Platelet-rich plasma (PRP) augmentation does not result in more favourable outcomes in arthroscopic meniscal repair: a meta-analysis.

BACKGROUND: The efficacy and safety of platelet-rich plasma (PRP) augmentation for arthroscopic meniscal repair is controversial. This meta-analysis compared arthroscopic meniscal repair performed in isolation or augmented with PRP. METHODS: The present study was conducted according to PRISMA 2020 guidelines. Pubmed, Web of Science, Google Scholar and Embase were accessed in August 2021. All the clinical trials which compared arthroscopic meniscal repair performed in isolation or augmented with PRP were included. RESULTS: Eight hundred thirty-seven patients were included: 38% (318 of 837 patients) were women; the mean age of the patients was 35.6 (range, 20.8-64.3) years; the mean follow-up was 26.2 (range, 6-54) months. Similarity was found in analogue scale (VAS) (P = 0.5) and Lysholm (P = 0.9), and International Knee Documentation Committee (IKDC) scores (P = 0.9). Similarity was found in the rate of failure (P = 0.4) and rate of revision (P = 0.07). CONCLUSION: The current published scientific evidence does not support PRP augmentation for arthroscopic meniscal repair.

Impact of Covid-19 on undergraduate and residency training.

BACKGROUND: The covid-19 pandemic has dramatically changed lives of residents and medical students. In particular, the learning process has undergone widely changes, especially due to the rules of social distancing which have forced universities and various institutes to modify lessons, work shifts and internships. PURPOSE: The purpose of our review is to evaluate how the various institutes have faced the covid-19 emergency and guaranteed the perpetuation of the learning process of resident and students. METHODS: A comprehensive search of the medical literature in PubMed and Google Scholar was performed including all the works explaining how the institutes have reorganized teaching for resident and undergraduate students. MAIN FINDINGS: The use of internet for the dissemination of teaching material and educational meetings has built bridges, albeit virtual, between resident and teachers. New techniques for teaching and conducting exams have been introduced. The rotating team system allowed the continuation of the teaching activity in safety. CONCLUSION: Thanks to remodulation of the teach modalities, the massive use of internet platforms, a wise distribution of work shifts, and others, universities and hospitals have not only reduced the impact on the learning process of resident and students but also turn this pandemic into a moment of personal and professional growth for the new generation of healthcare professionals.

An evidence based narrative review on treatment of diabetic foot osteomyelitis.

OBJECTIVE: The diagnosis of diabetic food infection is usually clinical, and its severity is related to location and depth of the lesion, and the presence of necrosis or gangrene. Osteomyelitis of the foot and ankle can be extremely debilitating, and, in the preantibiotic era acute staphylococcal osteomyelitis carried a mortality rate of 50%. The microbiology of diabetic foot osteomyelitis (DFO) is usually polymicrobial. Indeed, gram-negative and gram-positive bacilli can be identified using molecular techniques applied to bone biopsies compared to conventional techniques. The aim of the present study is to report a complete overview regarding medical and surgical management of diabetic foot osteomyelitis (DFO) in combination or alone. MATERIALS AND METHODS: We performed a search in PubMed and Scopus electronic databases (up to January 2019) of articles assessing the epidemiology, diagnostic strategy and pharmacological treatment of diabetic foot infection. In the search strategy, we used various combinations of the following key terms: infection, orthopaedic, diabetic foot, management, DFO. RESULTS: This article discusses the definition, epidemiology, microbiological assessment, clinical evaluation, pharmacological and surgical management and a comparison between them, of DFO. After the initial literature search and removal of duplicate records, a total of 756 potentially relevant citations were identified. After a further screening and according to the inclusion criteria, a total of 65 articles were included in the present review. CONCLUSION: The association of antibiotic and surgical therapy seems to be more effective compared to each one alone. The lack of comparison studies and randomized controlled trials makes it difficult to give information about the efficacy of the different management therapies.

Liposomes for Intra-Articular Analgesic Drug Delivery in Orthopedics: State-of-Art and Future Perspectives. Insights from a Systematic Mini-Review of the Literature.

Background and objectives: Liposomal structures are artificial vesicles composed of one or several lamellae of phospholipids which surround an inner aqueous core. Given the amphoteric nature of phospholipids, liposomes are promising systems for drug delivery. The present review provides an updated synthesis of the main techniques for the production of liposomes for orthopedic applications, focusing on the drawbacks of the conventional methods and on the advantages of high pressure techniques. Materials and Methods: Articles published in any language were systematically retrieved from two major electronic scholarly databases (PubMed/MEDLINE and Scopus) up to March 2020. Nine articles were retained based on the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) guidelines. Results: Liposome vesicles decrease the rate of inflammatory reactions after local injections, and significantly enhance the clinical effectiveness of anti-inflammatory agents providing controlled drug release, reducing toxic side effects. Conclusions: This review presents an update on the improvement in musculoskeletal ailments using liposome treatment.

