Most Orthopaedic Platelet-Rich Plasma Investigations Don't Report Protocols and Composition: An Updated Systematic Review.

PURPOSE: To systematically review the literature to assess the heterogeneity of platelet-rich plasma (PRP) preparation and composition reporting for the treatment of musculoskeletal/orthopaedic pathologies. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify Level I and Level II studies from 2016 to 2022 that evaluated the use of PRP therapy for musculoskeletal pathologies. The search phrase used was "platelet-rich plasma clinical studies." Studies were assessed based on their reporting of the PRP preparation methods and reporting of PRP composition. RESULTS: One hundred twenty-four studies (in 120 articles) met inclusion criteria for analysis. Of these studies, 15 (12.1%) provided comprehensive reporting, including a clear, well-described, and reproducible preparation protocol that future investigators can follow. Thirty-three studies (26.6%) quantitatively reported the final PRP product composition. CONCLUSIONS: Among the studies using PRP for the treatment of musculoskeletal/orthopaedic pathologies, less than 20% provided a clear, well-described, and reproducible PRP preparation protocol, and only one-fourth of studies reported on the final PRP product composition. CLINICAL RELEVANCE: A diverse current reporting of PRP composition between studies provides a high heterogeneity of the term "PRP," which becomes a limitation for a comparison of studies using PRP.

Patients With Knee Osteoarthritis Who Receive Platelet-Rich Plasma or Bone Marrow Aspirate Concentrate Injections Have Better Outcomes Than Patients Who Receive Hyaluronic Acid: Systematic Review and Meta-analysis.

PURPOSE: To systematically review the literature to compare the efficacy and safety of platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), and hyaluronic acid (HA) injections for the treatment of knee osteoarthritis (OA). METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify Level I studies that compared the clinical efficacy of at least 2 of the following 3 injection therapies: PRP, BMAC, and HA for knee OA. The search phrase used was knee AND osteoarthritis AND randomized AND ("platelet rich plasma" OR "bone marrow aspirate" OR "hyaluronic acid"). Patients were primarily assessed based on patient-reported outcome scores (PROs) including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and Subjective International Knee Documentation Committee (IKDC) score. RESULTS: Twenty-seven studies (all Level I) met inclusion criteria, including 1,042 patients undergoing intra-articular injection(s) with PRP (mean age 57.7 years, mean follow-up 13.5 months), 226 patients with BMAC (mean age 57.0 years, mean follow-up 17.5 months), and 1,128 patients with HA (mean age 59.0 years, mean follow-up 14.4 months). Nonnetwork meta-analyses demonstrated significantly better postinjection WOMAC (P < .001), VAS (P < .01), and Subjective IKDC scores (P < .001) in patients who received PRP compared with patients who received HA. Similarly, network meta-analyses demonstrated significantly better postinjection WOMAC (P < .001), VAS (P = .03), and Subjective IKDC (P < .001) scores in patients who received BMAC compared with patients who received HA. There were no significant differences in postinjection outcome scores when comparing PRP with BMAC. CONCLUSIONS: Patients undergoing treatment for knee OA with PRP or BMAC can be expected to experience improved clinical outcomes when compared with patients who receive HA. LEVEL OF EVIDENCE: Level I, meta-analysis of Level I studies.

Knotted Transosseous-Equivalent Technique for Rotator Cuff Repair Shows Superior Biomechanical Properties Compared With a Knotless Technique: A Systematic Review and Meta-analysis.

