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.

Autograft Demonstrates Superior Outcomes for Revision Anterior Cruciate Ligament Reconstruction When Compared With Allograft: A Systematic Review.

BACKGROUND: Multiple studies have compared outcomes among patients undergoing revision anterior cruciate ligament reconstruction (ACLR) with autograft versus allograft, but these data are inconsistently reported and long-term outcomes depending on graft type are yet to be determined. PURPOSE: To perform a systematic review of clinical outcomes after revision ACLR (rACLR) with autograft versus allograft. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of the literature was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that compared the outcomes of patients undergoing rACLR with autograft versus allograft. The search phrase used was autograft allograft revision anterior cruciate ligament reconstruction. Graft rerupture rates, return-to-sports rates, anteroposterior laxity, and patient-reported outcome scores (subjective International Knee Documentation Committee, Tegner, Lysholm, and Knee injury and Osteoarthritis Outcome Score) were evaluated. RESULTS: Eleven studies met inclusion criteria, including 3011 patients undergoing rACLR with autograft (mean age, 28.9 years) and 1238 patients undergoing rACLR with allograft (mean age, 28.0 years). Mean follow-up was 57.3 months. The most common autograft and allograft types were bone-patellar tendon-bone grafts. Overall, 6.2% of patients undergoing rACLR experienced graft retear, including 4.7% in the autograft group and 10.2% in the allograft group (P < .0001). Among studies that reported return-to-sports rates, 66.2% of patients with an autograft returned to sports as opposed to 45.3% of patients with an allograft (P = .01). Two studies found significantly greater postoperative knee laxity in the allograft group as compared with the autograft group (P < .05). Among all patient-reported outcomes, 1 study found 1 significant difference between groups: patients with an autograft had a significantly higher postoperative Lysholm score when compared with patients with an allograft. CONCLUSION: Patients undergoing revision ACLR with an autograft can be expected to experience lower rates of graft retear, higher rates of return to sports, and less postoperative anteroposterior knee laxity when compared with patients undergoing revision ACLR with an allograft.

Immobilization in External Rotation Versus Arthroscopic Stabilization After Primary Anterior Shoulder Dislocation: A Systematic Review of Level 1 and 2 Studies.

BACKGROUND: Arthroscopic stabilization has been established as a superior treatment option for primary glenohumeral instability when compared with immobilization in internal rotation. However, immobilization in external rotation (ER) has recently gained interest as a viable nonoperative treatment option for patients with shoulder instability. PURPOSE: To compare the rates of recurrent instability and subsequent surgery in patients undergoing treatment for primary anterior shoulder dislocation with arthroscopic stabilization versus immobilization in ER. STUDY DESIGN: Systematic review; Level of evidence, 2. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that'evaluated patients being treated for primary anterior glenohumeral dislocation with either arthroscopic stabilization or immobilization in ER. The search phrase used various combinations of the keywords/phrases "primary closed reduction,""anterior shoulder dislocation,""traumatic,""primary,""treatment,""management,""immobilization,""external rotation,""surgical,""operative,""nonoperative," and "conservative." Inclusion criteria included patients undergoing treatment for primary anterior glenohumeral joint dislocation with either immobilization in ER or arthroscopic stabilization. Rates of recurrent instability, subsequent stabilization surgery, return to sports, positive postintervention apprehension tests, and patient-reported outcomes were evaluated. RESULTS: The 30 studies that met inclusion criteria included 760 patients undergoing arthroscopic stabilization (mean age, 23.1 years; mean follow-up time, 55.1 months) and 409 patients undergoing immobilization in ER (mean age, 29.8 years; mean follow-up time, 28.8 months). Overall, 8.8% of operative patients experienced recurrent instability at latest follow-up compared with 21.3% of patients who had undergone ER immobilization (P < .0001). Similarly, 5.7% of operative patients had undergone a subsequent stabilization procedure at latest follow-up compared with 11.3% of patients who had undergone ER immobilization (P = .0015). A higher rate of return to sports was found in the operative group (P < .05), but no other differences were found between groups. CONCLUSION: Patients undergoing arthroscopic treatment for primary anterior glenohumeral dislocation with arthroscopic stabilization can be expected to experience significantly lower rates of recurrent instability and subsequent stabilization procedures compared with patients undergoing ER immobilization.

