The Reverse Fragility Index for Mortality End Points in Randomized Trials Comparing Uncemented and Cemented Hemiarthroplasty for Intracapsular Hip Fractures.

BACKGROUND: Interpreting clinical relevance of randomized clinical trials (RCTs) is challenging when P-values are marginally above or below the P = .05 threshold. This study examined the robustness of statistically insignificant mortality events from RCTs comparing hemiarthroplasty femoral fixation for displaced intracapsular hip fractures through the reverse fragility index (RFI). METHODS: RCTs were identified using Pubmed, OVID/Medline, and Cochrane databases. Mortality endpoints were stratified into 3 categories: (1) within 30-days, (2) within 90-days, and (3) at latest follow-up. The RFI was derived by manipulating reported mortality events utilizing a contingency table while maintaining a constant number of participants. The reverse fragility quotient (RFQ) was quantified by dividing the RFI by the study sample. RESULTS: Eight RCTs (2,494 participants) were included. The median RFI and RFQ within 30-days was 3.0 (interquartile range [IQR]: 3.0 to 6.0) and 0.016 (IQR: 0.015 to 0.021), suggesting nonsignificant findings were contingent on 1.6 mortality events/100 participants. The median RFI and RFQ within 90-days was 6.0 (IQR: 4.0 to 7.0) and 0.028 (IQR: 0.024 to 0.038), suggesting nonsignificant findings were contingent on 2.8 mortality events/100 participants. At latest follow-up, the median RFI and RFQ was 7.0 (IQR: 6.0 to 12.0) and 0.038 (IQR: 0.029 to 0.054), suggesting nonsignificant findings were contingent on only 3.8 mortality events/100 participants. Median loss to follow-up was 16.0 (IQR: 11.0 to 58.0; 228% greater than RFI), and exceeded the RFI in 6/7(85.7%) studies. CONCLUSIONS: A small number of events (median of 7) was required to convert a statistically nonsignificant finding to one that is significant for the endpoint of mortality. The median loss to follow-up exceeded the median RFI by greater than 200%, suggesting methodological limitations such as patient allocation could alter conclusions.

Retrieval Analysis of Titanium Nitride Coatings for Orthopaedic Implants.

BACKGROUND: The first generation of titanium nitride (TiN) coatings for orthopaedic implants was clinically introduced in the 1990s because of their promising biocompatibility, wear resistance, and corrosion resistance. This study evaluated the in vivo performance of early TiN-coated knee and hip implants, focusing on the bearing surfaces and mechanisms of in vivo damage. METHODS: There were 13 TiN-coated implants (5 knee and 8 hip) retrieved from 8 patients as part of a multi-institutional implant retrieval program. The average implantation time was 4.25 years for knees and 17.5 years for hips. Implant revisions occurred for various reasons, including polyethylene wear, loosening, pain, infection, and instability. Components were examined using a semiquantitative scoring method, and surface roughness measurements were performed using white-light interferometry. Surface morphology, chemistry, and particle characterization were also assessed by scanning electron microscopy. RESULTS: For hips, mild corrosion was found on femoral head tapers, along with severe scratching on certain femoral heads. Knee implants exhibited low burnishing and scratching for both mechanisms. Roughness measurements (Sa) were 37.3 nm (interquartile range = 22.0 to 62.4) for hips and 85.3 nm (interquartile range = 66.3 to 110) for knees. The observed scratch depth in both hip and knee implants due to third-body particles ranged from 0.3 to 1.3 µm. The coating coverage remained intact in the majority of the implants, with 2 cases of small, localized cohesive chipping and substrate exposure. CONCLUSIONS: The results of this study confirm the potential in vivo durability of early TiN coatings and will be useful in benchmarking wear tests for modern TiN-coated orthopaedic implants.

Short-Term Surface Damage Mechanisms of Retrieved Highly Cross-Linked Polyethylene Patellar Components.