PURPOSE: To compare the biomechanical properties of the knotted versus knotless transosseous-equivalent (TOE) techniques for rotator cuff repair (RCR). METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using PubMed, Embase, and the Cochrane Library to identify studies that compared the biomechanical properties of knotted and knotless TOE RCR techniques. The search phrase used was as follows: (Double Row) AND (rotator cuff) AND (repair) AND (biomechanical). Evaluated properties included ultimate load to failure, cyclic displacement, stiffness, footprint characteristics, and failure mode. RESULTS: Eight studies met the inclusion criteria, including a total of 67 specimens in each group. Of 6 studies reporting on ultimate load to failure, 4 found tendons repaired with the knotted TOE technique to experience significantly higher ultimate load to failure compared with knotless TOE repairs (knotted range, 323.5-549.0 N; knotless range, 166.0-416.8 N; P < .05). Of 6 studies reporting on failure stiffness, 2 found knotted TOE repairs to have significantly higher failure stiffness compared with knotless TOE repairs (knotted range, 30.0-241.8 N/mm; knotless range, 28.0-182.5 N/mm; P < .05), whereas 1 study found significantly higher failure stiffness in knotless TOE repairs compared with knotted TOE repairs (P = .039). Cyclic gap formation favored the knotted TOE group in 2 of 3 studies (knotted range, 0.6-5.2 mm; knotless range, 0.4-9.1 mm; P < .05). The most common mode of failure in both groups was suture tendon tear. CONCLUSIONS: On the basis of the included cadaveric studies, rotator cuff tendons repaired via the knotted TOE technique display superior time-zero biomechanical properties, including greater ultimate load to failure, compared with rotator cuffs repaired via the knotless TOE technique. Suture tearing through the tendon remains a common failure method for both techniques. CLINICAL RELEVANCE: The results of this systematic review provide helpful insight into the biomechanical differences between 2 popular techniques for RCR. Although these results should be carefully considered by surgeons who are using either of these techniques in the operating room, they should not be mistaken for direct clinical applicability because cadaveric studies may not directly correlate to clinical outcomes.

Shoulder Surgery as an Effective Treatment for Shoulder-Related Sleep Disturbance: A Systematic Review.

PURPOSE: The purpose of this systematic review is to evaluate the current literature in an effort to investigate sleep quality and disturbances and the association with clinical outcomes of patients undergoing shoulder surgery. METHODS: A systematic review of the PubMed, Embase, and Cochrane Library databases was performed according to PRISMA guidelines. All English-language literature reporting clinical outcomes and sleep quality and disturbance after shoulder surgery was reviewed by 2 independent reviewers. Outcomes assessed included patient-reported outcomes (PROs) and sleep quality. Specific PROs included the Pittsburgh Sleep Quality Index (PSQI), Visual Analog Scale (VAS) for pain, Simple Shoulder Test (SST), University of California Los Angeles (UCLA) Shoulder Rating Scale, and American Shoulder and Elbow Surgeons Score (ASES). Study methodology was assessed using the Modified Coleman Methodology Score. Descriptive statistics are presented. RESULTS: Sixteen studies (11 level IV, 2 level III, 3 level II) with a total of 2748 shoulders were included (age, 12-91 years; follow-up, 0.25-132 months). In total, 2198 shoulders underwent arthroscopic rotator cuff repair (RCR), 131 shoulders underwent arthroscopic capsular release, 372 shoulders underwent total shoulder arthroplasty (TSA), 18 shoulders underwent comprehensive arthroscopic management, and 29 shoulders underwent sternoclavicular joint procedures. All shoulder surgeries improved self-reported sleep and PROs from before to after surgery. In RCR patients, PSQI scores were significantly associated with VAS scores, SST scores (r = 0.453, r = -0.490, P < .05, respectively), but not significantly associated with UCLA Shoulder rating scale or the ASES scores (r = 0.04, r = 0.001, P > .05, respectively). In TSA patients, PSQI scores were significantly associated with ASES scores (r = -0.08, P < .05). All 4 RCR studies and 1 TSA study using PSQI found significant improvements in mean PSQI scores within 6 to 24 months (P < .05). CONCLUSIONS: Surgical intervention for rotator cuff tear and glenohumeral osteoarthritis significantly improves self-reported sleep in patients with shoulder pain. However, there remains a dearth of available studies assessing the effects of surgical intervention for adhesive capsulitis, sternoclavicular joint instability, and sternoclavicular osteoarthritis on sleep. Future studies should use sleep-specific PROs and quantitative measures of sleep to further elucidate the relationship between sleep and the effect of shoulder surgery. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Platelet-Rich Plasma Versus Hyaluronic Acid for Hip Osteoarthritis Yields Similarly Beneficial Short-Term Clinical Outcomes: A Systematic Review and Meta-analysis of Level I and II Randomized Controlled Trials.