Isolated Osteotomy Versus Combined Osteotomy and Cartilage Repair for Osteoarthritis or Focal Chondral Defects of the Medial Compartment of the Knee Joint: A Systematic Review.

Background: The extent to which concomitant cartilage repair provides an improvement in clinical outcomes after osteotomy is unclear. Purpose: To compare studies reporting clinical outcomes after isolated osteotomy with or without cartilage repair for osteoarthritis (OA) or focal chondral defects (FCDs) of the knee joint. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, Cochrane Library, and Embase databases. The search was done to identify comparative studies that directly compared outcomes between isolated osteotomy-high tibial osteotomy or distal femoral osteotomy-and osteotomy with concomitant cartilage repair for OA or FCDs of the knee joint. Patients were evaluated based on reoperation rate, magnetic resonance observation of cartilage repair tissue score, macroscopic International Cartilage Regeneration & Joint Preservation Society score, and patient-reported outcomes. Results: In total, 6 studies-level 2 evidence (n = 2);, level 3 evidence (n = 3);, and level 4 evidence (n = 1)-met the inclusion criteria, including a total of 228 patients undergoing osteotomy alone (group A) and 255 patients undergoing osteotomy with concomitant cartilage repair (group B). The mean patient age was 53.4 and 54.8 years, respectively, and the mean preoperative alignment was 6.6° and 6.7° of varus in groups A and B, respectively. The mean follow-up time was 71.5 months. All studies assessed medial compartment lesions with varus deformity. One study compared osteotomy alone for patients with medial compartment OA versus osteotomy with autologous chondrocyte implantation for patients with FCDs of the medial compartment. Three other studies included a heterogeneous cohort of patients with OA and FCDs in both groups. Only 1 study isolated its comparison to patients with medial compartment OA and 1 study isolated its comparison to patients with FCDs. Conclusion: There is limited evidence with substantial heterogeneity between studies on clinical outcomes after osteotomy alone versus osteotomy with cartilage repair for OA or FCDs of the knee joint. At this time, no conclusion can be made regarding the role of additional cartilage procedures in treating medial compartment OA or FCDs. Further studies are needed that isolate specific disease pathology and specific cartilage procedures.

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.

Cartilage Repair of the Tibiofemoral Joint With Versus Without Concomitant Osteotomy: A Systematic Review of Clinical Outcomes.

Background: The extent to which concomitant osteotomy provides an improvement in clinical outcomes after cartilage repair procedures is unclear. Purpose: To review the existing literature to compare clinical outcomes of patients undergoing cartilage repair of the tibiofemoral joint with versus without concomitant osteotomy. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify studies that directly compared outcomes between cartilage repair of the tibiofemoral joint alone (group A) versus cartilage repair with concomitant osteotomy (high tibial osteotomy [HTO] or distal femoral osteotomy [DFO]) (group B). Studies on cartilage repair of the patellofemoral joint were excluded. The search terms used were as follows: osteotomy AND knee AND ("autologous chondrocyte" OR "osteochondral autograft" OR "osteochondral allograft" OR microfracture). Outcomes in groups A and B were compared based on reoperation rate, complication rate, procedure payments, and patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score [KOOS], visual analog scale [VAS] for pain, satisfaction, and WOMAC). Results: Included in the review were 5 studies (1 level 2 study, 2 level 3 studies, 2 level 4 studies) with 1747 patients in group A and 520 patients in group B. The mean patient ages were 34.7 and 37.5 years in groups A and B, respectively, and the mean lesion sizes were 4.0 and 4.5 cm2, respectively. The mean follow-up time was 44.6 months. The most common lesion location was the medial femoral condyle (n = 999). Preoperative alignment averaged 1.8° and 5.5° of varus in groups A and B, respectively. One study found significant differences between groups in KOOS, VAS, and satisfaction, favoring group B. The reoperation rates were 47.4% and 17.3% in groups A and B, respectively (P < .0001). Conclusion: Patients undergoing cartilage repair of the tibiofemoral joint with concomitant osteotomy might be expected to experience greater improvement in clinical outcomes with a lower reoperation rate compared with those undergoing cartilage repair alone. Surgeons preparing for cartilage procedures of the knee joint should pay particular attention to preoperative malalignment of the lower extremity to optimize outcomes.

