Groin Pain Syndrome Italian Consensus Conference update 2023.

Groin pain syndrome (GPS) is a controversial topic in Sports Medicine. The GPS Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes was organized by the Italian Society of Arthroscopy in Milan, on 5 February 2016. In this Consensus Conference (CC) GPS etiology was divided into 11 different categories for a total of 63 pathologies. The GPS Italian Consensus Conference update 2023 is an update of the 2016 CC. The CC was based on a sequential, two-round online Delphi survey, followed by a final CC in the presence of all panelists. The panel was composed of 55 experts from different scientific and clinical backgrounds. Each expert discussed 6 different documents, one of which regarded the clinical and imaging definition of sports hernias, and the other 5 dealt with 5 new clinical situations thought to result in GPS. The panelists came to an agreement on the definition of a sports hernia. Furthermore, an agreement was reached, recognizing 4 of the 5 possible proposed pathologies as causes to GPS. On the contrary, the sixth pathology discussed did not find consensus given the insufficient evidence in the available scientific literature. The final document includes a new clinical and imaging definition of sports hernia. Furthermore, the etiology of GPS was updated compared to the previous CC of 2016. The new taxonomic classification includes 12 categories (versus 11 in the previous CC) and 67 pathologies (versus 63 in the previous CC).

Virtual Surgical Planning and Patient-Specific Instruments for Correcting Lower Limb Deformities in Pediatric Patients: Preliminary Results from the In-Office 3D Printing Point of Care.

(1) Background: Virtual reality and 3D printing are transforming orthopedic surgery by enabling personalized three-dimensional (3D) models for surgical planning and Patient-Specific Instruments (PSIs). Hospitals are establishing in-house 3D printing centers to reduce costs and improve patient care. Pediatric orthopedic surgery also benefits from these technologies, enhancing the precision and personalization of treatments. This study presents preliminary results of an In-Office 3D Printing Point of Care (PoC), outlining considerations and challenges in using this program for treating lower limb deformities in pediatric patients through Virtual Surgical Planning (VSP) and 3D-printed Patient-Specific Instruments (PSIs). (2) Materials and Methods: Pediatric patients with congenital or acquired lower limb deformities undergoing surgical correction based on VSP, incorporating 3D-printed PSIs when required, were included in this study. The entire process of VSP and 3D printing at the In-Office PoC was illustrated. Data about deformity characteristics, surgical procedures, and outcomes, including the accuracy of angular correction, surgical times, and complications, were reported. (3) Results: In total, 39 bone correction procedures in 29 patients with a mean age of 11.6 ± 4.7 years (range 3.1-18.5 years) were performed according to VSP. Among them, 23 procedures were accomplished with PSIs. Surgeries with PSIs were 45 min shorter, with fewer fluoroscopy shots. Optimal correction was achieved in 37% of procedures, while the remaining cases showed under-corrections (41%) or over-corrections (22%). Major complications were observed in four patients (13.8%). (4) Conclusions: The In-Office 3D Printing Point of Care is becoming an essential tool for planning and executing complex corrections of lower limb deformities, but additional research is needed for optimizing the prediction and accuracy of the achieved corrections.

Extracorporeal membrane oxygenation and effects on tendon tissue: A vibrational spectroscopy study.

Extracorporeal membrane oxygenation (ECMO) is an invasive medical technique used to provide life support in persons with insufficient cardiac and respiratory functionalities, or to preserve, postmortem, and organ function addressing organ/tissue transplant. Although a lot of information is available about organs in their entirety, the safety and effectiveness of allogeneic tissues collected from ECMO donors have not been fully elucidated. In this preliminary study, samples of tibial and peroneal human tendons were analyzed along their length with Raman microspectroscopy and attenuated total reflection-Fourier transform infrared micro-imaging. Both techniques evidenced a different chemical composition in the terminal with respect to the central part of the tendon. Thus, a differentiated analysis was performed depending on the specific position with respect to the bone or the muscle junctions. Spectroscopic analyses showed significant differences in the characteristics of the extracellular matrix between tendons from ECMO and non-ECMO donors, suggesting changes in the amino acid (proline and hydroxyproline) content and protein structure.