PURPOSE: To systematically review the literature to compare the efficacy of platelet-rich plasma (PRP) and hyaluronic acid (HA) injections for the treatment of hip osteoarthritis (OA). METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify randomized controlled trials that compared the clinical efficacy of PRP and HA injections for hip OA. The search phrase used was hip, osteoarthritis, platelet-rich plasma, hyaluronic acid, randomized. Patients were assessed based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Visual Analog Scale (VAS) for pain, and the Harris Hip Score (HHS). Subanalyses were performed for any outcome score in which ≥3 studies reported results. RESULTS: Six studies (5 level I, 1 level II) met inclusion criteria, including 211 patients undergoing intra-articular injection with PRP (mean age 60.0 years, mean follow-up 12.2 months) and 197 patients with HA (mean age 62.3 years, mean follow-up 11.9 months). No significant differences were found in the weighted improvement of any outcome score (WOMAC, VAS, or HHS) from preinjection to postinjection between groups. When excluding a study with the highest risk of bias to eliminate heterogeneity, pooled subanalysis demonstrated no significant differences in WOMAC subscores between PRP and HA groups. Similarly, in a pooled subanalysis that isolated patients treated with leukocyte-poor PRP, no significant differences in WOMAC subscores were found between PRP and HA groups. CONCLUSION: Patients undergoing treatment for hip OA with either PRP or HA injections can expect to experience similarly beneficial short-term clinical outcomes. LEVEL OF EVIDENCE: II, systematic review of level I and II studies.

Obesity and sex influence fatty infiltration of the rotator cuff: the Rotator Cuff Outcomes Workgroup (ROW) and Multicenter Orthopaedic Outcomes Network (MOON) cohorts.

BACKGROUND: Fatty infiltration (FI) is one of the most important prognostic factors for outcomes after rotator cuff surgery. Established risk factors include advancing age, larger tear size, and increased tear chronicity. A growing body of evidence suggests that sex and obesity are associated with FI; however, data are limited. METHODS: We recruited 2 well-characterized multicenter cohorts of patients with rotator cuff tears (Multicenter Orthopaedic Outcomes Network [MOON] cohort [n = 80] and Rotator Cuff Outcomes Workgroup [ROW] cohort [n = 158]). We used multivariable logistic regression to evaluate the relationship between body mass index (BMI) and the presence of FI while adjusting for the participant's age at magnetic resonance imaging, sex, and duration of shoulder symptoms, as well as the cross-sectional area of the tear. We analyzed the 2 cohorts separately and performed a meta-analysis to combine estimates. RESULTS: A total of 27 patients (33.8%) in the Multicenter Orthopaedic Outcomes Network (MOON) cohort and 57 patients (36.1%) in the Rotator Cuff Outcomes Workgroup (ROW) cohort had FI. When BMI < 25 kg/m2 was used as the reference category, being overweight was associated with a 2.37-fold (95% confidence interval [CI], 0.77-7.29) increased odds of FI and being obese was associated with a 3.28-fold (95% CI, 1.16-9.25) increased odds of FI. Women were 4.9 times (95% CI, 2.06-11.69) as likely to have FI as men. CONCLUSIONS: Among patients with rotator cuff tears, obese patients had a substantially higher likelihood of FI. Further research is needed to assess whether modifying BMI can alter FI in patients with rotator cuff tears. This may have significant clinical implications for presurgical surgical management of rotator cuff tears. Sex was also significantly associated with FI, with women having higher odds of FI than men. Higher odds of FI in female patients may also explain previously reported early suboptimal outcomes of rotator cuff surgery and higher pain levels in female patients as compared with male patients.

The Anterolateral Ligament of the Knee: An Updated Systematic Review of Anatomy, Biomechanics, and Clinical Outcomes.