Effects of Running on the Development of Knee Osteoarthritis: An Updated Systematic Review at Short-Term Follow-up.

Background: Some studies have suggested that running increases the risk of knee osteoarthritis (OA), while others believe it serves a protective function. Purpose: To perform an updated systematic review of the literature to determine the effects of running on the development of knee OA. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify studies evaluating the effect of cumulative running on the development of knee OA or chondral damage based on imaging and/or patient-reported outcomes (PROs). The search terms used were "knee AND osteoarthritis AND (run OR running OR runner)." Patients were evaluated based on plain radiographs, magnetic resonance imaging (MRI), and PROs (presence of knee pain, Health Assessment Questionnaire-Disability Index, and the Knee injury and Osteoarthritis Outcome Score). Results: Seventeen studies (6 level 2 studies, 9 level 3 studies, and 2 level 4 studies), with 7194 runners and 6947 nonrunners, met the inclusion criteria. The mean follow-up time was 55.8 months in the runner group and 99.7 months in the nonrunner group. The mean age was 56.2 years in the runner group and 61.6 years in the nonrunner group. The overall percentage of men was 58.5%. There was a significantly higher prevalence of knee pain in the nonrunner group (P < .0001). Although 1 study found a significantly higher prevalence of osteophytes in the tibiofemoral (TF) and patellofemoral (PF) joints within the runner group, multiple studies found no significant differences in the prevalence of radiographic knee OA (based on TF/PF joint-space narrowing or Kellgren-Lawrence grade) or cartilage thickness on MRI between runners and nonrunners (P > .05). One study found a significantly higher risk of knee OA progressing to total knee replacement among nonrunners (4.6% vs 2.6%; P = .014). Conclusion: In the short term, running is not associated with worsening PROs or radiological signs of knee OA and may be protective against generalized knee pain.

Shoulder Stabilization Versus Immobilization for First-Time Anterior Shoulder Dislocation: A Systematic Review and Meta-analysis of Level 1 Randomized Controlled Trials.

BACKGROUND: Multiple studies have compared redislocation rates after stabilization and immobilization for patients experiencing a traumatic, first-time anterior shoulder dislocation (ASD). PURPOSE: To systematically review the literature to compare rates of recurrent instability and subsequent instability surgery in patients undergoing treatment for a first-time ASD with surgical stabilization versus shoulder immobilization. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 1. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify level 1 randomized studies that compared outcomes of surgical stabilization versus immobilization for treatment of primary ASD. The following search phrase was used: (glenohumeral OR anterior shoulder) AND (conservative OR nonoperative OR nonsurgical OR physiotherapy) AND (Bankart OR repair OR stabilization OR surgical OR surgery OR arthroscopic OR arthroscopy) AND (instability OR dislocation). Patients with soft tissue disruption alone as well as those with additional minor bony lesions (Hill-Sachs, Bankart) were included. Recurrent instability and subsequent instability surgery rates, the Western Ontario Shoulder Instability Index (WOSI), and range of motion were evaluated. RESULTS: A total of 5 studies met inclusion criteria, including 126 patients undergoing surgical stabilization (mean age, 23.6 years; range, 15.0-39.0 years) and 133 patients undergoing treatment with sling immobilization only (mean age, 23.1 years; range, 15.0-31.0 years). Mean follow-up was 59.7 months. Overall, 6.3% of operative patients experienced recurrent instability at latest follow-up compared with 46.6% of nonoperative patients (P < .00001). Similarly, 4.0% of operative patients underwent a subsequent instability surgery compared with 30.8% of nonoperative patients (P < .00001). These same trends were demonstrated when data were isolated to nonoperative patients immobilized in internal rotation. When comparing the operative and nonoperative groups at latest follow-up, 1 study found significantly improved WOSI scores among operative patients (P = .035) and 1 study found significantly improved abducted external rotation in nonoperative patients (P = .02). CONCLUSION: Patients, particularly active men in their 20s and 30s, undergoing treatment for a first-time ASD with a surgical stabilization procedure can be expected to experience significantly lower rates of recurrent instability and a significantly decreased need for a future stabilization procedure when compared with patients treated nonoperatively.

