zhengbiao Jin
- Department of Sports Medicine, Huashan Hospital, Fudan University,
Shanghai, China
| | - Jiwu Chen
- Department of Sports Medicine, Huashan Hospital, Fudan University,
Shanghai, China
| | - Yinghui Hua
- Department of Sports Medicine, Huashan Hospital, Fudan University,
Shanghai, China
| | - Shiyi Chen
- Department of Sports Medicine, Huashan Hospital, Fudan University,
Shanghai, China
| | - Yunxia Li
- Department of Sports Medicine, Huashan Hospital, Fudan University,
Shanghai, China.,Yunxia Li, MD, Department of Sports Medicine, Huashan Hospital,
Fudan University, Shanghai, China (
)
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7
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Piedade SR, Leite Arruda BP, de Vasconcelos RA, Parker DA, Maffulli N. Rehabilitation And Advances In Surgical Reconstruction For Anterior Cruciate Ligament Insufficiency: What Has Changed Since The 1960s? - State Of The Art. J ISAKOS 2022:S2059-7754(22)00094-3. [PMID: 36410671 DOI: 10.1016/j.jisako.2022.10.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 03/29/2022] [Accepted: 10/10/2022] [Indexed: 11/20/2022]
Abstract
Anterior cruciate ligament (ACL) insufficiency can be disabling, given the physical and sports activity constraints that negatively impact the quality of life. Consequently, surgery is the main approach for most active patients. Nonetheless, ACL reconstruction (ACLR) cannot be successful without adequate preoperative and postoperative rehabilitation. Since the 1960s, post-ACLR rehabilitation has evolved, mainly from advances in surgery, coupled with a better understanding of the biological concepts of graft revascularization, maturation and integration, which have impacted ACL postoperative rehabilitation protocols. However, new technologies do involve a definite learning curve which could affect rehabilitation programs and produce inconsistent results. The development of rehabilitation protocols cannot be defined without an accurate diagnosis of ACL injury and considering the patient's main physical demands and expectations. This article discusses how postoperative rehabilitation following ACLR has changed from the 1960s to now, focussing on surgical technique (type of tendon graft, fixation devices, and graft tensioning), biological concepts (graft maturation and integration), rehabilitation protocols (prevention of ACL injuries, preoperative rehabilitation, postoperative rehabilitation), criteria to return to sports, patient's reported outcomes and outcome. Although rehabilitation plays an essential role in managing ACL injuries, it cannot be fully standardised preoperatively or postoperatively. Preoperative and postoperative rehabilitation should be based on an accurate clinical diagnosis, patients' understanding of their injury, graft tissue biology and biomechanics, surgical technique, the patient's physical demands and expectations, geographical differences in ACL rehabilitation and future perspectives.
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Affiliation(s)
- Sergio R Piedade
- Exercise and Sports Medicine, Department of Orthopedics, Rheumatology, and Traumatology, University of Campinas, UNICAMP, Campinas, SP, 13083-887, Brazil.
| | | | | | - David A Parker
- Sydney Orthopaedic Research Institute, Chatswood, NSW 206, Australia
| | - Nicola Maffulli
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK
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Baird JPE, Anz A, Andrews J, Plummer HA, McGowan B, Gonzalez M, Jordan S. Cellular Augmentation of Anterior Cruciate Ligament Surgery Is Not Currently Evidence Based: A Systematic Review of Clinical Studies. Arthroscopy 2022; 38:2047-2061. [PMID: 34921956 DOI: 10.1016/j.arthro.2021.11.056] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 11/15/2021] [Accepted: 11/30/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To perform a systematic review of clinical outcome studies exploring cellular augmentation of anterior cruciate ligament (ACL) surgery, including stem cell techniques. METHODS A systematic search was performed according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) guidelines using the Cochrane, PubMed, MEDLINE, SPORTDiscus, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases from 2000 to 2019. The inclusion criteria were clinical studies that reported on ACL surgery augmented with stem cells or cellular therapy and patient-reported outcome measures or graft healing. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool. Methodologic assessment was performed according to the Modified Coleman Methodology Score. RESULTS Four studies were found: 2 randomized clinical trials, 1 cohort study with a matched historical control group, and 1 case series. The mean Modified Coleman Methodology Score in these studies was 59, and there was a low risk of bias in 1 study. One study reported outcomes of augmented ACL repair, and 3 studies reported the results of augmented ACL reconstruction. Cellular therapies varied and included concentrated bone marrow aspirate, collagenase/centrifuge processed adipose, and marrow stimulation combined with platelet-rich plasma, as well as cells cultured from allograft bone marrow aspirate. The concentrated bone marrow aspirate and adipose tissue study results did not support their use. The marrow stimulation technique combined with repair led to promising clinical results. The use of allograft cultured cells improved patient-reported outcomes and postoperative radiographic findings. CONCLUSIONS Augmentation of ACL surgery with cellular therapy is not supported by clinical evidence at this time. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Joanne P E Baird
- Bayside Orthopaedics Sports Medicine & Rehab, Fairhope, Alabama, U.S.A
| | - Adam Anz
- Andrews Research & Education Foundation, Gulf Breeze, Florida, U.S.A..
| | - James Andrews
- Andrews Research & Education Foundation, Gulf Breeze, Florida, U.S.A
| | - Hillary A Plummer
- Andrews Research & Education Foundation, Gulf Breeze, Florida, U.S.A
| | - Britt McGowan
- John C. Pace Library, University of West Florida, Pensacola, Florida, U.S.A
| | - Melissa Gonzalez
- John C. Pace Library, University of West Florida, Pensacola, Florida, U.S.A
| | - Steve Jordan
- Andrews Research & Education Foundation, Gulf Breeze, Florida, U.S.A
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Kon E, Di Matteo B, Altomare D, Iacono F, Kurpyakov A, Lychagin A, Timashev P, Kalinsky E, Lipina M. Biologic agents to optimize outcomes following ACL repair and reconstruction: A systematic review of clinical evidence. J Orthop Res 2022; 40:10-28. [PMID: 33586785 DOI: 10.1002/jor.25011] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/03/2021] [Accepted: 02/10/2021] [Indexed: 02/04/2023]
Abstract
Treatment options for anterior cruciate ligament (ACL) injuries have greatly developed over the past decades. Although reconstruction surgery is a concrete reality, stimulation of ACL healing through biological techniques could represent a revolutionary conservative approach. The use of biologic products, such as platelet-rich plasma (PRP) or mesenchymal stem cells (MSCs), to treat partial ruptures or to enhance ligamentization after reconstruction, could thoroughly improve clinical outcomes. The aim of the present paper is to systematically review the available literature on this topic, to (i) describe the current state of the art in available biologic techniques; (ii) clarify the outcomes of their application; (iii) identify areas needing further investigation and possible future development. A systematic review of the literature on the use of biologically active agents (PRP and MSCs) to enhance outcomes of ACL surgery was performed: 31 studies were included. Based on the ACL injury pattern, 6 papers investigated biologic agents in ACL partial tears whereas 25 papers in ACL reconstruction. Sixteen of twenty-five studies dealing with ACL reconstruction were randomized controlled trials, whereas only case series are available for partial ACL tears. Current evidence is still lacking sound data to support the use of biological agents: no clinical superiority has been described when using PRP in ACL reconstruction. Concerning ACL healing in partial tears, the application of PRP has led to encouraging outcomes, but these findings should be confirmed by appropriately designed RCTs.