PURPOSE: To perform an updated systematic review of the anatomy, biomechanics, function of the anterolateral ligament (ALL), and the clinical outcomes of anterolateral ligament reconstruction (ALLR) when performed in conjunction with anterior cruciate ligament reconstruction (ACLR). METHODS: A systematic search of the literature was performed by searching PubMed, the Cochrane Library, and Embase with the search phrase anterolateral ligament for articles published from February 2017 to May 2020. Inclusion criteria included studies that evaluated the anatomy, function, or biomechanics of the ALL; surgical technique articles on ALLR; clinical articles reporting outcomes of ALLR; studies published in English; and full-text articles. Exclusion criteria included studies published before February 2017. A subjective synthesis was performed, in which ranges were reported, and individual study data were presented in forest plots. RESULTS: Overall, 40 articles were included in this systematic review, with 11 articles describing ALL anatomy, 14 articles analyzing ALL function and biomechanics, 7 articles discussing the surgical technique of combined ACLR and ALLR (ACLR/ALLR), and 8 articles describing the clinical outcomes of ACLR/ALLR. The addition of ALLR in combination with ACLR (ACLR+) results in lower graft failure rates for ACLR/ALLR (0.0%-15.7%) when compared with isolated ACLR (I-ACLR) patients (7.4%-21.7%). Three of 5 studies using the Subjective International Knee Documentation Committee score, 2 of 5 studies using the Lysholm score, and 1 of 2 studies using the Tegner score reported significantly better scores at latest follow-up among ACLR+ patients compared with I-ACLR (P < .05). CONCLUSIONS: The ALL acts as a secondary stabilizer to the anterior cruciate ligament and helps resist internal knee rotation and anterior tibial translation. Based on the current literature, combined ACLR with ALLR may result in lower graft failure rates and improved patient-reported outcomes when compared with I-ACLR in patients with specific indications, although several studies have shown equivalent outcomes between these 2 cohorts. CLINICAL RELEVANCE: The contents of this review provide great insight for orthopaedic surgeons who are performing ACLR and considering additional procedures to increase overall knee stability and decrease likeliness for re-rupture. The postoperative functional and clinical outcomes shown in patients undergoing ACLR+ compared with I-ACLR should be given proper consideration when evaluating available treatment courses.

Tranexamic Acid Use in Knee and Shoulder Arthroscopy Leads to Improved Outcomes and Fewer Hemarthrosis-Related Complications: A Systematic Review of Level I and II Studies.

PURPOSE: To systematically review the literature to compare the efficacy and safety of tranexamic acid (TXA) as a means to minimize hemarthrosis-related complications after arthroscopic procedures of the knee, hip, and shoulder. METHODS: A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed by searching PubMed, Cochrane Library, and Embase databases to locate randomized controlled trials comparing the clinical outcomes and postoperative complications of patients undergoing arthroscopy with and without TXA. Search terms used were "tranexamic acid," "arthroscopy," "knee," "hip," and "shoulder." Patients were evaluated based on early (<6 weeks) postoperative signs of hemarthrosis using the Coupens and Yates classification, postoperative complications (myocardial infarction, stroke, venous thromboembolism events), range of motion (ROM), and patient-reported outcome scores (Visual analog scale, Subjective International Knee Documentation Committee, Lysholm, and Tegner activity scores). RESULTS: Five studies (2 level I and 3 level II) met inclusion criteria, including a total of 299 patients undergoing arthroscopy with TXA and 299 patients without TXA. The average follow-up duration for all patients was 43.9 days. Procedures performed were partial meniscectomy, anterior cruciate ligament reconstruction, and rotator cuff repair. No studies evaluating TXA use in hip arthroscopy were identified. Coupens-Yates hemarthrosis grades significantly improved in the TXA groups across all studies. Three studies found TXA patients to experience significantly less postoperative pain at latest follow-up, 1 study found TXA patients to have significantly better postoperative Lysholm scores, and 1 study found TXA patients to have significantly more ROM at latest follow-up compared with non-TXA patients (P < .05). CONCLUSION: Patients undergoing arthroscopy, particularly arthroscopic meniscectomy, arthroscopic-assisted anterior cruciate ligament reconstruction, and arthroscopic rotator cuff repair, with TXA can be expected to experience improved outcomes and less hemarthrosis-related complications in the early postoperative period compared with non-TXA patients. LEVEL OF EVIDENCE: II, systematic review of level I and II studies.

Male Sex, Western Ontario Shoulder Instability Index Score, and Sport as Predictors of Large Labral Tears of the Shoulder: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study.

PURPOSE: To identify factors predictive of a large labral tear at the time of shoulder instability surgery. METHODS: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects. RESULTS: After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007). CONCLUSIONS: Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. LEVEL OF EVIDENCE: I, prognostic study.

Management of Shoulder Instability in 2020: What, When, and How.