The Most Common Rehabilitation Protocol After Matrix-Assisted Autologous Chondrocyte Implantation Is Immediate Partial Weight-Bearing and Continuous Passive Motion.

Purpose: To perform a systematic review of postoperative rehabilitation protocols for third-generation autologous chondrocyte implantation (ACI) of the knee joint. Methods: A systematic review was performed by searching PubMed, Cochrane Library, and EMBASE to locate randomized controlled trials that described a rehabilitation protocol following third-generation ACI of the knee joint. The search terms used were: "autologous" AND "chondrocyte" AND "randomized". Data extracted from each study included various components of postoperative rehabilitation, such as initial weight-bearing (WB) status and time to full WB, the use of continuous passive motion (CPM), the time to return to sports, and physical therapy (PT) modalities used and the timing of their initiation. Results: Twenty-five studies (22 Level I, 3 Level II) met inclusion criteria, including a total of 905 patients undergoing treatment with ACI. The average patient age ranged from 29.1 to 54.8 years, and the mean follow-up time ranged from 3 months to 10.0 years. The average lesion size ranged from 1.9 to 5.8 cm2, and the most common lesion location was the medial femoral condyle (n = 494). Twenty studies allowed partial WB postoperatively with all studies permitting full WB within 12 weeks. Twenty studies used CPM in their rehabilitation protocols and initiated its use within 24 hours postoperatively. Among 10 studies that reported time to return to sport, 9 (90%) allowed return by 12 months. While most protocols used strength training as well as the inclusion of proprioceptive training, there was disagreement on the timing and inclusion of specific PT modalities used during the rehabilitation process. Conclusions: Based on the included studies, most rehabilitation protocols for third-generation ACI initiate CPM within 24 hours postoperatively and allow partial WB immediately following surgery with progression to full WB within 12 weeks. There is variation of the PT modalities used as well as the timing of their initiation. Level of Evidence: Level II, systematic review of Level I-II studies.

Autograft and Nonirradiated Allograft for Anterior Cruciate Ligament Reconstruction Demonstrate Similar Clinical Outcomes and Graft Failure Rates: An Updated Systematic Review.

Purpose: To perform an updated systematic review comparing the clinical outcomes of autograft versus nonirradiated allograft for anterior cruciate ligament reconstruction (ACLR). Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify comparative studies directly comparing outcomes of primary ACLR with autograft versus nonirradiated allograft with a minimum 2-year follow-up. The search terms used were: "anterior cruciate ligament" AND autograft AND allograft AND (irradiation OR non-irradiated). Patients were evaluated based on graft failure rates, the Objective International Knee Documentation Committee (IKDC) score, anteroposterior laxity, and patient-reported outcomes (Subjective IKDC score, the visual analog scale [VAS], the Cincinnati Knee Rating System, Lysholm, and Tegner scores). Risk of bias was assessed using the ROBINS-I and Cochrane Collaboration's risk of bias tool for non-randomized and randomized studies, respectively. Results: Sixteen studies (3 Level I, 7 Level II, 6 Level III) met inclusion criteria, including a total of 15,502 patients undergoing ACLR with autograft and 1,577 with nonirradiated allograft. The average follow-up ranged from 24.0 to 132.0 months. Graft failure ranged from 0% to 9.4% of patients in the autograft group and 0% to 26.5% in the allograft group. Two studies showed greater failure rates among younger patients in the allograft group. There were no significant differences between the Objective IKDC score, anteroposterior laxity, or patient-reported outcomes between the groups within any of the included studies (P > .05). Conclusions: Autograft and nonirradiated allograft for primary ACLR demonstrate similar patient-reported outcomes and graft failure rates. Level of Evidence: III, systematic review of level I-III studies.