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Affiliation(s)
- Elizaveta Kon
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Traumatology, Orthopaedics and Disaster Surgery, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Berardo Di Matteo
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Daniele Altomare
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Francesco Iacono
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Anton Kurpyakov
- Department of Traumatology, Orthopaedics and Disaster Surgery, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Aleksey Lychagin
- Department of Traumatology, Orthopaedics and Disaster Surgery, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Peter Timashev
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.,Department of Polymers and Composites, N.N. Semenov Institute of Chemical Physics, Moscow, Russia.,Chemistry Department, Lomonosov Moscow State University, Moscow, Russia.,World-Class Research Center "Digital Biodesign and Personalized Healthcare," Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Eugene Kalinsky
- Department of Traumatology, Orthopaedics and Disaster Surgery, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Marina Lipina
- Department of Traumatology, Orthopaedics and Disaster Surgery, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Angele P, Docheva D, Pattappa G, Zellner J. Cell-based treatment options facilitate regeneration of cartilage, ligaments and meniscus in demanding conditions of the knee by a whole joint approach. Knee Surg Sports Traumatol Arthrosc 2022; 30:1138-1150. [PMID: 33666685 PMCID: PMC9007795 DOI: 10.1007/s00167-021-06497-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/08/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE This article provides an update on the current therapeutic options for cell-based regenerative treatment of the knee with a critical review of the present literature including a future perspective on the use of regenerative cell-based approaches. Special emphasis has been given on the requirement of a whole joint approach with treatment of comorbidities with aim of knee cartilage restoration, particularly in demanding conditions like early osteoarthritis. METHODS This narrative review evaluates recent clinical data and published research articles on cell-based regenerative treatment options for cartilage and other structures around the knee RESULTS: Cell-based regenerative therapies for cartilage repair have become standard practice for the treatment of focal, traumatic chondral defects of the knee. Specifically, matrix-assisted autologous chondrocyte transplantation (MACT) shows satisfactory long-term results regarding radiological, histological and clinical outcome for treatment of large cartilage defects. Data show that regenerative treatment of the knee requires a whole joint approach by addressing all comorbidities including axis deviation, instability or meniscus pathologies. Further development of novel biomaterials and the discovery of alternative cell sources may facilitate the process of cell-based regenerative therapies for all knee structures becoming the gold standard in the future. CONCLUSION Overall, cell-based regenerative cartilage therapy of the knee has shown tremendous development over the last years and has become the standard of care for large and isolated chondral defects. It has shown success in the treatment of traumatic, osteochondral defects but also for degenerative cartilage lesions in the demanding condition of early OA. Future developments and alternative cell sources may help to facilitate cell-based regenerative treatment for all different structures around the knee by a whole joint approach. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Peter Angele
- Sporthopaedicum Regensburg, Hildegard von Bingen Strasse 1, 93053, Regensburg, Germany.
- Department of Trauma Surgery, University Medical Center of Regensburg, Franz Josef Strauss Allee 11, 93042, Regensburg, Germany.
| | - Denitsa Docheva
- Department of Trauma Surgery, University Medical Center of Regensburg, Franz Josef Strauss Allee 11, 93042, Regensburg, Germany
| | - Girish Pattappa
- Department of Trauma Surgery, University Medical Center of Regensburg, Franz Josef Strauss Allee 11, 93042, Regensburg, Germany
| | - Johannes Zellner
- Department of Trauma Surgery, University Medical Center of Regensburg, Franz Josef Strauss Allee 11, 93042, Regensburg, Germany
- Department of Trauma Surgery, Caritas Hospital St. Josef Regensburg, Landshuter Strasse 65, 93053, Regensburg, Germany
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11
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Di Matteo B, Polignano A, Onorato F, La Porta A, Iacono F, Bonanzinga T, Raspugli G, Marcacci M, Kon E. Knee Intraosseous Injections: A Systematic Review of Clinical Evidence of Different Treatment Alternatives. Cartilage 2021; 13:1165S-1177S. [PMID: 32959675 PMCID: PMC8808871 DOI: 10.1177/1947603520959403] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To systematically review the available clinical evidence regarding the safety and efficacy of knee intraosseous injections for the treatment of bone marrow lesions in patients affected by knee osteoarthritis. DESIGN A literature search was carried out on PubMed, Embase, and Google Scholar databases in January 2020. The following inclusion criteria were adopted: (1) studies of any level of evidence, dealing with subchondral injection of bone substitute materials and/or biologic agents; (2) studies with minimum 5 patients treated; and (3) studies with at least 6 months' follow-up evaluation. All relevant data concerning clinical outcomes, adverse events, and rate of conversion to arthroplasty were extracted. RESULTS A total of 12 studies were identified: 7 dealt with calcium phosphate administration, 3 with platelet-rich plasma, and 2 with bone marrow concentrate injection. Only 2 studies were randomized controlled trials, whereas 6 studies were prospective and the remaining 4 were retrospective. Studies included a total of 459 patients treated with intraosseous injections. Overall, only a few patients experienced adverse events and clinical improvement was documented in the majority of trial. The lack of any comparative evaluation versus subchondral drilling alone is the main limitation of the available evidence. CONCLUSIONS Knee intraosseous injections are a minimally invasive and safe procedure to address subchondral bone damage in osteoarthritic patients. They are able to provide beneficial effects at short-term evaluation. More high-quality evidence is needed to confirm their potential and to identify the best product to adopt in clinical practice.
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Affiliation(s)
- Berardo Di Matteo
- First Moscow State Medical University-Sechenov University, Moscow, Russia
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Alberto Polignano
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Francesco Onorato
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Agostino La Porta
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Francesco Iacono
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Tommaso Bonanzinga
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Giovanni Raspugli
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Maurilio Marcacci
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Elizaveta Kon
- Humanitas University, Department of Biomedical Sciences, Milan, Italy
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
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12
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Knapik DM, Evuarherhe A, Frank RM, Steinwachs M, Rodeo S, Mumme M, Cole BJ. Nonoperative and Operative Soft-Tissue and Cartilage Regeneration and Orthopaedic Biologics of the Knee: An Orthoregeneration Network (ON) Foundation Review. Arthroscopy 2021; 37:2704-2721. [PMID: 34353568 DOI: 10.1016/j.arthro.2021.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 02/02/2023]
Abstract
Orthoregeneration is defined as a solution for orthopedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include: drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electro-magnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the knee, including symptomatic osteoarthritis and chondral injuries, as well as injuries to tendon, meniscus, and ligament, including the anterior cruciate ligament. Promising and established treatment modalities include hyaluronic acid (HA) in liquid or scaffold form; platelet-rich plasma (PRP); bone marrow aspirate (BMA) comprising mesenchymal stromal cells (MSCs), hematopoietic stem cells, endothelial progenitor cells, and growth factors; connective tissue progenitor cells (CTPs) including adipose-derived mesenchymal stem cells (AD-MSCs) and tendon-derived stem cells (TDSCs); matrix cell-based therapy including autologous chondrocytes or allograft; vitamin D; and fibrin clot. Future investigations should standardize solution preparations, because inconsistent results reported may be due to heterogeneity of HA, PRP, BMAC, or MSC preparations and regimens, which may inhibit meaningful comparison between studies to determine the true efficacy and safety for each treatment.
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Affiliation(s)
- Derrick M Knapik
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Aghogho Evuarherhe
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Rachel M Frank
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | | | - Scott Rodeo
- HSS Sports Medicine Institute, Hospital for Special Surgery, New York, New York, U.S.A
| | - Marcus Mumme
- Department of Orthopaedics and Traumatology, University Hospital and University Children's Hospital Basel, and Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Brian J Cole
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A..