Anterior glenohumeral instability remains a common clinical problem in the athletic and working patient populations, and further, recurrence rates following stabilization surgery continue to be problematic. Over the past 5 years, there have been substantial improvements in the understanding of anterior shoulder instability. To better counsel and treat patients, it is imperative for surgeons to have a comprehensive understanding of the epidemiology of shoulder instability, the anatomy of the glenohumeral joint particularly as it relates to glenoid and humeral head bone loss, surgical indications, and surgical techniques. These critical topics are summarized in an effort to provide a complete guide to managing anterior shoulder instability in 2020.

Biceps tenodesis versus tenotomy: a systematic review and meta-analysis of level I randomized controlled trials.

BACKGROUND: Biceps tenodesis and tenotomy are 2 surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior-to-posterior (SLAP) tears. The purpose of this systematic review was to compare the clinical outcomes and complications of biceps tenodesis and tenotomy for the treatment of LHBT or SLAP pathology during shoulder arthroscopy. METHODS: We performed a systematic review by searching PubMed, the Cochrane Library, and Embase to identify level I randomized controlled trials that compared the clinical outcomes of biceps tenodesis vs. tenotomy. The search phrase used was as follows: biceps tenodesis tenotomy randomized. Patients were assessed based on the American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Constant-Murley score, as well as postoperative range of motion, strength, and cosmetic deformity. RESULTS: Five studies (all level I) met the inclusion criteria, including 236 patients undergoing biceps tenodesis (mean age, 60.3 years) and 232 patients undergoing biceps tenotomy (mean age, 59.7 years). The mean follow-up period was 23.0 months. Overall, 6.8% of tenodesis patients experienced cosmetic deformity at latest follow-up compared with 23.3% of tenotomy patients (P < .001). No differences in Constant-Murley, visual analog scale, or American Shoulder and Elbow Surgeons scores were found between groups in any study, and of all the studies evaluating strength and range of motion at latest follow-up, only 1 found a significant difference between groups, in which tenodesis patients demonstrated significantly increased forearm supination strength (P = .02). One study found tenodesis patients to experience significantly more biceps cramping at 6-month follow-up compared with tenotomy patients (P = .043), although no differences in complication rates at latest follow-up were found in any study. CONCLUSION: Patients undergoing treatment for LHBT or SLAP pathology with either biceps tenodesis or tenotomy can be expected to experience similar improvements in patient-reported and functional outcomes. There is an increased rate of cosmetic deformity in patients undergoing biceps tenotomy compared with tenodesis.

Comparing Hamstring Autograft With Hybrid Graft for Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To systematically review the literature in an effort to compare the demographics and clinical outcomes of patients undergoing anterior cruciate ligament reconstruction (ACLR) with a hamstring tendon autograft (HT) versus an irradiated or nonirradiated hybrid autograft-allograft. METHODS: A systematic review of the PubMed, Cochrane Library, and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All English-language literature that reported general demographics and compared the clinical outcomes of patients undergoing primary ACLR with autograft versus hybrid graft (HG) with a minimum 2-year follow-up was reviewed by 2 independent reviewers. Search terms used were "anterior cruciate ligament" and "hybrid graft." Patients were assessed based on graft failure, anteroposterior laxity, and patient-reported outcomes (Knee Injury and Osteoarthritis Outcome Score, visual analog scale, Subjective International Knee Documentation Committee score, Lysholm, and Tegner scores). Study quality was evaluated with the Modified Coleman Methodology Score and ROBINS-I risk of bias tool. RESULTS: Twelve studies (1 level II, 11 level III) met inclusion criteria (follow-up, 2.0-8.9 years), including 471 patients undergoing ACLR with an irradiated hybrid graft (IH), 89 patients with a nonirradiated hybrid graft, and 829 patients with HT. Graft diameter ranged from 7.5 to 10.0 mm and from 6.5 to 10.0 mm in HG and HT patients, respectively. Overall, graft failure ranged from 0% to 30.0% and from 0% to 28.3% in HG and HT patients, respectively (I2 = 35.9%; 95% confidence interval 0%-74.8%). Among HG patients, graft failure ranged from 0%-30.0% and from 2.4%-4.2% in IH and nonirradiated hybrid graft groups, respectively (I2 = 33.6%; 95% confidence interval, 0%-71.8%). Results for postoperative anteroposterior laxity and patient-reported outcomes were also inconsistent. CONCLUSIONS: Patients undergoing ACLR with HT demonstrate inconsistent differences in clinical outcomes at midterm follow-up compared with IH patients. LEVEL OF EVIDENCE: III, systematic review of level II and III studies.