Predictors of Mid- to Long-Term Outcomes in Patients Experiencing a Knee Dislocation: A Systematic Review of Clinical Studies.

Knee dislocations (KDs) are devastating injuries for patients and present complex challenges for orthopaedic surgeons. Although short-term outcomes have been studied, there are few long-term outcomes of these injuries available in the literature. The purpose of this study is to determine factors that influence mid- to long-term clinical outcomes following surgical treatment of KD. A review of the current literature was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies published from 2010 to 2019 with a minimum 2-year follow-up that reported outcomes following surgical treatment of KDs. Ten studies (6 level III, 4 level IV) were included. At mid- (2-10 y) to long-term (>10 y) follow-up, concomitant arterial, cartilage, and combined meniscus damage were predictive factors for inferior Lysholm and International Knee Documentation Committee (IKDC) scores when compared with patients without these associated injuries. Although concomitant neurological damage may influence short-term outcomes due to decreased mobility, at longer follow-up periods it does not appear to predict worse clinical outcomes when compared with patients without concomitant neurological injury. Frank and polytrauma KDs have been associated with worse mid- to long-term outcomes when compared with transient and isolated KDs. Patients who underwent surgery within 6 weeks of trauma experienced better long-term outcomes than those who underwent surgery longer than 6 weeks after the initial injury. However, the small sample size of this study makes it difficult to make valid recommendations. Lastly, female sex, patients older than 30 years at the time of injury and a body mass index (BMI) greater than 35 kg/m2 are factors that have been associated with worse mid- to long-term Lysholm and IKDC scores. The results of this review suggest that female sex, age >30 years, BMI >35 kg/m2, concomitant cartilage damage, combined medial and lateral meniscal damage, KDs that do not spontaneously relocate, and KDs associated with polytrauma may predict worse results at mid- to long-term follow-up.

Bone Marrow Aspirate Concentrate for the Treatment of Knee Osteoarthritis: A Systematic Review.

BACKGROUND: Bone marrow aspirate concentrate (BMAC) has emerged as a therapeutic option for symptomatic knee osteoarthritis (OA). PURPOSE: To systematically review the literature to evaluate the efficacy of isolated BMAC injection in the treatment of OA of the knee joint. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was performed by searching the PubMed, Embase, and Cochrane Library databases up to July 2020 to identify human studies that assessed the clinical outcomes of isolated BMAC injection for the treatment of knee OA. The electronic search strategy used was "bone marrow aspirate concentrate knee osteoarthritis." RESULTS: Eight studies met the inclusion criteria, including a total of 299 knees with a mean follow-up of 12.9 months (range, 6-30 months). Of all patient-reported outcomes assessed across studies, 34 of 36 (94.4%) demonstrated significant improvement from baseline to latest follow-up (P < .05). Five studies evaluating numerical pain scores (visual analog scale and Numeric Rating Scale) reported significant improvements in pain level at final follow-up (P < .01). However, 3 comparative studies evaluating BMAC in relation to other therapeutic injections failed to demonstrate the clinical superiority of BMAC. CONCLUSION: The BMAC injection is effective in improving pain and patient-reported outcomes in patients with knee OA at short- to midterm follow-up. Nevertheless, BMAC has not demonstrated clinical superiority in relation to other biologic therapies commonly used in the treatment of OA, including platelet-rich plasma and microfragmented adipose tissue, or in relation to placebo. The high cost of the BMAC injection in comparison with other biologic and nonoperative treatment modalities may limit its utility despite demonstrable clinical benefit.