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13
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Zicaro JP, Garcia-Mansilla I, Zuain A, Yacuzzi C, Costa-Paz M. Has platelet-rich plasma any role in partial tears of the anterior cruciate ligament? Prospective comparative study. World J Orthop 2021; 12:423-432. [PMID: 34189080 PMCID: PMC8223727 DOI: 10.5312/wjo.v12.i6.423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/18/2021] [Accepted: 05/07/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Partial tears of the anterior cruciate ligament (ACL) are frequent, and there is still considerable controversy surrounding their diagnosis, natural history and treatment.
AIM To examine patient-reported outcomes, physical examination and magnetic resonance imaging (MRI) findings of partial ACL tears treated with an intraarticular injection of platelet-rich plasma (PRP) compared to a control group.
METHODS From January 2015 to November 2017, consecutive patients from a single institution with partial ACL tears treated nonoperatively were prospectively evaluated. Partial tears were defined as a positive Lachman test with a clear end-point, a negative pivot-shift and less than 3 mm of side-to-side difference using the KT1000 arthrometer. Patients in group 1 were treated with one intraarticular injection of PRP and specific physical therapy protocol. Control group consisted of patients treated only with physical therapy. Prospective analyzed data included physical examination, Tegner activity level and Lysholm and International Knee Documentation Committee scores. Baseline MRI findings and at 6 mo follow-up were reviewed. Failure was defined as those patients with clinical instability at follow-up that required a subsequent ACL reconstruction.
RESULTS A total of 40 patients where included, 21 treated with PRP injection with a mean follow-up of 25 mo [standard deviation (SD): 3.6] and 19 in the control group with a mean follow-up of 25 mo (SD: 5.68). Overall failure rate was 32.0% (n = 13). No significant differences were observed between groups regarding subjective outcomes, return to sport and failure rate. MRI findings revealed an improvement in the ACL signal in half of the patients of both groups. However, we did not find a significant relationship between MRI findings and clinical outcomes.
CONCLUSION Overall, 95.0% of patients returned to sports at a mean follow-up of 25 mo. Mean time to return to sports was 4 mo. Out of these patients, almost 30.0% in each group had a new episode of instability and required surgery at a median time of 5 mo in group 1 and 8 mo in group 2. The addition of PRP alone was not sufficient to enhance any of the outcome measures evaluated, including MRI images, clinical evaluation and failure rate.
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Affiliation(s)
- Juan Pablo Zicaro
- Knee Division, Hospital Italiano de Buenos Aires, Buenos Aires 1181, Argentina
| | | | - Andres Zuain
- Knee Division, Hospital Italiano de Buenos Aires, Buenos Aires 1181, Argentina
| | - Carlos Yacuzzi
- Knee Division, Hospital Italiano de Buenos Aires, Buenos Aires 1181, Argentina
| | - Matias Costa-Paz
- Knee Division, Hospital Italiano de Buenos Aires, Buenos Aires 1181, Argentina
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14
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Cole BJ, Gilat R, DiFiori J, Rodeo SA, Bedi A. The 2020 NBA Orthobiologics Consensus Statement. Orthop J Sports Med 2021; 9:23259671211002296. [PMID: 34017878 PMCID: PMC8114275 DOI: 10.1177/23259671211002296] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/14/2020] [Indexed: 12/26/2022] Open
Abstract
This 2020 NBA Orthobiologics Consensus Statement provides a concise summary of available literature and practical clinical guidelines for team physicians and players. We recognize that orthobiologic injections are a generally safe treatment modality with a significant potential to reduce pain and expedite early return to play in specific musculoskeletal injuries. The use of orthobiologics in sports medicine to safely reduce time loss and reinjury is of considerable interest, especially as it relates to the potential effect on a professional athlete. While these novel substances have potential to enhance healing and regeneration of injured tissues, there is a lack of robust data to support their regular use at this time. There are no absolutes when considering the implementation of orthobiologics, and unbiased clinical judgment with an emphasis on player safety should always prevail. Current best evidence supports the following: Key Points There is support for the use of leukocyte-poor platelet-rich plasma in the treatment of knee osteoarthritis. There is support for consideration of using leukocyte-rich platelet-rich plasma for patellar tendinopathy. The efficacy of using mesenchymal stromal cell injections in the management of joint and soft tissue injuries remains unproven at this time. There are very few data to suggest that current cell therapy treatments lead to any true functional tissue regeneration. Meticulous and sterile preparation guidelines must be followed to minimize the risk for infection and adverse events if these treatments are pursued.Given the high variability in orthobiologic formulations, team physicians must stay up-to-date with the most recent peer-reviewed literature and orthobiologic preparation protocols for specific injuries.Evidence-based treatment algorithms are necessary to identify the optimal orthobiologic formulations for specific tissues and injuries in athletes.Changes in the regulatory environment and improved standardization are required given the exponential increase in utilization as novel techniques and substances are introduced into clinical practice.
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Affiliation(s)
- Brian J Cole
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Ron Gilat
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA.,Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel
| | - John DiFiori
- Hospital for Special Surgery, New York, New York, USA
| | - Scott A Rodeo
- Hospital for Special Surgery, New York, New York, USA
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
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15
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Alves AFF, de Arruda Miranda JR, de Souza SAS, Pereira RV, de Almeida Silvares PR, Yamashita S, Deffune E, de Pina DR. Texture analysis to differentiate anterior cruciate ligament in patients after surgery with platelet-rich plasma. J Orthop Surg Res 2021; 16:283. [PMID: 33910605 PMCID: PMC8080342 DOI: 10.1186/s13018-021-02437-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/20/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Platelet-rich plasma (PRP) has been used to favor anterior cruciate ligament (ACL) healing after reconstruction surgeries. However, clinical data are still inconclusive and subjective about PRP. Thus, we propose a quantitative method to demonstrate that PRP produced morphological structure changes. METHODS Thirty-four patients undergoing ACL reconstruction surgery were evaluated and divided into control group (sixteen patients) without PRP application and experiment group (eighteen patients) with intraoperative application of PRP. Magnetic resonance imaging (MRI) scans were performed 3 months after surgery. We used Matlab® and machine learning (ML) in Orange Canvas® to texture analysis (TA) features extraction. Experienced radiologists delimited the regions of interest (RoIs) in the T2-weighted images. Sixty-two texture parameters were extracted, including gray-level co-occurrence matrix and gray level run length. We used the algorithms logistic regression (LR), naive Bayes (NB), and stochastic gradient descent (SGD). RESULTS The accuracy of the classification with NB, LR, and SGD was 83.3%, 75%, 75%, respectively. For the area under the curve, NB, LR, and SGD presented values of 91.7%, 94.4%, 75%, respectively. In clinical evaluations, the groups show similar responses in terms of improvement in pain and increase in the IKDC index (International Knee Documentation Committee) and Lysholm score indices differing only in the assessment of flexion, which presents a significant difference for the group treated with PRP. CONCLUSIONS Here, we demonstrated quantitatively that patients who received PRP presented texture changes when compared to the control group. Thus, our findings suggest that PRP interferes with morphological parameters of the ACL. TRIAL REGISTRATION Protocol no. CAAE 56164316.6.0000.5411.