Adductor Canal Versus Femoral Nerve Block after Anterior Cruciate Ligament Reconstruction: A Systematic Review of Level I Randomized Controlled Trials Comparing Early Postoperative Pain, Opioid Requirements, and Quadriceps Strength.

PURPOSE: To systematically review the literature to compare the adductor canal block (ACB) with the femoral nerve block (FNB) following primary anterior cruciate ligament reconstruction (ACLR) in terms of early postoperative analgesic requirements and postoperative quadriceps strength. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to August 2019 to identify randomized controlled trials that compared postoperative pain and functional outcomes in patients following primary ACLR with ACB versus FNB. The search phrase used was: adductor canal femoral nerve anterior cruciate ligament. Patients were evaluated based on analgesic consumption and quadriceps muscle strength. Study quality and risk of bias were evaluated with the Modified Coleman Methodology Score and Cochrane risk-of-bias tool respectively. RESULTS: Five studies (all Level I evidence) were identified that met inclusion criteria, including 221 patients undergoing primary ACLR with ACB (mean age 26.8 years, 68.3% male) and 221 with FNB (mean age 28.2 years, 67.0% male). Statistical assessment for heterogeneity found for opioid consumption of ACB versus FNB groups was I2 = 97% (P < .0001). There were no significant differences in analgesic consumption within the first 24 hours following surgery between groups except in 1 study, in which patients receiving ACB required significantly greater analgesics (P < .001). Three studies using 3 different techniques to measure strength found patients receiving ACB to have significantly greater quadriceps muscle function within 24 hours of surgery when compared with patients receiving FNB (P < .05). CONCLUSIONS: In patients undergoing ACLR, the ACB may provide similar analgesic requirements, and the included studies suggest a potential advantage in preserving muscle strength at short-term (24-48 hours) follow-up when compared with FNB. However, the differences in muscle strength assessments between studies do not allow for strong conclusions. LEVEL OF EVIDENCE: I, systematic review and meta-analysis of Level I studies.

Prevention of Cutibacterium acnes infection in arthroscopic shoulder surgery: a systematic review.

BACKGROUND: Cutibacterium acnes is a gram-positive anaerobe that can lead to postoperative shoulder infections. The purpose of this study was to determine the incidence of C acnes infections following shoulder arthroscopy and evaluate the efficacy of perioperative antibiotic prophylaxis in the prevention of these infections. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that evaluated the prevalence and clinical indications of C acnes infections after various arthroscopic shoulder surgical procedures. Patients were assessed based on positive culture rates, the contraction of infection, and antibiotic regimens used to prevent infection. RESULTS: A total of 9 studies (1 level I, 5 level II, 1 level III, and 2 level IV) met the inclusion criteria, including a total of 3758 patients with a mean age of 59.9 years (range, 17-87 years) at the time of surgery. The mean follow-up time was 1.6 months (range, 1.0-12.0 months). Overall, 37.3% of patients (173 of 464) had positive C acnes skin and/or joint culture results, and in 0.22% of patients (8 of 3586), a C acnes infection was diagnosed postoperatively. The application of a topical benzoyl peroxide antibiotic in the days leading up to surgery significantly reduced the positive culture rate from 41.6% to 9.6% (P < .001). CONCLUSIONS: C acnes infections occur at a very low rate (0.22%) following shoulder arthroscopy. The application of a topical benzoyl peroxide antibiotic in the days leading up to surgery in combination with preoperative antibiotic prophylaxis significantly reduces the prevalence of C acnes in shoulder arthroscopy patients.

Traumatic Primary Anterior Glenohumeral Joint Dislocation in Sports: A Systematic Review of Operative versus Nonoperative Management.