BACKGROUND: Previous retrieval studies of patellar components for total knee arthroplasty focused on historical designs and polyethylene materials that are no longer clinically relevant. Therefore, this study aimed to compare revision reasons and surface damage mechanisms of conventional, gamma inert sterilized polyethylene and highly cross-linked polyethylene (HXLPE) patellar components in contemporary designs from a single manufacturer. METHODS: A total of 114 gamma inert and 76 HXLPE patellar components were gathered in a multicenter orthopaedic implant retrieval program. Patient age and body mass index were similar between cohorts (P = .27 and P = .42, respectively); however, the gamma inert cohort was implanted longer (µdifference = 3.1 years; P = .005). A matched subset was created based on the total knee arthroplasty design, patellar shape, and implantation time. Revision reasons were gathered from revision operating notes, and surface damage was examined via the Hood scoring method. Differences between HXLPE and gamma inert cohorts were evaluated using Mann-Whitney U-tests. RESULTS: The most common revision reasons were infection, loosening, and instability, with the most common patellar complication resulting in revision being patellar loosening for both cohorts with similar incidences for both (chi-square; P = .60, P = .59). The most common surface damage modes were burnishing, scratching, and pitting in both cohorts. Total surface damage was significantly higher in the gamma inert components (P = .02), but not in the matched subset (P = .46). CONCLUSION: Overall, the clinical performance of HXLPE was similar to that of conventional polyethylene for patellar components with short implantation times. While this study provides much needed information on the performance of HXLPE patellae in short-term retrievals, long-term studies are still needed.

Fretting Corrosion, Third-Body Polyethylene Damage, and Cup Positioning in Primary vs Revision Dual Mobility Total Hip Arthroplasty.

BACKGROUND: Dual mobility (DM) articulations were introduced for total hip arthroplasty to reduce the risk of instability for patients who have a high risk of dislocation. The use of DM constructs in both primary and revision total hip arthroplasty has been steadily increasing, leading to concerns regarding potential risks of fretting corrosion, polyethylene wear, metal release, and failure due to component positioning. METHODS: A total of 56 retrieved DM constructs were collected. The inner and outer polyethylene liner surfaces were assessed for 7 damage mechanisms, and fretting corrosion was evaluated for the femoral stem, head, and modular liner. Three polyethylene liners with the greatest amounts of embedded debris were examined using scanning electron microscopy. Energy-dispersive X-ray spectroscopy was used to determine the elemental content of the debris. Acetabular cup orientation was analyzed radiographically using the EBRA (Einzel-Bild-Roentgen-Analyse) method. RESULTS: The devices were revised most frequently for infection (36%), loosening (21%), and instability/dislocation (18%). The most common polyethylene damage mechanisms were scratching, pitting, burnishing, and embedded debris, and no difference in total damage was found between primary and revision cases. Scanning electron microscopy/energy-dispersive X-ray spectroscopy revealed that debris morphology and composition were consistent with porous titanium coating, resulting from cup loosening or broken screws and augments. A total of 71% and 50% of the constructs were determined to be within the Lewinnek safe zone for inclination and anteversion, respectively. CONCLUSION: The most notable mechanisms of surface damage were due to third-body debris, especially for the polyethylene surfaces which articulate against cobalt-chromium femoral heads and acetabular liners. Scratching of the femoral head and the metal liner from this debris may support the clinical use of ceramic for DM bearing surfaces in the future.

What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections?