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Affiliation(s)
- Allan Felipe Fattori Alves
- grid.410543.70000 0001 2188 478XMedical School, Sao Paulo State University Julio de Mesquita Filho, Av. Prof. Mário Rubens Guimarães Montenegro, s/n - UNESP - Campus de Botucatu, Botucatu, SP CEP 18618687 Brazil
| | - José Ricardo de Arruda Miranda
- grid.410543.70000 0001 2188 478XInstitute of Bioscience, Sao Paulo State University Julio de Mesquita Filho, R. Prof. Dr. Antônio Celso Wagner Zanin, 250 - Distrito de Rubião Junior, Botucatu, SP CEP 18618687 Brazil
| | - Sérgio Augusto Santana de Souza
- grid.410543.70000 0001 2188 478XInstitute of Bioscience, Sao Paulo State University Julio de Mesquita Filho, R. Prof. Dr. Antônio Celso Wagner Zanin, 250 - Distrito de Rubião Junior, Botucatu, SP CEP 18618687 Brazil
| | - Ricardo Violante Pereira
- grid.410543.70000 0001 2188 478XMedical School, Sao Paulo State University Julio de Mesquita Filho, Av. Prof. Mário Rubens Guimarães Montenegro, s/n - UNESP - Campus de Botucatu, Botucatu, SP CEP 18618687 Brazil
| | - Paulo Roberto de Almeida Silvares
- grid.410543.70000 0001 2188 478XMedical School, Sao Paulo State University Julio de Mesquita Filho, Av. Prof. Mário Rubens Guimarães Montenegro, s/n - UNESP - Campus de Botucatu, Botucatu, SP CEP 18618687 Brazil
| | - Seizo Yamashita
- grid.410543.70000 0001 2188 478XMedical School, Sao Paulo State University Julio de Mesquita Filho, Av. Prof. Mário Rubens Guimarães Montenegro, s/n - UNESP - Campus de Botucatu, Botucatu, SP CEP 18618687 Brazil
| | - Elenice Deffune
- grid.410543.70000 0001 2188 478XMedical School, Sao Paulo State University Julio de Mesquita Filho, Av. Prof. Mário Rubens Guimarães Montenegro, s/n - UNESP - Campus de Botucatu, Botucatu, SP CEP 18618687 Brazil
| | - Diana Rodrigues de Pina
- grid.410543.70000 0001 2188 478XMedical School, Sao Paulo State University Julio de Mesquita Filho, Av. Prof. Mário Rubens Guimarães Montenegro, s/n - UNESP - Campus de Botucatu, Botucatu, SP CEP 18618687 Brazil
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16
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Smith PA, Stannard JP, Bozynski CC, Kuroki K, Cook CR, Cook JL. Patellar Bone-Tendon-Bone Autografts versus Quadriceps Tendon Allograft with Synthetic Augmentation in a Canine Model. J Knee Surg 2020; 33:1256-1266. [PMID: 31461759 DOI: 10.1055/s-0039-1695040] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patellar bone-tendon-bone (pBTB) autografts are often considered the "gold standard" for complete anterior cruciate ligament (ACL) reconstruction and are also associated with significant complications and early-onset knee osteoarthritis (OA). A novel quadriceps tendon allograft with synthetic augmentation, or "internal brace" (QTIB), has been reported to have potential advantages for ACL reconstruction based on animal model data. In this preclinical canine comparison study, we hypothesized that QTIB allograft compared with pBTB autograft would provide superior durability for knee stability, function, and prevention of OA. Under approval from our Institutional Animal Care and Use Committee, adult purpose-bred research hounds (n = 10) underwent arthroscopic complete transection of the ACL followed by either an arthroscopic-assisted all-inside ACL reconstruction using the QTIB allograft (n = 5) or pBTB autograft (n = 5). Contralateral knees were used as nonoperated controls (n = 10). Radiographic and arthroscopic assessments were performed at 2 and 6 months, respectively, after surgery. Anterior drawer, internal rotation, lameness, kinetics, pain, effusion, and comfortable range of knee motion were measured at 2, 3, and 6 months. Biomechanical and histologic assessments were performed at 6 months. All reconstructed knees were stable and had intact ACL grafts 6 months after surgery. At 6 months, QTIB reconstructed knees had significantly less lameness, lower pain, less effusion, and increased range of motion when compared with BTB knees (p < 0.05). BTB knees had significantly higher radiographic OA scores than QTIB knees at 6 months (p < 0.05). Superior outcomes associated with QTIB allograft may be due to the lack of donor site morbidity, the use of a robust tendon graft, and/or protection of the graft from the synthetic augmentation. Robust tendon grafts combined with a synthetic internal brace and platelet-rich plasma (PRP) may allow for more rapid and robust tendon-bone healing and graft "ligamentization," which protects the graft from early failure and rapid OA development that can plague commonly-used allografts.
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Affiliation(s)
- Patrick A Smith
- Department of Orthopedic Surgery, University of Missouri, Columbia, Missouri.,Department of Orthopedic Surgery, Columbia Orthopedic Group, Columbia, Missouri
| | - James P Stannard
- Department of Orthopedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopedics, University of Missouri, Columbia, Missouri
| | - Chantelle C Bozynski
- Department of Orthopedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopedics, University of Missouri, Columbia, Missouri
| | - Keiichi Kuroki
- Thompson Laboratory for Regenerative Orthopedics, University of Missouri, Columbia, Missouri
| | - Cristi R Cook
- Department of Orthopedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopedics, University of Missouri, Columbia, Missouri
| | - James L Cook
- Department of Orthopedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopedics, University of Missouri, Columbia, Missouri
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Kon E, Di Matteo B, Delgado D, Cole BJ, Dorotei A, Dragoo JL, Filardo G, Fortier LA, Giuffrida A, Jo CH, Magalon J, Malanga GA, Mishra A, Nakamura N, Rodeo SA, Sampson S, Sánchez M. Platelet-rich plasma for the treatment of knee osteoarthritis: an expert opinion and proposal for a novel classification and coding system. Expert Opin Biol Ther 2020; 20:1447-1460. [PMID: 32692595 DOI: 10.1080/14712598.2020.1798925] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/17/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Platelet-rich plasma (PRP) is able to modulate the joint environment by reducing the inflammatory distress and promoting tissue anabolism. Therefore, it has gained increasing popularity among clinicians in the treatment of osteoarthritis (OA), and it is currently proposed beside consolidated options such as viscosupplementation. AREAS COVERED A systematic review of all available meta-analyses evaluating intra-articular PRP injections in patients affected by knee OA was performed, to understand how this biologic treatment approach compares to the traditional injective therapies available in clinical practice. Moreover, a novel coding system and 'minimum reporting requirements' are proposed to improve future research in this field and promote a better understanding of the mechanisms of action and indications. EXPERT OPINION The main limitation in the current literature is the extreme variability of PRP products used, with often paucity or even lack of data on the biologic features of PRP, which should not be considered as a simple substance, but rather a 'procedure' requiring accurate reporting of the characteristics of the product but also all preparation and application modalities. This approach will aid in matching the optimal PRP product to specific patient factors, leading to improved outcomes and the elucidation of the cost-effectiveness of this treatment.