Immunohistochemical features of rotator cuff tendinopathy.

BACKGROUND: Rotator cuff tendinopathy is a common musculoskeletal ailment in sedentary and athletic individuals. Various mediators of inflammation have been detected in human tendons: they are thought to initiate or progress the course of tendinopathy. SOURCES OF DATA: An online search was conducted using AMED, CINAHL, Embase, The Cochrane Library, PEDro and Pubmed, using the terms tendinopathy, tendon, tendinitis, tendinosis, histology, histopathology, immunohistochemistry, immunohistochemical, rotator cuff and pain. AREAS OF AGREEMENT: Histological examination of tendinopathic tendons shows degeneration of the collagen structure and infiltration of fat and vessels, together with increased expression of inflammatory cytokines, MMP-1, 2, 3, 9, 13, vascular endothelial growth factor and Hypoxia inducible factor (HIF). AREAS OF CONTROVERSY: Most of the studies about this topic exhibited limited validity because of lack of appropriately matched controls and no inclusion or exclusion criteria. The evidence associated with the histopathological analysis of the rotator cuff is limited. GROWING POINTS: The histochemical and immunohistochemical features of rotator cuff tendinopathy are still unclear. A thorough understanding of the vascularity, innervation and biochemical mediators of pain could be used to target rotator cuff pathology, and possibly guide the therapy of painful rotator cuff disorders. AREAS TIMELY FOR DEVELOPING RESEARCH: There is a need for a validated reproducible method of rotator cuff tendon biopsy evaluation. We require further studies with improved designs to effectively evaluate the histological and immunohistochemical features of rotator cuff tendinopathy.

Biomechanical issues of tissue-engineered constructs for articular cartilage regeneration: in vitro and in vivo approaches.

BACKGROUND: Given the limited regenerative capacity of injured articular cartilage, the absence of suitable therapeutic options has encouraged tissue-engineering approaches for its regeneration or replacement. SOURCES OF DATA: Published articles in any language identified in PubMed and Scopus electronic databases up to August 2019 about the in vitro and in vivo properties of cartilage engineered constructs. A total of 64 articles were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. AREAS OF AGREEMENT: Regenerated cartilage lacks the biomechanical and biological properties of native articular cartilage. AREAS OF CONTROVERSY: There are many different approaches about the development of the architecture and the composition of the scaffolds. GROWING POINTS: Novel tissue engineering strategies focus on the development of cartilaginous biomimetic materials able to repair cartilage lesions in association to cell, trophic factors and gene therapies. AREAS TIMELY FOR DEVELOPING RESEARCH: A multi-layer design and a zonal organization of the constructs may lead to achieve cartilage regeneration.

Endoscopic debridement for non-insertional Achilles tendinopathy with and without platelet-rich plasma.

BACKGROUND: When non-operative management fails to improve symptoms in patients with non-insertional Achilles tendinopathy, surgery may be required. Various open and endoscopic techniques have been proposed, and platelet-rich plasma (PRP) injections have been proposed as an adjunct to aid tendon healing. METHODS: Thirty-six patients with mid-portion Achilles tendinopathy were randomized to undergo endoscopic debridement alone (n = 19) or in combination with intraoperative PRP application (n = 17). Clinical outcome measures included the Visual Analogue Scale for pain, function, and satisfaction and the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. Patients were followed-up at 6 weeks, 3 months, 6 months, and 12 months after surgery. An MRI examination at 3 and 12 months was used to assess signal alterations within the tendon. RESULTS: Both groups showed significant clinical improvement (p < 0.05) after surgery, with no difference between the 2 groups. Tendon diameter increased at 3 months and decreased at 12 months. The tendinopathy area increased at 3 months and decreased at 12 months below baseline level in both groups. There was no significant difference between the groups regarding the MRI parameters. Nodular thickening and MRI-detected signal alteration persisted after surgery, with no association between imaging and clinical outcome. Five minor complications were reported: 2 in the PRP group and 3 in the control group. CONCLUSION: Endoscopic debridement of the Achilles tendon improved clinical outcomes in patients with mid-portion tendinopathy. The addition of PRP did not improve outcomes compared to debridement alone. MRI parameters showed no association with clinical outcomes.