BACKGROUND: Thorough irrigation and debridement using an irrigation solution is a well-established treatment for both acute and chronic periprosthetic joint infections (PJIs). In the absence of concrete data, identifying the optimal irrigation agent and protocol remains challenging. METHODS: A thorough review of the current literature on the various forms of irrigations and their additives was performed to evaluate the efficacy and limitations of each solution as pertaining to pathogen eradication in the treatment of PJI. As there is an overall paucity of high-quality literature comparing irrigation additives to each other and to any control, no meta-analyses could be performed. The literature was therefore summarized in this review article to give readers concise information on current irrigation options and their known risks and benefits. RESULTS: Antiseptic solutions include povidone-iodine, chlorhexidine gluconate, acetic acid, hydrogen peroxide, sodium hypochlorite, hypochlorous acid, and preformulated commercially available combination solutions. The current literature suggests that intraoperative use of antiseptic irrigants may play a role in treating PJI, but definitive clinical studies comparing antiseptic to no antiseptic irrigation are lacking. Furthermore, no clinical head-to-head comparisons of different antiseptic irrigants have identified an optimal irrigation solution. CONCLUSION: Further high-quality studies on the optimal irrigation additive and protocol for the management of PJI are warranted to guide future evidence-based decisions.

Gamer's Health Guide: Optimizing Performance, Recognizing Hazards, and Promoting Wellness in Esports.

Electronic sports (esports), or competitive video gaming, is a rapidly growing industry and phenomenon. While around 90% of American children play video games recreationally, the average professional esports athlete spends 5.5 to 10 h gaming daily. These times and efforts parallel those of traditional sports activities where individuals can participate at the casual to the professional level with the respective time commitments. Given the rapid growth in esports, greater emphasis has been placed on identification, management, and prevention of common health hazards that are associated with esports participation while also focusing on the importance of health promotion for this group of athletes. This review outlines a three-point framework for sports medicine providers, trainers, and coaches to provide a holistic approach for the care of the esports athlete. This esports framework includes awareness and management of common musculoskeletal and health hazards, opportunities for health promotion, and recommendations for performance optimization.

Skin closure with 2-octyl cyanoacrylate and polyester mesh after primary total knee arthroplasty offers superior cosmetic outcomes and patient satisfaction compared to staples: a prospective trial.

INTRODUCTION: The goals of this study were to compare patient satisfaction and wound-related complications in patients receiving 2-octyl cyanoacrylate (glue) and polyester mesh for skin closure after primary total knee arthroplasty (TKA) versus staples. METHODS: A total of 60 knees in 54 patients undergoing TKA were enrolled in a prospective trial and randomized to receive either skin closure with glue and polyester mesh (n = 30) or a control group closed with staples (n = 30). Hollander wound cosmesis score (measured on a scale of 0-5, with 0 being the best) and visual analog scale (VAS) scores (range 0-100 mm) for patient satisfaction with wound cosmesis, as well as wound-related readmission, reoperation, and complications, including superficial surgical site infection, wound dehiscence, wound hematoma, stitch abscess, and wound discharge, were assessed at 6 weeks and 90 days after TKA. Baseline characteristics were not statistically significantly different between the groups (p > 0.05). RESULTS: At 6 weeks and 90 days, the Hollander wound cosmesis score was significantly lower (p < 0.01) in the glue and polyester mesh groups. Similarly, at 6 weeks and 90 days, the VAS for patient satisfaction with wound cosmesis was significantly higher (p < 0.01) in the glue and polyester mesh groups. The rate of superficial surgical site infection was 1/30 (3%) in glue and polyester mesh groups versus zero in the control group (p = 1.00). The rate of wound dehiscence was 1/30 (3%) in glue and polyester mesh groups versus zero in the control group (p = 1.00). CONCLUSION: These results suggest that glue and polyester mesh closure may offer superior cosmetic outcomes to staples for skin closure in TKA.

Cementless Posteriorly Stabilized Total Knee Arthroplasty: Seven-Year Minimum Follow-Up Report.