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Affiliation(s)
- Elizaveta Kon
- Department of Biomedical Sciences, Humanitas University , Milan, Italy
- Humanitas Clinical and Research Center, IRCCS , Rozzano, Milan, Italy
| | - Berardo Di Matteo
- Department of Biomedical Sciences, Humanitas University , Milan, Italy
- Humanitas Clinical and Research Center, IRCCS , Rozzano, Milan, Italy
- First Moscow State Medical University - Sechenov University , Moscow, Russia
| | - Diego Delgado
- Advanced Biological Therapy Unit, Hospital Vithas San José , Vitoria-Gasteiz, Spain
| | - Brian J Cole
- Department of Orthopaedics, Rush University Medical Center , Chicago, Illinois, USA
| | - Andrea Dorotei
- Department of Biomedical Sciences, Humanitas University , Milan, Italy
- Humanitas Clinical and Research Center, IRCCS , Rozzano, Milan, Italy
| | - Jason L Dragoo
- Department of Orthopedic Surgery, University of Colorado , Englewood, Colorado, USA
| | - Giuseppe Filardo
- Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli , Bologna, Italy
| | - Lisa A Fortier
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University , Ithaca, NY, USA
| | - Alberto Giuffrida
- Department of Biomedical Sciences, Humanitas University , Milan, Italy
- Humanitas Clinical and Research Center, IRCCS , Rozzano, Milan, Italy
| | - Chris H Jo
- Department of Orthopedic Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine , Seoul, Republic of Korea
| | - Jeremy Magalon
- Aix Marseille Univ, INSERM, INRA, C2VN , Marseille, France
- Cell Therapy Laboratory, Hôpital De La Conception, AP-HM, IN, SERM CIC BT , Marseille, France
| | - Gerard A Malanga
- New Jersey Regenerative Institute LLC, Cedar Knolls, NJ; Department of Physical Medicine and Rehabilitation, Rutgers University, New Jersey Medical School , Newark, NJ, USA
| | - Allan Mishra
- Department of Orthopaedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, Menlo Park , CA, USA
| | - Norimasa Nakamura
- Institute for Medical Science in Sports, Osaka Health Science University , Osaka, Japan
| | - Scott A Rodeo
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery , New York, New York, USA
| | - Steven Sampson
- David Geffen School of Medicine at UCLA , Los Angeles, CA, USA
| | - Mikel Sánchez
- Advanced Biological Therapy Unit, Hospital Vithas San José , Vitoria-Gasteiz, Spain
- Arthroscopic Surgery Unit, Hospital Vithas San José , Vitoria-Gasteiz, Spain
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18
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Alentorn-Geli E, Seijas R, Martínez-De la Torre A, Cuscó X, Steinbacher G, Álvarez-Díaz P, Barastegui D, Navarro J, Serra-Renom JM, Nishishinya B, Català J, Laiz P, García-Balletbó M, Cugat R. Effects of autologous adipose-derived regenerative stem cells administered at the time of anterior cruciate ligament reconstruction on knee function and graft healing. J Orthop Surg (Hong Kong) 2020; 27:2309499019867580. [PMID: 31470759 DOI: 10.1177/2309499019867580] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To compare the healing and clinical outcomes of anterior cruciate ligament (ACL) reconstruction between patients with or without intraoperative administration of adipose-derived regenerative stem cells (ADRC). METHODS Between 2013 and 2014, the outcomes of 20 soccer players undergoing ACL reconstruction using bone-patellar tendon-bone autograft infiltrated with ADRC at the end of the procedure were compared to a historical, matched cohort of 19 soccer players undergoing the same procedure without ADRC. Outcomes were obtained at baseline, and 6 and 12 months postop for IKDC (International Knee Documentation Committee), Lysholm, and Lequesne, and at 2, 4, 6, and 12 months postop for VAS (visual analogue scale) for pain and graft maturation to evaluate the ligamentization process (magnetic resonance imaging (MRI)-based). RESULTS Both groups significantly improved the IKDC (p < 0.001 in both groups), Lysholm (p < 0.001 in both groups), Lequesne index (p < 0.001 in both groups), VAS for pain (p = 0.002 for the ADRC and p < 0.001 for the control group), and MRI scores (p < 0.001 in both groups) in the 12 months postop compared to baseline scores. However, there were no significant differences in the improvement of the outcomes between groups across time (p > 0.05). All patients returned to sports after surgery, but 8 (40%) patients in the ADRC and 13 (68.4%) patients in the control group had lower Tegner activity score at 12 months postop. CONCLUSIONS Patients receiving ADRC at the time of ACL reconstruction significantly improved knee function and healing/maturation of the graft at 12 months. However, this improvement was not statistically significant compared to a control group undergoing ACL reconstruction alone.
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Affiliation(s)
- Eduard Alentorn-Geli
- 1 Instituto Cugat, Barcelona, Spain.,2 Mutualidad Catalana de Futbolistas, Real Federación Española de Fútbol, Delegación Cataluña, Barcelona, Spain.,3 Fundación García Cugat, Barcelona, Spain
| | - Roberto Seijas
- 1 Instituto Cugat, Barcelona, Spain.,3 Fundación García Cugat, Barcelona, Spain.,4 Universitat Internacional de Catalunya, Barcelona, Spain
| | - Adrián Martínez-De la Torre
- 5 Institute of Pharmaceutical Sciences, Swiss Federal Institute of Technology, ETH Zurich, Zurich, Switzerland
| | - Xavier Cuscó
- 1 Instituto Cugat, Barcelona, Spain.,3 Fundación García Cugat, Barcelona, Spain
| | - Gilbert Steinbacher
- 2 Mutualidad Catalana de Futbolistas, Real Federación Española de Fútbol, Delegación Cataluña, Barcelona, Spain.,3 Fundación García Cugat, Barcelona, Spain
| | - Pedro Álvarez-Díaz
- 2 Mutualidad Catalana de Futbolistas, Real Federación Española de Fútbol, Delegación Cataluña, Barcelona, Spain.,3 Fundación García Cugat, Barcelona, Spain.,4 Universitat Internacional de Catalunya, Barcelona, Spain
| | - David Barastegui
- 1 Instituto Cugat, Barcelona, Spain.,2 Mutualidad Catalana de Futbolistas, Real Federación Española de Fútbol, Delegación Cataluña, Barcelona, Spain.,3 Fundación García Cugat, Barcelona, Spain
| | - Jordi Navarro
- 1 Instituto Cugat, Barcelona, Spain.,2 Mutualidad Catalana de Futbolistas, Real Federación Española de Fútbol, Delegación Cataluña, Barcelona, Spain.,3 Fundación García Cugat, Barcelona, Spain
| | - José Maria Serra-Renom
- 6 Institute of Aesthetic and Plastic Surgery Dr. Serra-Renom, Hospital Quironsalud, Barcelona, Spain
| | | | | | - Patricia Laiz
- 1 Instituto Cugat, Barcelona, Spain.,3 Fundación García Cugat, Barcelona, Spain
| | | | - Ramón Cugat
- 1 Instituto Cugat, Barcelona, Spain.,2 Mutualidad Catalana de Futbolistas, Real Federación Española de Fútbol, Delegación Cataluña, Barcelona, Spain.,3 Fundación García Cugat, Barcelona, Spain
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19
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Editorial Commentary: Bone Tunnel Grafting for Two-Stage Anterior Cruciate Ligament Revision and the Meaning of Life for an Arthroscopic Surgeon. Arthroscopy 2020; 36:186-188. [PMID: 31864575 DOI: 10.1016/j.arthro.2019.09.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 02/02/2023]
Abstract
Accurate bone tunnel filling in a 2-staged anterior cruciate ligament revision is indubitably fundamental for a successful outcome. Bone autograft is commonly employed and it is usually harvested from the iliac crest: this requires longer surgical time, and donor-site morbidity following bone harvest is a well-known problem. Therefore, strategies to minimize or abolish it have been attempted: the use of allografts may seem promising, but their use is associated with high costs and strict regulatory limitations. Bony substitutes instead represent a new and potentially effective solution: they could help surgeons to fill bone tunnels in an easier and faster way that elicits satisfactory lamellar bone formation within the tunnels, and their use is associated with fewer postoperative complications, such as pain and local hematoma. Evidence from literature suggests that this approach could provide significant advantages over traditional autograft harvesting, with comparable outcomes in terms of bone formation and integration, allowing a correct tunnel placement during revision surgery.