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.

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.

Autograft Versus Allograft for Medial Patellofemoral Ligament Reconstruction: A Systematic Review.

BACKGROUND: Patients with recurrent lateral patellar dislocations are often treated with reconstruction of the medial patellofemoral ligament (MPFL). PURPOSE: To perform a systematic review to evaluate clinical outcomes and the risk of recurrent patellar dislocation after MPFL reconstruction (MPFLR) with autograft versus allograft. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: The authors conducted a search of PubMed, the Cochrane Library, and Embase to identify studies comparing outcomes of MPFLR with autograft versus allograft. The inclusion criteria were full-text studies that directly compared clinical outcomes and/or risk of recurrent patellar instability between patients undergoing MPFLR with autograft versus allograft. A quality assessment was performed using the modified Coleman Methodology Score, and risk-of-bias assessment was performed using the Risk Of Bias In Non-randomized Studies-of Interventions and the Cochrane Collaboration tools. RESULTS: Seven studies (1 evidence level 2, 3 level 3, 3 level 4) that met inclusion criteria were identified and included a total of 150 patients who underwent MPFLR with autograft and 193 with MPFLR with allograft. One study found a significantly higher failure rate among patients with autograft, and another study found a trend toward a significantly higher failure rate among patients with autograft. One study demonstrated no significant difference between postoperative tibial tubercle-trochlear groove distance (measured on magnetic resonance imaging scans) in failed versus successful grafts. One study found that patellar tilt angle improved significantly from preoperatively to postoperatively (P < .001) but there was no difference between the groups. Kujala scores significantly improved for both autograft and allograft groups across studies. Two studies found significant differences in postoperative Kujala scores between the 2 groups, 1 of which found better scores in the allograft group (P = .0032) and another in which scores were better in the autograft group (P = .02). CONCLUSION: Patients undergoing MPFLR with either autograft or allograft can expect to experience improvement in clinical outcomes. Subjective outcomes improved to a similar degree in both groups. Graft failure was more frequently observed in patients with autograft. Allograft may be a better option for MPFLR owing to lower failure rate.

The Quality and Content of Internet-Based Information on Orthopaedic Sports Medicine Requires Improvement: A Systematic Review.

PURPOSE: To evaluate the quality and content of internet-based information available for some of the most common orthopaedic sports medicine terms. METHODS: A search of the PubMed, Embase, and Cochrane databases following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines was performed. All English-language literature published from 2010 to 2020 discussing information quality pertaining to orthopaedic sports medicine terms was included. Outcomes included the search engines used, number and type of websites evaluated, platform, and quality scoring metrics. Descriptive statistics are presented. RESULTS: This review includes 21 studies. Of these, 3 evaluated both the upper and lower extremity. Twelve focused on either the upper or lower extremity, most commonly rotator cuff tears (3 of 12) and/or anterior cruciate ligament pathologies (7 of 12). The most common engines were Google (18 of 21), Bing (16 of 21), Yahoo (16 of 21), YouTube (3 of 21), Ask (3 of 21), and AOL (2 of 21). The average number of media files assessed per study was 87 ± 55. Website quality was assessed with DISCERN (7 of 21), Flesch-Kincaid (9 of 21), Health on the Net (7 of 21), and/or Journal of the American Medical Association Benchmark (7 of 21) scores. YouTube was evaluated with Journal of the American Medical Association Benchmark scores (1.74 ± 1.00). Image quality was reported in 2 studies and varied with search terminology. CONCLUSIONS: The results of this systematic review suggest that physicians should improve the quality of online information and encourage patients to access credible sources when conducting their own research. CLINICAL RELEVANCE: Doctors can and should play an active role in closing the gap between the level of health literacy of their patients and that of most common online resources.