BACKGROUND: The purpose of this study is to evaluate (1) implant survivorship; (2) patient outcomes; (3) complications; and to (4) perform a radiographic analysis of cementless posteriorly stabilized total knee arthroplasty (TKA) patients at a minimum of 7-year follow-up. METHODS: Our original cohort was composed of 114 consecutive cementless posteriorly stabilized total knee arthroplasties (110 patients) performed by a single surgeon between 2008 and 2010. Since our original report, 4 (1 bilateral) patients died and 2 were lost to follow-up. Therefore, there were 104 patients who had 107 knees available for final follow-up. The final cohort included 43 men and 61 women, who had a mean age of 69 years (range 47-87) and were followed from 7 to 9 years (mean 8 years). Patient outcomes and complications were obtained from electronic medical records. Radiographic assessment was done using the Knee Society Radiographic Evaluation System. RESULTS: The all-cause survivorship was 98% (95% confidence interval 1.01-0.96). Since the original report, there has been 1 post-traumatic loosening of the tibial baseplate, and 1 revision for instability. There were no femoral revisions or patella revisions. The mean Knee Society pain score was 93 points (range 80-100) and the function score was 78 points (range 68-95). Excluding revisions, there was no evidence of progressive loosening of any implant components. CONCLUSION: Based on these 7-year minimum follow-ups, femoral, tibial, and patellar cementless hydroxylapatite-coated beaded implants perform well at up to 9 years postoperatively and offer surgeons and patients a cementless option that may provide long-lasting biological fixation.

The Effect of Surgical Technique and Spacer Texture on Bone Regeneration: A Caprine Study Using the Masquelet Technique.

BACKGROUND: The Masquelet-induced-membrane technique is a commonly used method for treating segmental bone defects. However, there are no established clinical standards for management of the induced membrane before grafting. QUESTIONS/PURPOSES: Two clinically based theories were tested in a chronic caprine tibial defect model: (1) a textured spacer that increases the induced-membrane surface area will increase bone regeneration; and (2) surgical scraping to remove a thin tissue layer of the inner induced-membrane surface will enhance bone formation. METHODS: Thirty-two skeletally mature female goats were assigned to four groups: smooth spacer with or without membrane scraping and textured spacer with or without membrane scraping. During an initial surgical procedure (unilateral, left tibia), a defect was created excising bone (5 cm), periosteum (9 cm), and muscle (10 g). Segments initially were stabilized with an intramedullary rod and an antibiotic-impregnated polymethylmethacrylate spacer with a smooth or textured surface. Four weeks later, the spacer was removed and the induced-membrane was either scraped or left intact before bone grafting. Bone formation was assessed using micro-CT (total bone volume in 2.5-cm central defect region) as the primary outcome; radiographs and histologic analysis as secondary outcomes, with the reviewer blinded to the treatment groups of the samples being assessed 12 weeks after grafting. All statistical tests were performed using a linear mixed effects model approach. RESULTS: Micro-CT analysis showed greater bone formation in defects with scraped induced membrane (mean, 3034.5 mm3; median, 1928.0 mm3; quartile [Q]1-Q3, 273.3-2921.1 mm3) compared with defects with intact induced membrane (mean, 1709.5 mm3; median, 473.8 mm3; Q1-Q3, 132.2-1272.3 mm3; p = 0.034). There was no difference in bone formation between textured spacers (mean, 2405.5 mm3; median, 772.7 mm3; Q1-Q3, 195.9-2743.8 mm3) and smooth spacers (mean, 2473.2 mm3; median, 1143.6 mm3; Q1-Q3, 230.2-451.1 mm3; p = 0.917). CONCLUSIONS: Scraping the induced-membrane surface to remove the innermost layer of the induced-membrane increased bone regeneration. A textured spacer that increased the induced-membrane surface area had no effect on bone regeneration. CLINICAL RELEVANCE: Scraping the induced membrane during the second stage of the Masquelet technique may be a rapid and simple means of improving healing of segmental bone defects, which needs to be confirmed clinically.