Anterior shoulder (glenohumeral joint [GHJ]) dislocations are relatively common injuries in sports. Previous studies have evaluated clinical outcomes of operative and nonoperative management for primary traumatic anterior GHJ dislocations. The purpose of this study was to systematically review the literature in an effort to provide a thorough analysis of patients after undergoing closed reduction of a traumatic anterior GHJ dislocation, particularly among the athletic population. Two independent reviewers performed a comprehensive search of PubMed and the Cochrane Library through February 23, 2020. Unfortunately, the quantity and quality of published articles on this subject is very limited. In many studies, younger age (between 21 and 30 years) was associated with greater risk for recurrence of GHJ dislocations. Twelve studies (total N = 753) directly compared outcomes of operative versus nonoperative management. It seems that operative management significantly reduces recurrence rates with patients treated operatively among the young and active population. Operative management should be considered as a treatment option for young and athletic patients presenting with a first-time anterior GHJ dislocation.

Editorial Commentary: How to Treat the Overweight Pediatric Patient.

Obese pediatric patients that incur an anterior cruciate ligament tear have an increased risk of an irreparable meniscal tear. Nevertheless, these patients should be treated the same as normal weight patients because they can do very well with standard anterior cruciate ligament reconstruction techniques and appropriate postoperative physical therapy as well as a delayed return to sports of at least 9 months. Obesity is an ever-increasing issue in the United States. Further work should be done to stem the rise of obesity because 1 consequence is a deleterious effect on meniscal tissue when a ligamentous knee injury occurs.

Knee Osteoarthritis After Single-Bundle Versus Double-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review of Randomized Controlled Trials.

PURPOSE: To systematically review high-quality studies in the literature to compare the postoperative radiographic incidence of knee osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR) with a single-bundle (SB) versus double-bundle (DB) graft. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to locate randomized controlled trials that compared the postoperative progression of knee OA in SB versus DB ACLR patients. The search terms used were "anterior cruciate ligament reconstruction," "single-bundle," "double-bundle," "randomized," and "osteoarthritis." Patients were assessed based on radiographic evaluation (Kellgren-Lawrence [K-L] and objective International Knee Documentation Committee scales) and graft failure. RESULTS: A total of 7 studies (5 Level I and 2 Level II) met the inclusion criteria, including 375 SB and 477 DB ACLR patients with a mean follow-up period of 5.3 years. Graft failure occurred in 3.2% of patients overall (27 of 852), with no significant difference between groups (P = .10). No significant difference in overall K-L grade distribution was found between groups (P = .90). Overall, 15.1% of patients (58 of 383) were given a K-L grade of 2 or greater, including 14.4% in the SB group (31 of 215) and 16.1% in the DB group (27 of 168) (P = .65). Using other, unconventional grading schemes, 2 studies found DB ACLR patients to have significantly fewer signs of radiographic knee OA at follow-up compared with SB ACLR patients (P < .05). CONCLUSIONS: Patients undergoing ACLR with either an SB or DB graft can be expected to experience a similar incidence of postoperative knee OA at midterm follow-up according to the K-L grading system. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

An In-Depth Analysis of Publication Characteristics of Podium Presentations at the Arthroscopy Association of North America Annual Meetings, 2011-2014.

PURPOSE: To determine the publication rate of abstracts presented at the annual meetings of the Arthroscopy Association of North America (AANA) from 2011 through 2014 and to compare the level of evidence (LoE) between published and unpublished studies. METHODS: A comprehensive search was performed using PubMed and Google Scholar for all abstracts given as podium presentations at the 2011 through 2014 AANA Annual Meetings. A publication rate was calculated from all presented abstracts. Each abstract was reviewed to determine the study's LoE (I-V or nonclinical). Among published studies, the average time from presentation to publication was calculated. The journals in which these studies were published were also noted. RESULTS: A total of 290 abstracts were given as podium presentations at AANA Annual Meetings from 2011 through 2014. Of the 290 studies presented, 195 (195/290, 67%) were published in peer-reviewed journals. Of the 195 published studies, 184 (184/195, 94%) were published within 3 years of the meeting date. Studies were most frequently published in Arthroscopy (n = 59) and the American Journal of Sports Medicine (n = 48). The average time from presentation to publication was 12.2 months. Overall, there was no significant difference between published and unpublished studies in terms of LoE (P = .24). CONCLUSIONS: In recent years, studies presented at AANA Annual Meetings have achieved a high publication rate (67%). Based on other studies, this publication rate is comparable to recent American Orthopaedic Society for Sports Medicine (AOSSM) Annual Meetings and is higher than that of AANA Annual Meetings from previous years. The level of evidence of presented studies does not necessarily correlate with eventual publication. CLINICAL RELEVANCE: The publication rate and level of evidence of podium presentations at AANA demonstrate the scientific impact the annual meeting has for peers pursuing orthopaedic research.