Risk of Infection in Knee Arthroscopy Patients Undergoing Corticosteroid Injections in the Perioperative Period.

BACKGROUND: Recent evidence suggests that there may be an increased risk of infection for patients undergoing a corticosteroid injection before, during, or after knee arthroscopy. PURPOSE: To systematically review the literature to evaluate the risk of postoperative infection in patients undergoing intra-articular corticosteroid injections (CSI) before, during, or after knee arthroscopy. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify studies that evaluated the rate of postoperative infection in patients undergoing knee arthroscopy who received an intra-articular CSI during the perioperative period. The search phrase used was "knee AND arthroscopy AND injection AND (infection OR revision)." A subanalysis was also performed to analyze infection rates based on the timing of the corticosteroid injection in relation to arthroscopy. RESULTS: Four studies met the inclusion criteria, representing 11,925 patients undergoing knee arthroscopy with an intra-articular CSI administered during the perioperative period (mean follow-up, 5.3 months) and 247,329 patients without a corticosteroid injection during the perioperative period (mean follow-up, 5.9 months). Patients who received an injection experienced a statistically significantly higher rate of postoperative infection (2.2%) when compared with patients who did not receive an injection (1.1%; P < .001). When analyzed by the timing of the injection, patients receiving an injection preoperatively or intraoperatively experienced a statistically significantly higher rate of postoperative infection (3% and 2.6%, respectively) when compared with patients receiving an injection postoperatively (1.4%; P = .001 for both). CONCLUSION: Patients undergoing knee arthroscopy who receive an intra-articular CSI during the perioperative period can be expected to experience significantly higher postoperative infection rates when compared with patients not receiving an injection. Furthermore, patients receiving a corticosteroid injection pre- or intraoperatively may experience significantly higher rates of postoperative infection when compared with patients receiving an injection postoperatively.

Subpectoral versus suprapectoral biceps tenodesis yields similar clinical outcomes: a systematic review.

IMPORTANCE: Arthroscopic suprapectoral biceps tenodesis (ABT) and open subpectoral biceps tenodesis (OBT) are two surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior to posterior (SLAP) tears. There is insufficient knowledge regarding the clinical superiority of one technique over the other. OBJECTIVE: To systematically review the literature in order to compare the clinical outcomes and safety of ABT and OBT for treatment of LHBT or SLAP pathology. EVIDENCE REVIEW: A systematic review was performed by searching PubMed, the Cochrane Library and Embase to identify studies that compared the clinical efficacy of ABT versus OBT. The search phrase used was: (bicep OR biceps OR biceps brachii OR long head of biceps brachii OR biceps tendinopathy) AND (tenodesis). Patients were assessed based on the American Shoulder and Elbow Surgeons Score, the visual analogue scale, the Single Assessment Numeric Evaluation, Constant-Murley Score, clinical failure, range of motion, bicipital groove pain and strength. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, and both the Cochrane Collaboration's and Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) risk of bias tools were used to evaluate risk of bias. FINDINGS: Eight studies (one level I, seven level III) met inclusion criteria, including 326 patients undergoing ABT and 381 patients undergoing OBT. No differences were found in treatment failure rates or patient-reported outcome scores between groups in any study. One study found OBT patients to experience significantly increased range of shoulder forward flexion when compared with ABT patients (p=0.049). Two studies found ABT patients to experience significantly more postoperative stiffness when compared with OBT patients (p<0.05). CONCLUSIONS: Patients undergoing ABT and OBT can be expected to experience similar improvements in clinical outcomes at latest follow-up without differences treatment failure or functional performance. ABT patients may experience an increased incidence of stiffness in the early postoperative period. LEVEL OF EVIDENCE: III.

A Systematic Review Shows High Variation in Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/Inguinal Disruption.