Similar Healthcare Utilization and 1-Year Patient-Reported Outcomes between Cemented and Cementless Primary Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

Cementless fixation for total knee arthroplasty (TKA) has gained traction with the advent of newer fixation technologies. This study assessed (1) healthcare utilization (length of stay (LOS), nonhome discharge, 90-day readmission, and 1-year reoperation); (2) 1-year mortality; and (3) 1-year joint-specific and global health-related patient-reported outcome measures (PROMs) among patients who received cementless versus cemented TKA. Patients who underwent cementless and cemented TKA at a single institution (July 2015-August 2018) were prospectively enrolled. A total of 424 cementless and 5,274 cemented TKAs were included. The cementless cohort was propensity score-matched to a group cemented TKAs (1:3-cementless: n = 424; cemented: n = 1,272). Within the matched cohorts, 76.9% (n = 326) cementless and 75.9% (n = 966) cementless TKAs completed 1-year PROMs. Healthcare utilization measures, mortality and the median 1-year change in knee injury and osteoarthritis outcome score (KOOS)-pain, KOOS-physical function short form (PS), KOOS-knee related quality of life (KRQOL), Veteran Rand (VR)-12 mental composite (MCS), and physical composite (PCS) scores were compared. The minimal clinically important difference (MCID) for PROMs was calculated. Cementless TKA exhibited similar rates of median LOS (p = 0.109), nonhome discharge disposition (p = 0.056), all-cause 90-day readmission (p = 0.226), 1-year reoperation (p = 0.597), and 1-year mortality (p = 0.861) when compared with cemented TKA. There was no significant difference in the median 1-year improvement in KOOS-pain (p = 0.370), KOOS-PS (p = 0.417), KOOS-KRQOL (p = 0.101), VR-12-PCS (p = 0.269), and VR-12-MCS (p = 0.191) between the cementless and cemented TKA cohorts. Rates of attaining MCID were similar in both cohorts for assessed PROMs (p > 0.05, each) except KOOS-KRQOL (cementless: n = 313 (96.0%) vs. cemented: n = 895 [92.7%]; p = 0.036). Cementless TKA provides similar healthcare-utilization, mortality, and 1-year PROM improvement versus cemented TKA. Cementless fixation in TKA may provide value through higher MCID improvement in quality of life. Future episode-of-care cost-analyses and longer-term survivorship investigations are warranted.

Effect of liner offset and inclination on cement retention strength of metal-in-metal acetabular constructs: A biomechanical study.

Cementing metallic liners into well-fixed acetabular shells facilitates utilizing dual-mobility cups in revision total hip arthroplasty without shell replacement. The current biomechanical study investigated the effect of increasing cemented liner (a) inclination; and (b) offset on the cement retention strength measured as the lever-out moment at cement failure. Eighteen metallic liner prototypes were cemented into cluster-hole acetabular shells at variable inclinations (0°, 10°, and 20°) and offsets (0 and 10 mm) relative to the enclosing acetabular shell (6 groups; n = 3 constructs per group). The constructs were connected to a material testing frame, and lever-out failure moments were tested through an established protocol. Failure occurred at the liner-cement interface (18/18). There was no correlation between liner inclination and the lever-out failure moment (r = -0.327, P = .185). Liner offset demonstrated a strong negative correlation to mean lever-out failure moments (r = -0.788, P < .001). There was no significant difference between mean lever-out failure moments at variable liner inclinations, regardless of offset (P = .358). Greater liner offset was associated with diminished mean lever-out failure moments (P < .001). Compared with neutral (0° inclination, 0 mm offset), the maximum inclination and offset group had the lowest mean lever-out failure moment (P = .011). Cemented metal-in-metal constructs are significantly affected by the liner positioning. While a correlation between liner inclination and cement retention strength could not be asserted, cement retention strength is significantly diminished by increased liner offset.

Survivorship and Functional Outcomes of Cementless versus Cemented Total Knee Arthroplasty: A Meta-Analysis.

