Platelet-Rich Plasma Augmentation of Arthroscopic Rotator Cuff Repair Lowers Retear Rates and Improves Short-Term Postoperative Functional Outcome Scores: A Systematic Review of Meta-Analyses.

Purpose: The purpose of this study is to conduct a systematic review of meta-analyses of rotator cuff repair using platelet-rich plasma (PRP) to identify whether PRP improves clinical function and rate of tendon retears. We will (1) conduct a systematic review of the current meta-analyses of rotator cuff repair using platelet-rich plasma available in the literature, (2) evaluate the quality of these meta-analyses using the Preferred Reporting Items for Systematic Review (PRISMA) methodology, (3) identify whether PRP improves clinical function and rate of tendon retears, and develop guidance to improve future studies in this area. Methods: We carried out a systematic review of previous meta-analyses published on the clinical outcomes of PRP used in the treatment of rotator cuff tears. We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases, using various combinations of the commercial names of each PRP preparation and "rotator cuff" (with its associated terms), looking specifically at human meta-analysis studies involving the repair of the rotator cuff tendon surgically in the English language. Data validity was assessed and collected on clinical outcomes. Following this, a meta-analysis was undertaken. Results: Thirteen meta-analyses met the inclusion and exclusion criteria. All were considered of similar quality with Oxman-Guyatt index of 9 and PRISMA score of more than 24. A total of 1,800 patients with an average follow up of 12 to 36 months. The use of PRP for arthroscopic rotator cuff tear, when compared with controls, leads to a lower number of retears, improved short-term postoperative scores, and functional outcome. The following postoperative scores were reported: Constant: 12, Simple Shoulder Test: 10, ASES (American Shoulder and Elbow Surgeons): 9, UCLA (University of California, Los Angeles) 11, SANE (Single Assessment Numeric Evaluation) 1, VAS (visual analog scale): 6, and Retears: 13. Subgroup analysis showed that leukocyte content and gel application make no difference in the effectiveness of PRP. VAS score subgroup analysis showed short-term pain relief. Conclusions: Our study shows that PRP is effective in reducing retears after rotator cuff repair and improving functional outcome scores and reducing short-term pain. Level of Evidence: Level III, systematic review of Level I-III studies.

Holding on by a thread: the continuing story of rotator cuff tears.

Rotator cuff tears are a common cause of shoulder pain. The incidence of these tears has increased significantly over the years, with the demands of an increasingly active elderly population. Therefore, a detailed understanding of rotator cuff tears will help doctors manage their patients' condition. This field has rapidly advanced over the past decade and this review provided an insight into the latest developments.

Tissue Engineering for the Ovine Rotator Cuff: Surgical Anatomy, Approach, Implantation and Histology Technique, along with Review of Literature.

Aim: Tissue engineering is a contemporary topic, which is widely discussed in shoulder surgery. The preclinical success of tissue engineering has not yet fully translated to clinical studies. In this study, we present our experience in this subject and discuss measurements to analyze the sheep tissue as comparative model. We also present a comprehensive systematic review of the literature in relation to tissue engineering and rotator cuff. Method: We studied the anatomy, histology and surgical approach of 24 infraspinatus tendons specimens in sheep and focused on certain measurements such as: (1) size of the normal tendon; (2) diameter of the normal footprint; and (3) bone hardness of the footprint using a durometer. Blood from six sheep was obtained and processed to produce platelet rich plasma using both the Harvest Smartprep and Cascade kit. We then outlined an approach to the infraspinatus tendon footprint in preparation for implantation of a biological augmentation material, which was repaired using a double row technique. This was followed by a histological analysis. Results: The average measurements of the footprint were 21 mm ×21 mm, the tendon length was 35.1 mm and the width proximal and distal was 21.9 and 14 mm, respectively. The average bone hardness at the 12, 3, 6, and 9 o'clock position was 64.1, 52.3, 50.1, and 37.7 respectively. Central footprint and lateral edge hardness was 44.8 and 43.4. Only the Harvest Smartprep and using a modified method, was able to produce a platelet concentration factor of 4. The Cascade method was unable to concentrate sheep blood. Conclusion: The sheep model is a suitable tissue for studying the rotator cuff. The researcher must be aware of certain interspecies caveats. Clinical tissue engineering and surgical techniques must be modified in order to be suitable when using sheep model.