The Intraoperative Use of Defensive Antibacterial Coating (DAC®) in the Form of a Gel to Prevent Peri-Implant Infections in Orthopaedic Surgery: A Clinical Narrative Review.

Periprosthetic joint infections (PJIs) in arthroplasty and osteosynthesis-associated infections (OAIs) in reconstructive surgery still represent a challenging complication in orthopaedics and traumatology causing a burden worsening the patient's quality of life, for caregiver and treating physicians, and for healthcare systems. PJIs and OAIs are the result of bacterial adhesion over an implant surface with subsequent biofilm formation. Therefore, the clinical pathological outcome is a difficult-to-eradicate persistent infection. Strategies to treat PJIs and OAIs involve debridement, the replacement of internal fixators or articular prostheses, and intravenous antibiotics. However, long treatments and surgical revision cause discomfort for patients; hence, the prevention of PJIs and OAIs represents a higher priority than treatment. Local antibiotic treatments through coating-release systems are becoming a smart approach to prevent this complication. Hydrophilic coatings, loaded with antibiotics, simultaneously provide a barrier effect against bacterial adhesion and allow for the local delivery of an antibiotic. The intraoperative use of a hyaluronan (HY)-derivative coating in the form of a gel, loaded with antibiotics to prevent PJI, has recently raised interest in orthopaedics. Current evidence supports the use of this coating in the prophylaxis of PJI and IRIs in terms of clinical outcomes and infection reduction. Thus, the purpose of this narrative review is to assess the use of a commercially available HY derivative in the form of a gel, highlighting the characteristics of this biomaterial, which makes it attractive for the management of PJIs and IRIs in orthopaedics and traumatology.

Cadaver Homologous Banked Fascia Lata in Skull Base Reconstruction: Preliminary Multidisciplinary Experiences.

Skull base reconstruction has been a widely debated issue. Both autologous and heterologous materials have been proposed, however the formers are usually preferred due to their optimal healing outcomes and integration. Nevertheless they are still associated with donor-site functional and aesthetic morbidity. The aim of this study is to report a preliminary experience of different sites defects skull base repair with Cadaver homologous banked fascia lata graft. Patients who underwent reconstruction of skull base defects with Cadaver homologous banked fascia lata between January 2020 until July 2021 were included in the study. Three patients were finally identified for the study. Patient 1 underwent combined craniotomic-endoscopic surgical access for extended anterior skull base neoplasm with subsequent repair with homologous cadaver fascia lata. Patient 2 underwent endoscopic transphenoidal surgery for sellar-parasellar neoplasm. After tumor debulking the surgical cavity was obliterated with homologous cadaver fascia lata. Patient 3 finally had politrauma with otic capsule-violating fracture with profused CSF leak. An endoscopic obliteration of external and middle ear was performed using homologous cadaver fascia lata with blind sac closure of external auditory canal. No graft displacement or reabsorption was observed in these patients at the last follow-up. Cadaver homologous banked fascia lata has proved safety, efficacy and ductility in reconstruction of different skull base defects. Level of Evidence: Level IV-retrospective cohort study.

Hip Labral Morphological Changes in Patients with Femoroacetabular Impingement Speed Up the Onset of Early Osteoarthritis.

Over the last decade, evidence has mounted for a prominent etiologic role of femoroacetabular impingement (FAI) in the development of early hip osteoarthritis (OA). The aim of this study was to compare the ultrastructure and tissue composition of the hip labrum in healthy and pathological conditions, as FAI and OA, to provide understanding of structural changes which might be helpful in the future to design targeted therapies and improve treatment indications. We analyzed labral tissue samples from five healthy multi-organ donors (MCDs) (median age, 38 years), five FAI patients (median age, 37 years) and five late-stage OA patients undergoing total hip replacement (median age, 56 years). We evaluated morpho-functional by histology and transmission electron microscopy. Extracellular matrix (ECM) structure changes were similar in specimens from FAI compared to those from patients with OA (more severe in the latter) showing disorganization of collagen fibers and increased proteoglycan content. In FAI and in OA nuclei the chromatin was condensed, organelle degenerated and cytoplasm vacuolized. Areas of calcification were mainly observed in FAI and OA labrum, as well as apoptotic-like features. We showed that labral tissue of patients with FAI had similar pathological alterations of tissue obtained from OA patients, suggesting that FAI patients might have high susceptibility to develop OA.