Low-Dose NSAIDs Efficacy in Orthopedic Applications.

Non-steroidal anti-inflammatory drugs (NSAIDs) [cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) inhibitors] and COXIBs (the COX-2 selective inhibitors) may induce several potentially severe and life-threatening issues especially in elderly patients. The use of low-dose NSAIDs is associated with lower risk of side effects compared to the standard dosage. Low-dose NSAIDs could minimize the side effects of these drugs while maintaining their clinical efficacy and effectiveness. The present study evaluates the effectiveness and safety of low-dose NSAIDs in musculoskeletal applications.

Platelet-Rich Plasma, Mesenchymal Stem Cell, and Non-metallic Suture-Based Fixation Technique in a Patellar Fracture Nonunion: A Technical Note and Systematic Review.

BACKGROUD: We performed a systematic review on the management of patellar fracture nonunion and report a novel suture-based non-metallic fixation technique associated with platelet-rich plasma and mesenchymal stem cell injections in the management of this injury. METHODS: A systematic search was performed up to August 2020 in PubMed and Scopus electronic databases of scholarly articles evaluating different surgical techniques used for nonunion of patellar fractures, with no restrictions on language or year of publication. Furthermore, we describe our novel non-metallic suture fixation technique and a patient in whom this technique was applied. RESULTS: A total of 9 articles were included in the systematic review. Tension band wiring was the most commonly used procedure (62.7%). Nonoperative procedures (8.1%) resulted in nonunion in all patients. The most common complication after open reduction and internal fixation was infection (7.8%). Our patient at the latest follow-up reported full functional recovery and full extension and flexion of the affected knee with no pain and subjectively normal strength. CONCLUSIONS: The management of patella nonunions is still a challenge. The technique reported here can be used in patellar fracture nonunion, as well as in primary patellar fractures.

Extensor Retinaculum Flap and Fibular Periosteum Ligamentoplasty After Failed Surgery for Chronic Lateral Ankle Instability.

BACKGROUND: The anterior talofibular ligament and the calcaneofibular ligament are 2 of the most frequently injured structures in sports, being damaged in 30% to 45% of all sports injuries. Most reconstructive procedures are successful but can deteriorate with time and can lead to low-grade radiographic degeneration. METHODS: We operated on 26 consecutive patients from 2001 to 2008 who had failed previous surgical procedures for the lateral ligamentous complex of the ankle, with an average of 104 (range, 75-140) months. RESULTS: The overall functional rating was excellent in 14 ankles, good in 10, fair in 1, and poor in 1. Twenty-four patients (92.3%) were satisfied with the procedure and 15 (57.7%) were able to return to their preinjury level of activity. Local complications were detected in 2 patients who presented with skin necrosis; 1 patient developed severe reflex sympathetic dystrophy. CONCLUSION: Revision surgery for the management of failure after surgical treatment of chronic lateral ankle instability is under debate, and the literature is devoid of clinical studies with long-term follow-up. The technique described offers a high rate of long-term excellent and good results, with a low rate of complications and a good rate of return to preinjury level. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Preliminary Experience With a Minimally Invasive Technique for Hallux Valgus Correction With No Fixation.

BACKGROUND: Percutaneous operative techniques for hallux valgus (HV) correction are less damaging to soft tissues and the first metatarsophalangeal joint, and they carry a lower risk of wound complications. We report our preliminary results using a percutaneous technique that allowed correction of the deformity without internal fixation. METHODS: One hundred ninety-five consecutive patients with isolated symptomatic HV were surgically treated using a percutaneous technique without any form of internal fixation, with a mean follow-up of 34.6 months. The American Orthopaedic Foot & Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale score was used for clinical assessment. Radiographic evaluation included pre- and postoperative assessment of the hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), and sesamoid position in weightbearing radiographs. RESULTS: According to the AOFAS score, the patients improved from a preoperative median of 54.7 to 89.6 at 2 years' follow-up (P = .002). Patients were satisfied or very satisfied in 94% of cases at the latest follow-up. A mean radiographic correction of the HVA of 15.5 degrees, of the IMA of 5.4 degrees, and of the DMAA of 5.4 degrees was achieved. The AOFAS global score and every individual parameter improved significantly between pretreatment and latest follow-up (P > .01). A total of 19 (9.7%) complications were reported. CONCLUSION: This percutaneous technique, which did not use any form of internal fixation described, produced durable results for the correction of HV, reliably correcting the deformity and resulting in significant improvement in function and decrease of pain. LEVEL OF EVIDENCE: Level IV, retrospective case series.