Revolving doors of tendinopathy: definition, pathogenesis and treatment.

The ultimate cure for the tendon pathology continues to elude current science. Despite great steps in technology, the causation and treatment is still not clear. The number of different theories and treatment modalities in the literature may confuse clinicians and patients. In this paper we outline the definitions, evolution of pathogenesis and treatment for tendinopathy. By highlighting these, the aim of this paper is to guide the practitioner in counselling and treating their patients.

Metal tolerant bacteria enhanced phytoextraction of lead by two accumulator ornamental species.

Microbially enhanced availability and phytoextraction is a promising technique for phytoremediation of lead (Pb). In this study, Pb resistant strains were isolated and investigated for potential effects on plant growth and Pb phytoextraction. Incubation experiments were carried for inoculated and un-inoculated soil containing different levels of Pb. Results revealed that 20% of the isolated bacteria could tolerate Pb up to 800 mg L-1. Five Pb resistant strains with plant growth promoting (PGP) abilities were evaluated for possible influence on water soluble Pb through soil incubation experiments and significant increase i.e. 1.85- and 1.49-folds in water soluble Pb was observed for NCCP-1848 and NCCP-1862 strains, respectively. Pot experiments indicated significantly higher uptake by Pelargonium hortorum than that by Mesembryanthemum criniflorrum at all levels of soil Pb concentrations with the highest increase (1.9-folds) in plants inoculated with NCCP-1848 followed by NCCP-1862 (1.8-folds increase) compared to the control (Pb and without bacterial strain). The strains NCCP-1848 and NCCP-1862 were identified by 16S rRNA gene sequencing as Microbacterium sp. and Klebsiella sp. The results of present study suggest that Pb resistant plant growth promoting bacteria can serve as an effective bio-inoculant through wide action spectrum for maximizing efficiency of phytoremediation system.

Adolescent Idiopathic Scoliosis.

BACKGROUND: Scoliosis refers to deviation of spine greater than 10 degrees in the coronal plane. Idiopathic Scoliosis is the most common spinal deformity that develops in otherwise healthy children. The sub types of scoliosis are based on the age of the child at presentation. Adolescent idiopathic scoliosis (AIS) by definition occurs in children over the age of 10 years until skeletal maturity. OBJECTIVE: The objective of this review is to outline the features of AIS to allow the physician to recognise this condition and commence early treatment, thereby optimizing patient outcome. METHOD: A thorough literature search was performed using available databases, including Pubmed and Embase, to cover important research published covering AIS. CONCLUSION: AIS results in higher incidence of back pain and discontent with body image. Curves greater than 50 degrees in thoracic region and greater than 30 degrees in lumbar region progress at a rate of 0.5 to 1 degree per year into adulthood. Curves greater than 60 degrees can lead to pulmonary functional deficit. Therefore once the disease is recognized, effective treatment should be instituted to address the deformity and prevention of its long-term sequelae.

Effect of 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide and N-hydroxysuccinimide concentrations on the mechanical and biological characteristics of cross-linked collagen fibres for tendon repair.