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van Gogh AM, Li X, Youn GM, Alvarez A, Yin S, Chakrabarti MO, McGahan PJ, Chen JL. Arthroscopic Harvesting of Autologous Bone Graft for Use as a Mesenchymal Stem Cell Carrier in Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2019; 9:e45-e50. [PMID: 32021773 PMCID: PMC6993187 DOI: 10.1016/j.eats.2019.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/27/2019] [Indexed: 02/03/2023] Open
Abstract
Anterior cruciate ligament (ACL) tears are detrimental to knee stability and normal function. Although the standard of treatment is an ACL reconstruction, technical improvements are sought to enhance clinical outcomes due to the appreciable failure rate. The use of autologous biologic substances as carriers of stem cells are desirable because of their multipotent properties. Traditionally, the collection of autologous bone grafts is through an open incision of the iliac crest, which causes substantial morbidity to the patient. This Technical Note describes an arthroscopic, minimally invasive collection method of autologous tibial and femoral bone graft to use in backfilling the tunnels during an ACL reconstruction to improve graft incorporation and clinical outcomes.
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Affiliation(s)
- Angelica Marie van Gogh
- Address correspondence to Angelica Marie van Gogh, B.S., Advanced Orthopaedics and Sports Medicine, 450 Sutter St., Suite 400, San Francisco, CA 94108.
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Abstract
PURPOSE OF REVIEW The emergence of cell-based therapies has brought much excitement to the field of orthopedic sports medicine. However, the significant inconsistency of reporting has led to the poor understanding, misinformation, and false expectations for patients and clinicians alike. In this paper, we aim to clarify the available cell-therapy treatments and summarize some of the latest research. RECENT FINDINGS Although this technology is in early development, our understanding of cell biology has grown significantly over the last decade. Furthermore, it is becoming evident that tissue specificity may play a significant role in determining the effectiveness and overall clinical benefit attributed to cell therapy. Cell therapy is an emerging field with tremendous potential for clinically significant benefit. However, in its current state, clinical application of these treatments is limited by federal regulations, variability in formulation, and limited understanding of the biologic activity of various cell formulations.
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Affiliation(s)
- Bijan Dehghani
- Hospital for Special Surgery, 525 East 71 Street, 1st floor, New York, NY 10021 USA
| | - Scott Rodeo
- Hospital for Special Surgery, 525 East 71 Street, 1st floor, New York, NY 10021 USA
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22
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Berdis AS, Veale K, Fleissner PR. Outcomes of Anterior Cruciate Ligament Reconstruction Using Biologic Augmentation in Patients 21 Years of Age and Younger. Arthroscopy 2019; 35:3107-3113. [PMID: 31439458 DOI: 10.1016/j.arthro.2019.05.047] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 05/21/2019] [Accepted: 05/23/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To report on the outcomes of a subset of patients ≤21 years of age after anterior cruciate ligament (ACL) reconstruction coupled with biologic augmentation using platelet-rich plasma (PRP) and a porous collagen carrier. METHODS A cohort of patients was retrospectively reviewed after ACL reconstruction with hamstring autograft tendon. All reconstructive surgeries combined biologic augmentation in which the ACL graft was coupled with PRP contained within porous collagen membrane. Patients were included if they maintained a minimum follow-up period of 24 months. Outcomes were assessed through patient-reported questionnaires and physical examination in the clinical setting. Patient-reported outcomes including International Knee Documentation Committee (IKDC), Lysholm, Tegner, and Single Assessment Numeric Evaluation (SANE) scores were collected. ACL stability was evaluated using Lachman and KT-1000 testing. Patients were also evaluated for return to play at the same level of competition, family history of ACL injury, and time to complete rehabilitation. RESULTS A total of 194 patients were initially eligible; 143 (74%) patients with 151 knees were ultimately evaluated. The average patient age was 16 years; 79 patients were female and 64 were male. Follow-up duration averaged 52 months. IKDC and Lysholm scores averaged 91 and 91; the average SANE score was 94. The KT-1000 side-to-side difference averaged 1.2 mm. The average time to complete physical therapy was 22 weeks, and 132 patients (92%) returned to their preinjury level of competition. There were 23 cases of contralateral ACL injury (15%) and 7 cases of ACL reinjury necessitating revision surgery (5%). CONCLUSIONS Biologic augmentation with hamstring autograft in ACL reconstruction shows a decreased rate of second ACL injury, specifically with regard to ACL revision surgery. The patients in this study also show higher return to preinjury level of competition at a faster rate than other studies have shown. LEVEL OF EVIDENCE Level IV, Therapeutic Case Series.
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Affiliation(s)
- Anthony S Berdis
- Department of Graduate Medical Education, Aultman Hospital, Canton, Ohio, U.S.A..
| | - Kodi Veale
- Crystal Clinic Orthopaedic Center, Bell Chapter of the Hawkins Foundation, Akron, Ohio, U.S.A
| | - Paul R Fleissner
- Crystal Clinic Orthopaedic Center, Bell Chapter of the Hawkins Foundation, Akron, Ohio, U.S.A
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23
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Milano G, Sánchez M, Jo CH, Saccomanno MF, Thampatty BP, Wang JHC. Platelet-rich plasma in orthopaedic sports medicine: state of the art. J ISAKOS 2019. [DOI: 10.1136/jisakos-2019-000274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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24
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Hulet C, Sonnery-Cottet B, Stevenson C, Samuelsson K, Laver L, Zdanowicz U, Stufkens S, Curado J, Verdonk P, Spalding T. The use of allograft tendons in primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:1754-1770. [PMID: 30830297 DOI: 10.1007/s00167-019-05440-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 02/22/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE Graft choice in primary anterior cruciate ligament (ACL) reconstruction remains controversial. The use of allograft has risen exponentially in recent years with the attraction of absent donor site morbidity, reduced surgical time and reliable graft size. However, the published evidence examining their clinical effectiveness over autograft tendons has been unclear. The aim of this paper is to provide a current review of the clinical evidence available to help guide surgeons through the decision-making process for the use of allografts in primary ACL reconstruction. METHODS The literature in relation to allograft healing, storage, sterilisation, differences in surgical technique and rehabilitation have been reviewed in addition to recent comparative studies and all clinical systematic reviews and meta-analyses. RESULTS Early reviews have indicated a higher risk of failure with allografts due to association with irradiation for sterilisation and where rehabilitation programs and post-operative loading may ignore the slower incorporation of allografts. More recent analysis indicates a similar low failure rate for allograft and autograft methods of reconstruction when using non-irradiated allografts that have not undergone chemically processing and where rehabilitation has been slower. However, inferior outcomes with allografts have been reported in young (< 25 years) highly active patients, and also when irradiated or chemically processed grafts are used. CONCLUSION When considering use of allografts in primary ACL reconstruction, use of irradiation, chemical processing and rehabilitation programs suited to autograft are important negative factors. Allografts, when used for primary ACL reconstruction, should be fresh frozen and non-irradiated. Quantification of the risk of use of allograft in the young requires further evaluation. LEVELS OF EVIDENCE III.
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Affiliation(s)
- Christophe Hulet
- Department of Orthopedics and Traumatology, Caen University Hospital, Avenue Cote de Nacre, 14000, Caen, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Ciara Stevenson
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
| | - Kristian Samuelsson
- Sahlgrenska University Hospital, Mölndal, Sweden
- Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lior Laver
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
| | - Urszula Zdanowicz
- Carolina Medical Center, Pory 78, 02-757, Warsaw, Poland
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Suite 300, Pittsburgh, PA, 15219-3110, USA
| | - Sjoerd Stufkens
- Academic Medical Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jonathan Curado
- Department of Orthopedics and Traumatology, Caen University Hospital, Avenue Cote de Nacre, 14000, Caen, France
| | - Peter Verdonk
- Antwerp Orthopedic Center, Monica Hospitals, Antwerp, Belgium
| | - Tim Spalding
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK.