The purpose of this meta-analysis was to assess the evidence supporting the use of cementless versus cemented total knee arthroplasties (TKAs). Specifically, we evaluated (1) all-cause survivorship, (2) aseptic survivorship, and (3) functional outcomes (Knee Society Scores [KSS], Oxford Knee Scores, Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] scores, and ranges of motion [ROMs]). A literature search was performed for studies that evaluated cementless versus cemented TKAs published between 2000 and 2017. Selected studies included three randomized controlled trials, three retrospective observational studies, and one prospective observational study that met the following criteria: (1) primary TKAs, (2) compared cementless and cemented TKAs, (3) implant survivorship that described the causes of failure, and (4) at least one functional outcome. To compare the two cohorts, pooled odds ratios (OR) and 95% confidence intervals (95% CI) were used to calculate tibial and femoral implant survivorship, and pooled mean differences (MD) and 95% CI calculated the functional scores and ROMs. Based on pooled data from the few number of studies, cementless TKAs had a better all-cause survivorship (OR = 0.37; 95% CI, 0.15-0.92) and tended to have a better aseptic survivorship (OR = 0.44; 95% CI, 0.17-1.14). However, this is likely due to the 83.3% weight of the single cementless study potentially influencing the analysis. There were no differences in terms of KSS knee (MD = 1.03; 95% CI, -1.13-3.20) or function scores (MD = 5.36; 95% CI, -3.75-14.51), Oxford knee scores (MD = 0.36; 95% CI, -3.84-4.56), or WOMAC scores (MD = 0.62; 95% CI, -0.87-2.11). Moreover, there was no difference in ROMs (MD = 1.47; 95% CI, -0.11-3.05). Cementless TKA had a better all-cause survivorship when compared with cemented fixation, and similar functional outcomes were demonstrated. However, these findings are based on only a few number of studies (n = 7). Therefore, additional prospective, randomized control trials need to be performed to best compare cementless versus cemented outcomes.

Postoperative Infection in Cementless and Cemented Total Knee Arthroplasty: A Propensity Score Matched Analysis.

The ongoing debate on fixation in total knee arthroplasty (TKA) has become increasingly relevant with its increased use in a younger patient population and the advent of novel cementless prostheses. Recent literature suggests modern cementless implants are comparable to their cemented counterparts in terms of survivorship and functional outcomes. What has not been well-assessed is whether the two modalities differ with respect to infection rates which was the purpose of this study. Specifically, a propensity score matched study population was used to compare: (1) overall infection; (2) prosthetic joint infection (PJI); and (3) surgical site infection (SSI) rates between cementless and cemented TKAs. Using a large institutional database, 3,180 consecutive primary TKAs were identified. Cementless and cemented TKA patients were propensity score matched by age (p = 0.069), sex (p = 0.395), body mass index (BMI; p = 0.308), and Charlson's comorbidity index (CCI) score (p = 0.616) in a 1:1 ratio. Univariate analysis was performed to compare 2-year overall infection rates. Infections were further analyzed separately as PJIs (deep joint infections requiring surgery) and SSIs (skin/superficial wound infections). Multivariate logistic regression was performed to evaluate infection incidences after adjusting for procedure-related factors (i.e., operative time, hospital volume, and surgeon volume). There were no significant differences between the matched cohorts in terms of overall infection rates (3.8 vs. 2.3%, p = 0.722), as well as when PJI (p = 1.000) and SSI (p = 1.000) rates were analyzed separately. Multivariate analysis revealed no significant differences in overall postoperative infection rates (p = 0.285), PJI rates (p = 0.446), or SSI rates (p = 0.453) even after adjusting for procedure-related factors. There is increasing literature investigating various outcomes demonstrating the comparable efficacies of cementless versus cemented TKAs. To the best of the author's knowledge, this was the first matched case-control study to directly compare their post-operative infection rates. The findings from this study show that post-operative infection rates were similar between fixation modalities even after accounting for a range of patient- and procedure-related factors.