Reconstituted type I collagen fibres have received considerable interest as tendon implant materials due to their chemical and structural similarity to the native tissue. Fibres produced through a semi-continuous extrusion process were cross-linked with different concentrations of the zero-length cross-linker 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide (EDC) in combination with N-hydroxysuccinimide (NHS). Tensile properties of the fibres were considered, along with imaging of both surface structure and fibrillar alignment. Resistance of the fibres to bacterial collagenase was investigated and fibre sections seeded with human tendon cells for biological characterization, including cell adhesion and proliferation. The work clearly demonstrated that whilst the concentration of EDC and NHS had no significant effect on the mechanics, a higher concentration was associated with higher collagenase resistance, but also provided a less attractive surface for cell adhesion and proliferation. A lower cross-linking concentration offered a more biocompatible material without reduction in mechanics and with a potentially more optimal degradability.

Hematological profile and risk factors associated with pulmonary tuberculosis patients in Quetta, Pakistan.

OBJECTIVES: Tuberculosis (TB) is a chronic debilitating infectious disease affecting more than one third of the global population. This study was designed to investigate different peripheral blood parameters and risk factors in TB patients. METHODS: A total of 600 (Male, 238 and Female, 362) aging 20-80 Years patients with clinical signs of prolonged cough, chest pain and fever, were evaluated for peripheral blood parameters using hematology analyzer. All the informations related to the disease were collected from the patients and recorded using predesigned questionnaire. RESULTS: Erythrocytic Sedimentation Rate (ESR), Hemoglobin (Hb) and lymphocytes were markedly changed in both sexes. Hemoglobin was recorded lower than normal value in 55% and 53% of male and female population respectively. Total leukocyte count was also lower than normal values in 8% and 6% of male and female respectively. Similarly neutropenia was observed in 5% and 8% cases, while neutrophilia was recorded as 60% and 64% in male and female patients respectively. Lymphocytopenia was also observed in 59% and 43% patients in male and female respectively. Illiteracy, smoking habits, overcrowding and living in shared houses were the main associated risk factors contributing in the enhancement of the disease. CONCLUSION: The disease was present significantly more in females and was relatively higher in older patients. Different hematological parameters like Erythrocytic sedimentation Rate (ESR), platelets and leukocytes work as hallmark and help the clinicians in early diagnosis of the disease. Malnutrition, smoking tobacco, living in shared houses, illiteracy and poverty were the common risk factors contributing to the dissemination of the tuberculosis in the target area population.

Review article: Regenerative techniques for repair of rotator cuff tears.

The failure rate of rotator cuff repair is high. Regenerative techniques using material scaffolds, stem cells, and growth factors help augment repair and regenerate tissue. We reviewed the literature of various regenerative techniques in terms of (1) enhancing the repair process, (2) tissue regeneration, (3) mechanical strength, and (4) clinical outcome.

The effect of platelet-rich plasma on clinical outcomes in lateral epicondylitis.

PURPOSE: To evaluate the evidence for application of platelet-rich plasma (PRP) in lateral epicondylitis. METHODS: We carried out a systematic review of the current evidence on the effects of PRP in lateral epicondylitis on clinical outcomes. We performed a comprehensive search of the PubMed, Medline, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases using various combinations of the commercial names of each PRP preparation and "lateral epicondylitis" (with its associated terms), looking specifically at human studies. Data validity was assessed and collected on clinical outcome. RESULTS: Nine studies met the inclusion criteria, of which 5 were randomized controlled trials. Two cohort studies showed that PRP improved clinical satisfaction scores. One case-control study showed that PRP yielded a significantly greater improvement in symptoms compared with bupivacaine. Two randomized controlled trials compared the effect of injections of PRP and blood. Only 1 of the studies noted a significant difference at the 6-week time point. Three randomized controlled trials compared corticosteroids with PRP. Two of the smaller trials, which had follow-up periods of 6 weeks and 3 months, showed no significant difference between treatment groups. The largest randomized controlled trial found that PRP had significant benefit compared with corticosteroids with regard to pain and Disabilities of the Arm, Shoulder and Hand scores at 1- and 2-year time points. CONCLUSIONS: This review highlights the limited but evolving evidence for the use of PRP in lateral epicondylitis; however, further research is required to understand the concentration and preparation that facilitate the best clinical outcome. Characterizing the timing of the intervention would optimize the health economics behind the decision to treat for the patient and health care provider. LEVEL OF EVIDENCE: Level III, systematic review of Level I to III studies.