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Abstract
Platelet-rich plasma (PRP) is a promising treatment for musculoskeletal maladies and clinical data to date have shown that PRP is safe. However, evidence of its efficacy has been mixed and highly variable depending on the specific indication. Additional future high-quality large clinical trials will be critical in shaping our perspective of this treatment option. The heterogeneity of PRP preparations, both presently and historically, leads sweeping recommendations about its utility impossible to make. This heterogeneity has also made interpreting existing literature more complicated.
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Affiliation(s)
- Adrian D K Le
- Department of Orthopedic Surgery, Stanford University, 450 Broadway Street, Redwood City, CA 94063, USA
| | - Lawrence Enweze
- Department of Orthopedic Surgery, Stanford University, 450 Broadway Street, Redwood City, CA 94063, USA
| | - Malcolm R DeBaun
- Department of Orthopedic Surgery, Stanford University, 450 Broadway Street, Redwood City, CA 94063, USA
| | - Jason L Dragoo
- Department of Orthopedic Surgery, Stanford University, 450 Broadway Street, Redwood City, CA 94063, USA.
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26
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Le ADK, Enweze L, DeBaun MR, Dragoo JL. Current Clinical Recommendations for Use of Platelet-Rich Plasma. Curr Rev Musculoskelet Med 2018; 11:624-634. [PMID: 30353479 PMCID: PMC6220007 DOI: 10.1007/s12178-018-9527-7] [Citation(s) in RCA: 211] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW This review evaluates current clinical literature on the use of platelet-rich plasma (PRP), including leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP), in order to develop evidence-based recommendations for various musculoskeletal indications. RECENT FINDINGS Abundant high-quality evidence supports the use of LR-PRP injection for lateral epicondylitis and LP-PRP for osteoarthritis of the knee. Moderate high-quality evidence supports the use of LR-PRP injection for patellar tendinopathy and of PRP injection for plantar fasciitis and donor site pain in patellar tendon graft BTB ACL reconstruction. There is insufficient evidence to routinely recommend PRP for rotator cuff tendinopathy, osteoarthritis of the hip, or high ankle sprains. Current evidence demonstrates a lack of efficacy of PRP for Achilles tendinopathy, muscle injuries, acute fracture or nonunion, surgical augmentation in rotator cuff repair, Achilles tendon repair, and ACL reconstruction. PRP is a promising treatment for some musculoskeletal diseases; however, evidence of its efficacy has been highly variable depending on the specific indication. Additional high-quality clinical trials with longer follow-up will be critical in shaping our perspective of this treatment option.
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Affiliation(s)
- Adrian D. K. Le
- Department of Orthopedic Surgery, Stanford University, 450 Broadway St, Redwood City, CA USA
- Lifemark Health Group, Toronto, ON Canada
| | - Lawrence Enweze
- Department of Orthopedic Surgery, Stanford University, 450 Broadway St, Redwood City, CA USA
| | - Malcolm R. DeBaun
- Department of Orthopedic Surgery, Stanford University, 450 Broadway St, Redwood City, CA USA
| | - Jason L. Dragoo
- Department of Orthopedic Surgery, Stanford University, 450 Broadway St, Redwood City, CA USA
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27
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Kia C, Baldino J, Bell R, Ramji A, Uyeki C, Mazzocca A. Platelet-Rich Plasma: Review of Current Literature on its Use for Tendon and Ligament Pathology. Curr Rev Musculoskelet Med 2018; 11:566-572. [PMID: 30203334 PMCID: PMC6220011 DOI: 10.1007/s12178-018-9515-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Platelet-rich plasma (PRP) contains numerous growth factors and cytokines that potentially offer an alternative treatment modality to assist in the healing of multiple musculoskeletal issues. The purpose of this review was to examine the latest literature on the use of PRP for various ligament and tendon pathologies. RECENT FINDINGS Recent literature has shown moderate- to high-quality evidence that PRP can have positive clinical effects in certain conditions such as lateral epicondylitis and rotator cuff tendinopathy. Prospective studies have shown that it can also be useful in the treatment of patella tendinopathy. In summary, we found PRP to have variable success in ligament and tendon pathology; however, it should be considered a viable option in chronic musculoskeletal disease that has failed other treatments. Patient selection, duration of symptoms, and combining with other modalities such as physical therapy should all be taken into consideration in treatment with PRP.
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Affiliation(s)
- Cameron Kia
- University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT, USA.
| | - Joshua Baldino
- University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT, USA
| | - Ryan Bell
- University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT, USA
| | - Alim Ramji
- University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT, USA
| | - Colin Uyeki
- University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT, USA
| | - Augustus Mazzocca
- University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT, USA
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Gobbi A, Whyte GP. Long-term Outcomes of Primary Repair of the Anterior Cruciate Ligament Combined With Biologic Healing Augmentation to Treat Incomplete Tears. Am J Sports Med 2018; 46:3368-3377. [PMID: 30398894 DOI: 10.1177/0363546518805740] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical treatment to repair partial anterior cruciate ligament (ACL) injury without reconstruction has demonstrated inconsistent clinical success. PURPOSE To examine the long-term clinical outcomes of primary ACL repair combined with biologic healing augmentation in patients with symptomatic partial ACL tears. STUDY DESIGN Case series; Level of evidence, 4. METHODS 50 patients (mean age, 29.5 years) with a partial ACL tear and symptomatic knee instability were treated with primary ligament repair in conjunction with marrow stimulation and followed prospectively for a mean duration of 10.2 years (range, 5.3-14.3 years). Comparative analysis of preinjury, preoperative, and postoperative scores using patient-reported assessment instruments was performed to examine clinical outcomes. Correlation of final outcome scores with patient age, type of ACL tear, side-to-side difference in ligamentous laxity, and body mass index (BMI) was performed through use of Spearman rank analysis. RESULTS 44 patients were available for assessment at final follow-up. The median Tegner Activity Scale score of 7 at final follow-up was the same as the preinjury median score of 7 ( P = .128). The mean Marx Activity Scale, International Knee Documentation Committee (IKDC) Subjective, and Lysholm Knee Questionnaire scores were 10.8, 90.4, and 96.2, respectively, at final follow-up. Mean final Knee injury and Osteoarthritis Outcome Score (KOOS) subset assessments of Pain, Symptoms, Activities of Daily Living, Sports, and Quality of Life were 98.6, 97.5, 99.7, 94.3, and 95.6, respectively. Secondary ACL insufficiency occurred in 27% of patients. Clinical outcome scores were similar for all scoring instruments between patients treated for an associated diagnosis of meniscal or articular cartilage injury. No significant correlations of age, BMI, ACL tear type, or laxity and final IKDC Subjective, Lysholm, or KOOS scores were found. Analysis revealed a negative correlation of patient age and Tegner score at preinjury ( rs = -0.333, P = .022) and at final follow-up ( rs = -0.376, P = .013). The mean side-to-side difference in ligamentous laxity of 3.4 mm at short-term follow-up in those patients who developed secondary ACL insufficiency over the duration of follow-up was significantly greater than the mean of 0.9 mm in those who did not ( P = .010). CONCLUSION Primary ACL repair combined with biologic healing augmentation to treat select cases of knee instability secondary to incomplete ACL rupture demonstrated good to excellent long-term outcomes in this cohort for those patients who did not experience secondary ACL insufficiency, with high rates of restoration of knee stability and return to preinjury athletic activities. The rate of secondary treatment for recurrent ACL insufficiency over the course of long-term follow-up was greater than would be expected for primary ACL reconstruction. Greater side-to-side differences in objective findings of ligamentous laxity were identified at shorter term follow-up in the patients who later went on to experience symptomatic secondary ACL insufficiency, compared with those who maintained stability long term.