Knee Osteoarthritis After Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autograft: A Systematic Review of Randomized Controlled Trials.

PURPOSE: The primary purpose of this study was to systematically review high-quality studies in the literature to compare the postoperative radiographic incidence of knee osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR) with bone-patellar tendon-bone (BPTB) versus hamstring tendon (HT) autograft. The secondary purpose of this study was to compare other symptoms of postoperative knee OA between these 2 groups through patient-reported outcome scores and knee range of motion. METHODS: A systematic review was performed by searching PubMed, Embase, and Cochrane Library to locate randomized controlled trials that compared postoperative progression of knee OA in patients who had undergone ACLR with BPTB versus HT autograft. Search terms used were "anterior cruciate ligament reconstruction," "patellar tendon," "hamstring," "randomized," and "osteoarthritis." Patients were assessed based on radiographic evaluation (Kellgren-Lawrence, Ahlbäck, Fairbank, and the Objective International Knee Documentation Committee scales), patient-reported outcome scores (Knee Injury and Osteoarthritis Outcome Score and visual analog scale scores), graft failure, and active knee flexion and extension deficit. RESULTS: Eight studies (6 Level I, 2 Level II) were identified that met inclusion criteria, including a total of 237 and 268 nonoverlapping patients who had undergone ACLR with BPTB and HT autograft, respectively, with a mean follow-up of 11.5 years (range, 3-16 years). Graft failure was experienced by 7.0% of patients in each group (P = .99). A Kellgren-Lawrence grade ≥2 was found in 52.0% and 51.0% of BPTB and HT autograft patients, respectively (P = .85). An Ahlbäck and Fairbank grade ≥2 was found in 5.0% and 8.4% of BPTB and HT autograft patients, respectively (P = .36). There were no significant differences in any patient-reported outcomes between groups within any study. CONCLUSIONS: Patients undergoing ACLR with BPTB autograft or HT autograft can be expected to experience a similar incidence of postoperative knee OA at long-term follow-up. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

Quadriceps Tendon Autograft for Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review of Comparative Studies With Minimum 2-Year Follow-Up.

PURPOSE: To systematically review the literature in an effort to compare outcomes of patients undergoing primary anterior cruciate ligament reconstruction (ACLR) with a quadriceps tendon (QT) autograft versus a bone-patellar tendon-bone (BPTB) or hamstring tendon (HT) autograft. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to locate studies (Level of Evidence I-III) comparing the clinical outcomes of the QT autograft versus the BPTB or HT autograft in patients undergoing primary ACLR. Patients were evaluated based on graft failure rate, examination of knee laxity, and patient-reported outcome scores. RESULTS: Eight studies (1 Level II, 7 Level III) were identified that met inclusion criteria, including a total of 368 patients undergoing primary ACLR with a QT autograft, 225 with a BPTB autograft, and 150 with an HT autograft. The average follow-up duration for all patients was 2.9 years. Overall, 2.8% of patients (17/603) experienced graft failure. Within the studies that compared the QT versus BPTB autograft, no study found a significant difference in graft failure rate between groups, and the odds ratio for graft failure between QT and BPTB was found to be 1.58 (95% confidence interval: 0.49-5.07; P = .44). Within the studies that compared graft failure rate between the QT and HT autograft, none found significant differences between groups, although a meta-analysis was not performed because of a low number of trials. Two studies found significantly greater postoperative knee laxity in HT patients compared with QT patients (P < .05), although there were no significant differences found in laxity measurements between QT and BPTB patients. CONCLUSIONS: Patients undergoing primary ACLR with either a QT, BPTB, or HT autograft can all be expected to experience improvement in clinical outcomes. QT patients experienced less knee laxity postoperatively compared with HT patients, although no significant differences were found in graft failure rate between groups. LEVEL OF EVIDENCE: Level III, systematic review of Level II and III studies.