PURPOSE: To perform a systematic review of reported terminologies, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of core muscle injury (CMI)/athletic pubalgia/inguinal disruption. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies or articles that described a surgical technique to treat CMI refractory to nonoperative treatment. The search phrase used was "core muscle injury" OR "sports hernia" OR "athletic pubalgia" OR "inguinal disruption." The diagnostic terminology, country of publication, preoperative diagnostic measures, surgical technique, and subspecialty of the operating surgeons described in each article were extracted and reported. RESULTS: Thirty-one studies met the inclusion and exclusion criteria, including 3 surgical technique articles and 28 clinical articles (2 Level I evidence, 1 Level II, 4 Level III, and 21 Level IV). A total of 1,571 patients were included. The most common terminology used to describe the diagnosis was "athletic pubalgia," followed by "sports hernia." Plain radiographs and magnetic resonance imaging of the pelvis were the most common imaging modalities used in the preoperative evaluation of CMI/athletic pubalgia/inguinal disruption. Tenderness-to-palpation testing was the most common technique performed during physical examination, although the specific locations assessed with this technique varied substantially. The operating surgeons were general surgeons (16 articles), a combination of orthopaedic and general surgeons (7 articles), or orthopaedic surgeons (5 articles). The most common procedures performed were open or laparoscopic mesh repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis repair. The procedures performed differed on the basis of surgeon subspecialty, geographic location, and year of publication. CONCLUSIONS: A variety of diagnostic methods and surgical procedures have been used in the treatment of a CMI/athletic pubalgia/sports hernia/inguinal disruption. These procedures are performed by orthopaedic and/or general surgeons, with the procedures performed differing on the basis of surgeon subspecialty and geographic location. LEVEL OF EVIDENCE: Level V, systematic review of Level I to V studies.

Characteristics of Orthopaedic Sports Medicine Fellowship Directors.

BACKGROUND: No study in the orthopaedic literature has analyzed the demographic characteristics or surgical training of sports medicine fellowship directors (FDs). Objective determinations as to what makes a physician qualified for this leadership position remain unclear; thus, it is important to identify these qualities as future physicians look to fill these roles. PURPOSE: To illustrate characteristics common among sports medicine FDs. STUDY DESIGN: Cross-sectional study. METHODS: The 2020 Accreditation Council for Graduate Medical Education Fellowship Directory was used to identify the FDs for all orthopaedic sports medicine fellowship programs in the United States. The characteristics and educational background data for FDs were gathered by 2 independent reviewers from up-to-date curricula vitarum, Web of Science, and institutional biographies and consolidated into 1 database. Data points gathered included age, sex, residency/fellowship training location and graduation year, name of current institution, length of time at current institution, time since training completion until being appointed FD, length of time in current FD role, and personal research H-index. RESULTS: We identified 90 current orthopaedic sports medicine FDs. The mean Scopus H-index was 24.1 (median, 17). The mean age of FDs was 55.4 years; 87 of 90 (96.7%) were male and 3 (3.3%) were female; and 79/90 (87.8%) were White and 3/90 (3.3%) were African-American. The mean time to complete residency was 5.1 years (range, 5.0-6.0 years), and the most attended residency programs were the Hospital for Special Surgery (n = 9), the Harvard Combined Orthopaedic Residency Program (n = 5), and Duke University Medical Center (n = 4). The mean time required to complete a fellowship was 1.1 years (range, 1.0-2.0 years), and the fellowship programs that produced the most future FDs were the American Sports Medicine Institute (n = 11), the Steadman Hawkins Clinic (Vail) (n = 8), the Kerlan-Jobe Orthopaedic Clinic (n = 7), and the Hospital for Special Surgery (n = 7). The mean time from completion of fellowship to appointment as a FD was 12.8 years (range, 1-39 years). CONCLUSION: Women and minority groups are largely underrepresented among leadership positions in the field of orthopaedic sports medicine.