Are Subchondral Intraosseous Injections Effective and Safe for the Treatment of Knee Osteoarthritis? A Systematic Review.

Knee osteoarthritis (OA) is a highly prevalent disease and treatment options for early stages of OA are needed. Intraosseous injections of bone substitute and biologic materials have been proposed to expand the therapeutic arsenal by potentially halting OA progression and delaying the need for knee arthroplasty in patients with early/moderate-stage disease. Therefore, the goal of this study was assessed the efficacy and safety of subchondral intraosseous injection for the treatment of knee OA. A systematic review was performed on PubMed-Medline, and the Cochrane Database of systematic reviews. English and Spanish retrospective and prospective studies assessing the results of subchondral intraosseous injection of bone substitute materials and/or biologicals in human patients with knee OA, with a minimum of 6 months of follow-up were collected. A total of 1,081 potential articles were identified through our search. Six studies were included with a total of 163 patients. The mean follow-up was 18 months (range: 6-24 months). Patient reported outcomes measures (PROMs), complications, and conversion to total knee arthroplasty (TKA) were collected. All six studies showed PROMs improvement relative to baseline. Overall, the five studies reporting visual-analog scale (VAS) pain outcomes improved from a baseline mean score of 6.68 to 2.74. Also, knee injury and osteoarthritis score (KOOS), Tegner-Lysholm, and/or international knee documentation committee (IKDC) scores rose compared with baseline scores in all studies. Overall, 2.5% (4/163) of patients had a complication attributed to study-related treatment. Most patients (81%, 86/106) remained TKA-free at a 1-year follow-up. Subchondral intraosseous injections of bone substitute materials and platelet-rich plasma (PRP) suggest (1) improved PROMs of pain and functional status, (2) low complication rate, and (3) relatively low rates of conversion to TKA. However, the current studies investigating these treatments exhibited high degree of heterogeneity in both measurement of outcomes and delivery of treatment, with a high risk of bias. This procedure should not be utilized in advanced knee OA. In light of the limitations of the current literature, advising in favor or against this therapy for early to moderate knee OA is challenging.

A Call for Standardization in Platelet-Rich Plasma Preparation Protocols and Composition Reporting: A Systematic Review of the Clinical Orthopaedic Literature.

BACKGROUND: Platelet-rich plasma (PRP) is a blood-derived preparation whose use has grown exponentially in orthopaedic practice. However, there remains an unclear understanding of the biological properties and effects of PRP on musculoskeletal healing. Heterogeneous processing methods, unstandardized nomenclature, and ambiguous classifications make comparison among studies challenging. A comprehensive assessment of orthopaedic clinical PRP trials is key to unraveling the biological complexity of PRP, while improving standardized communication. Toward this goal, we performed a systematic review of the PRP preparation protocols and PRP composition utilized in clinical trials for the treatment of musculoskeletal diseases. METHODS: A systematic review of the literature was performed from 2006 to 2016. Inclusion criteria were human clinical trials, English-language literature, and manuscripts that reported on the use of PRP in musculoskeletal/orthopaedic conditions. Basic-science articles, editorials, surveys, special topics, letters to the editor, personal correspondence, and nonorthopaedic applications (including cosmetic use or dental application studies) were excluded. RESULTS: A total of 105 studies (in 104 articles) met the inclusion criteria for analysis. Of these studies, only 11 (10%) provided comprehensive reporting that included a clear description of the preparation protocol that could be used by subsequent investigators to repeat the method. Only 17 studies (16%) provided quantitative metrics on the composition of the final PRP product. CONCLUSIONS: Reporting of PRP preparation protocols in clinical studies is highly inconsistent, and the majority of studies did not provide sufficient information to allow the protocol to be reproduced. Furthermore, the current reporting of PRP preparation and composition does not enable comparison of the PRP products being delivered to patients. A detailed, precise, and stepwise description of the PRP preparation protocol is required to allow comparison among studies and provide reproducibility.