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Affiliation(s)
- Alberto Gobbi
- Orthopaedic Arthroscopic Surgery International (OASI) Bioresearch Foundation, Milan, Italy
| | - Graeme P Whyte
- Orthopaedic Arthroscopic Surgery International (OASI) Bioresearch Foundation, Milan, Italy.,Cornell University, Weill Medical College, New York, NY, USA.,New York Presbyterian Hospital/Queens, Queens, New York, NY, USA
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Mao G, Qin Z, Li Z, Li X, Qiu Y, Bian W. A tricalcium phosphate/polyether ether ketone anchor bionic fixation device for anterior cruciate ligament reconstruction: Safety and efficacy in a beagle model. J Biomed Mater Res B Appl Biomater 2018; 107:554-563. [PMID: 29722123 DOI: 10.1002/jbm.b.34146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 02/10/2018] [Accepted: 04/09/2018] [Indexed: 01/22/2023]
Affiliation(s)
- Genwen Mao
- Department of Orthopedics Surgery; The First Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shaanxi People's Republic of China
| | - Zili Qin
- Department of Otorhinolaryngology; The First Hospital of Sun Yat-Sen University; Guangzhou People's Republic of China
| | - Zheng Li
- Department of Orthopedics Surgery; Tangdu Hospital of the Fourth Military Medical University; Xi'an Shaanxi People's Republic of China
| | - Xiang Li
- Department of Health Sciences and Technology; ETH Zurich; Zurich Switzerland
- Department of Orthopedics; Hospital of Balgrist University; Zurich Switzerland
| | - Yusheng Qiu
- Department of Orthopedics Surgery; The First Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shaanxi People's Republic of China
| | - Weiguo Bian
- Department of Orthopedics Surgery; The First Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shaanxi People's Republic of China
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What Factors Influence the Biomechanical Properties of Allograft Tissue for ACL Reconstruction? A Systematic Review. Clin Orthop Relat Res 2017; 475:2412-2426. [PMID: 28353048 PMCID: PMC5599386 DOI: 10.1007/s11999-017-5330-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Allograft tissue is used in 22% to 42% of anterior cruciate ligament (ACL) reconstructions. Clinical outcomes have been inconsistent with allograft tissue, with some series reporting no differences in outcomes and others reporting increased risk of failure. There are numerous variations in processing and preparation that may influence the eventual performance of allograft tissue in ACL reconstruction. We sought to perform a systematic review to summarize the factors that affect the biomechanical properties of allograft tissue for use in ACL reconstruction. Many factors might impact the biomechanical properties of allograft tissue, and these should be understood when considering using allograft tissue or when reporting outcomes from allograft reconstruction. QUESTIONS/PURPOSES What factors affect the biomechanical properties of allograft tissue used for ACL reconstruction? METHODS We performed a systematic review to identify studies on factors that influence the biomechanical properties of allograft tissue through PubMed and SCOPUS databases. We included cadaveric and animal studies that reported on results of biomechanical testing, whereas studies on fixation, histologic evaluation, and clinical outcomes were excluded. There were 319 unique publications identified through the search with 48 identified as relevant to answering the study question. For each study, we recorded the type of tissue tested, parameters investigated, and the effects on biomechanical behavior, including load to failure and stiffness. Primary factors identified to influence allograft tissue properties were graft tissue type, sterilization methods (irradiation and chemical processing), graft preparation, donor parameters, and biologic adjuncts. RESULTS Load to failure and graft stiffness varied across different tissue types, with nonlooped tibialis grafts exhibiting the lowest values. Studies on low-dose irradiation showed variable effects, whereas high-dose irradiation consistently produced decreased load to failure and stiffness values. Various chemical sterilization measures were also associated with negative effects on biomechanical properties. Prolonged freezing decreased load to failure, ultimate stress, and ultimate strain. Up to eight freeze-thaw cycles did not lead to differences in biomechanical properties of cadaveric grafts. Regional differences were noted in patellar tendon grafts, with the central third showing the highest load to failure and stiffness. Graft diameter strongly contributed to load-to-failure measurements. Age older than 40 years, and especially older than 65 years, negatively impacted biomechanical properties, whereas gender had minimal effect on the properties of allograft tissue. Biologic adjuncts show potential for improving in vivo properties of allograft tissue. CONCLUSIONS Future clinical studies on allograft ACL reconstruction should investigate in vivo graft performance with standardized allograft processing and preparation methods that limit the negative effects on the biomechanical properties of tissue. Additionally, biologic adjuncts may improve the biomechanical properties of allograft tissue, although future preclinical and clinical studies are necessary to clarify the role of these treatments. CLINICAL RELEVANCE Based on the findings of this systematic review that emphasize biomechanical properties of ACL allografts, surgeons should favor the use of central third patellar tendon or looped soft tissue grafts, maximize graft cross-sectional area, and favor grafts from donors younger than 40 years of age while avoiding grafts subjected to radiation doses > 20 kGy, chemical processing, or greater than eight freeze-thaw cycles.
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Platelet-Rich Plasma as an Autologous and Proangiogenic Cell Delivery System. Mediators Inflamm 2017; 2017:1075975. [PMID: 28845088 PMCID: PMC5563430 DOI: 10.1155/2017/1075975] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 06/20/2017] [Indexed: 12/18/2022] Open
Abstract
Angiogenesis is a key factor in early stages of wound healing and is crucial for the repair of vascularized tissues such as the bone. However, supporting timely revascularization of the defect site still presents a clinical challenge. Tissue engineering approaches delivering endothelial cells or prevascularized constructs may overcome this problem. In the current study, we investigated platelet-rich plasma (PRP) gels as autologous, injectable cell delivery systems for prevascularized constructs. PRP was produced from human thrombocyte concentrates. GFP-expressing human umbilical vein endothelial cells (HUVECs) and human bone marrow-derived mesenchymal stem cells (MSCs) were encapsulated in PRP gels in different proportions. The formation of cellular networks was assessed over 14 days by time-lapse microscopy, gene expression analysis, and immunohistology. PRP gels presented a favorable environment for the formation of a three-dimensional (3D) cellular network. The formation of these networks was apparent as early as 3 days after seeding. Networks increased in complexity and branching over time but were only stable in HUVEC-MSC cocultures. The high cell viability together with the 3D capillary-like networks observed at early time points suggests that PRP can be used as an autologous and proangiogenic cell delivery system for the repair of vascularized tissues such as the bone.
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Abstract
Sports medicine physicians have a keen clinical and research interest in the anterior cruciate ligament (ACL). The biomechanical, biologic, and clinical data researchers generate, help drive injury management and prevention practices globally. The current concepts in ACL injury and surgery are being shaped by technological advances, expansion in basic science research, resurging interest in ACL preservation, and expanding efforts regarding injury prevention. As new methods are being developed in this field, the primary goal of safely improving patient outcomes will be a unifying principle. With this review, we provide an overview of topics currently in controversy or debate, and we identify paradigm shifts in the understanding, management, and prevention of ACL tears.
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Affiliation(s)
| | - Emily Naclerio
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA,Address for correspondence: Dr. Seth L Sherman, Department of Orthopaedic Surgery, University of Missouri, Missouri Orthopaedic Institute, 1100 Virginia Ave., Columbia, MO 65212, USA. E-mail:
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