Solitary amyloidoma related to THA.

Amyloidoma of soft tissues is rare, and no previously published reports describe it in relation to hip prostheses. This article presents the case of a 78-year-old woman with a medical history of myelodysplasia and mild renal failure who underwent a right-sided metal-on-polyethylene total hip arthroplasty in 2003. She presented to the outpatient clinic with a 1-year history of right anterior thigh pain. On examination, a large proximal anteromedial lump was palpable and was nontender, nonpulsatile, and firm. She had a positive Trendelenburg test but good hip range of motion. Plain radiographs showed signs of osteolysis around the hip prosthesis. Serology showed mildly raised liver function and renal function but a normal erythrocyte sedimentation rate and white blood cell count. Magnetic resonance imaging revealed a large mixed-signal soft tissue mass directly opposing the anterior cortex of the right femur, related to the hip prosthesis, measuring 16×10×7 cm. Associated destruction of the underlying cortex existed. Histological staining of a biopsy of the mass confirmed that the mass contained AL-type amyloid seen in primary amyloidosis. Mean patient age at diagnosis for amyloid tumors of soft tissues is 66 years. By definition, they start as solitary lesions. The types are important: AA type is related to infection and AL type is a primary process. Patients with AL amyloidomas have a poorer prognosis because they have a higher chance of malignancies. Early diagnosis can prevent long-term serious consequences of this condition.

Revision of unicondylar to total knee arthroplasty: a systematic review.

Isolated unicompartmental osteoarthritis in the young patient is a difficult problem to treat; they may be too young to consider total knee arthroplasty due to difficulties with inevitable future revision. Unicompartmental knee arthroplasty is one possible solution as it is perceived by some as being a smaller surgical insult than total knee arthroplasty, with easier revision to total knee arthroplasty than a revision total knee arthroplasty. A total knee arthroplasty performed as a revision unicondylar knee arthroplasty is thought by some authors to have equivalent functional outcomes to a primary total knee replacement.However, there have been several studies suggesting that revision is not as simple as suggested, and that function is not as good as primary total knee arthroplasty.We performed a systematic review of the literature regarding outcomes after revision of a unicondylar knee arthroplasty.Although there are many studies proposing selective use of the unicondylar knee arthroplasty, there are a number of studies highlighting difficulties with revision and poorer outcomes, and, therefore, the unicondylar knee arthroplasty cannot be considered a small procedure that will 'buy time' for the patient, and have results equal to a primary knee arthroplasty when revised. Further controlled studies, ideally randomised, are required before final conclusions can be drawn.

The role of platelet rich plasma in musculoskeletal science.

The idea of using platelet rich plasma (PRP) in medicine has been around since the 1970s. It is only more recently that its use has been employed in the area of musculoskeletal science. Platelet rich plasma in this area has received much media attention being used by many celebrity sports athletes for musculoskeletal injuries. Therefore it is important for the musculoskeletal practitioner to be aware of the concepts surrounding its use and application. In this article we cover what platelet rich plasma is, how it is prepared and administered, its potential clinical application, and what the current literature discusses in the various areas of musculoskeletal science.

Exploring the application of stem cells in tendon repair and regeneration.

PURPOSE: To conduct a systematic review of the current evidence for the effects of stem cells on tendon healing in preclinical studies and human studies. METHODS: A systematic search of the PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, and Embase databases was performed for stem cells and tendons with their associated terminology. Data validity was assessed, and data were collected on the outcomes of trials. RESULTS: A total of 27 preclinical studies and 5 clinical studies met the inclusion criteria. Preclinical studies have shown that stem cells are able to survive and differentiate into tendon cells when placed into a new tendon environment, leading to regeneration and biomechanical benefit to the tendon. Studies have been reported showing that stem cell therapy can be enhanced by molecular signaling adjunct, mechanical stimulation of cells, and the use of augmentation delivery devices. Studies have also shown alternatives to the standard method of bone marrow-derived mesenchymal stem cell therapy. Of the 5 human studies, only 1 was a randomized controlled trial, which showed that skin-derived tendon cells had a greater clinical benefit than autologous plasma. One cohort study showed the benefit of stem cells in rotator cuff tears and another in lateral epicondylitis. Two of the human studies showed how stem cells were successfully extracted from the humerus and, when tagged with insulin, became tendon cells. CONCLUSIONS: The current evidence shows that stem cells can have a positive effect on tendon healing. This is most likely because stem cells have regeneration potential, producing tissue that is similar to the preinjury state, but the results can be variable. The use of adjuncts such as molecular signaling, mechanical stimulation, and augmentation devices can potentially enhance stem cell therapy. Initial clinical trials are promising, with adjuncts for stem cell therapy in development.

Frequency of otitis media in patients of nasal polypi.

BACKGROUND: Otitis media is a common disease encountered in ENT practice. Its incidence has fallen in the developed world. It is expected that nasal polypi causes Eustachian tube dysfunction which in turn leads to negative middle ear pressure causing to develop otitis media with effusion or recurrent otitis media. The objective of this study was to find the frequency of Otitis Media in patients of nasal polypi. SUBJECTS AND METHODS: It was a cross-sectional study. Seventy patients with bilateral nasal polypi were taken for study from OPD of ENT Department, Fauji Foundation Hospital Rawalpindi. Purposive (non-probability) sampling was done keeping p=4%. There were 24 (34.3%) males and 46 (65.7%) females included in the study. Age range was 26-38 years. Tympanometry was done in every patient to look for signs of Otitis media. Duration of study was from 24th Apr 2008 to 30th Jul 2009. RESULTS: In our study, all patients were having bilateral nasal polypi. Age range was between 26 and 38 years. Frequency of patients having retracted tympanic membrane on right side was 25 (35.7%), and those who developed it on left side was 30 (42.9%). However, 35 (50%) of the 70 patients were having retraction of tympanic membrane whether right or left. This shows frequency of otitis media in patients of nasal polypi was found to be 50%. CONCLUSION: Frequency of developing otitis media in patients of nasal polypi is quite high. Nasal problems lead to development of ear diseases.

Sarcoid myositis: a rare presentation.

A 50-year-old lady with a background of Perthes disease and multiple bilateral hip revisions presented with symptoms of right hip pain. She was unable to raise and weight bear on the right leg. Hip examination revealed limited flexion and extension to 15-20 ° due to pain. Her blood tests and x-rays showed no obvious acute problems. She was treated with mobilisation and analgesia, and had a bone scan that revealed no acute issues. Further examination revealed she had generalised weakness in her upper arm. A creatine kinase marker showed a level of over 2000. Therefore, an MRI and a muscle biopsy were done. A diagnosis of sarcoid myositis was made and the patient was put on steroids. She was able to make a full recovery. This case highlights the consideration of rare diseases in more highly complex cases.

Laryngomalacia: an atypical case and review of the literature.

Laryngomalacia is the most common cause of stridor in newborns and infants. Patients usually present with an inspiratory stridor only, although some exhibit other anomalies. To rule out other possible pathologies, bronchoscopy is advisable. However, the authors of some recent studies have advocated the use of fiberoptic laryngoscopy as a more cost-effective and less-invasive alternative. No surgical intervention is required to treat laryngomalacia in most cases. The disease usually resolves spontaneously by the time a patient reaches the age of 24 months. In this article, we describe a case of laryngomalacia that was atypical in that the patient was 10 years old. We also review the literature in an effort to increase awareness of this condition.