Brillouin-Raman micro-spectroscopy and machine learning techniques to classify osteoarthritic lesions in the human articular cartilage.

In this study, Brillouin and Raman micro-Spectroscopy (BRamS) and Machine Learning were used to set-up a new diagnostic tool for Osteoarthritis (OA), potentially extendible to other musculoskeletal diseases. OA is a degenerative pathology, causing the onset of chronic pain due to cartilage disruption. Despite this, it is often diagnosed late and the radiological assessment during the routine examination may fail to recognize the threshold beyond which pharmacological treatment is no longer sufficient and prosthetic replacement is required. Here, femoral head resections of OA-affected patients were analyzed by BRamS, looking for distinctive mechanical and chemical markers of the progressive degeneration degree, and the result was compared to standard assignment via histological staining. The procedure was optimized for diagnostic prediction by using a machine learning algorithm and reducing the time required for measurements, paving the way for possible future in vivo characterization of the articular surface through endoscopic probes during arthroscopy.

Allogenic bone grafts and postoperative surgical site infection: are positive intraoperative swab cultures predictive for a higher infectious risk?

In spine surgery, allogenic bone grafts are often required to ensure bone fusion, however, the main concern regarding their use is the infection risk: therefore, an intraoperative swab for culture test is performed. The cost-effectiveness of these swabs and their influence on the patients' postoperative course have often been questioned. This study aims at determining whether positive spine allograft culture results are predictive of an increased risk of surgical site infection and whether they influence the surgeon's choices in postoperative management. The records of 340 patients who received allogenic bone graft during spinal fusion surgery in our institution were reviewed, for a total of 677 allografts. Each graft was swabbed intraoperatively. All patients were followed clinically for postoperative complications. Infection was diagnosed based on clinical data, blood tests and radiographic images, all assessed by an infectious disease specialist. Only 4 of the 677 allografts used (0.6%) resulted positive at the intraoperative swab culture. Three cultures were positive for Staphylococcus epidermidis and one culture for S. warneri. No clinical infection occurred in any of these patients. Twenty-eight of the 340 patients (8.2%) developed an infection, but none of them had a positive intraoperative swab culture. The most common microbiologic pathogen isolated from this cohort was S. aureus. According to our series, intraoperative swab culture results were not predictive for higher risk of infection and did not affect the clinical behavior of the surgeons in postoperative management.

Virtual Surgical Planning, 3D-Printing and Customized Bone Allograft for Acute Correction of Severe Genu Varum in Children.

Complex deformities of lower limbs are frequent in children with genetic or metabolic skeletal disorders. Early correction is frequently required, but it is technically difficult and burdened by complications and recurrence. Herein, we described the case of a 7-year-old girl affected by severe bilateral genu varum due to spondyloepiphyseal dysplasia. The patient was treated by patient-specific osteotomies and customized structural wedge allograft using Virtual Surgical Planning (VSP) and 3D-printed patient-specific instrumentation (PSI). The entire process was performed through an in-hospital 3D-printing Point-of-Care (POC). VSP and 3D-printing applied to pediatric orthopedic surgery may allow personalization of corrective osteotomies and customization of structural allografts by using low-cost in-hospital POC. However, optimal and definitive alignment is rarely achieved in such severe deformities in growing skeleton through a single operation.

Umbilical Cord PRP vs. Autologous PRP for the Treatment of Hip Osteoarthritis.

Umbilical cord platelet-rich plasma (C-PRP) has more growth factors and anti-inflammatory molecules compared with autologous PRP (A-PRP) derived from peripheral blood. The aim of this study was to compare intra-articular C-PRP or A-PRP injections in terms of safety and clinical efficacy for the treatment of patients with hip osteoarthritis (OA). This study investigated the results of 100 patients with hip OA treated with three weekly ultrasound-guided injections of either C-PRP or A-PRP. Clinical evaluations were performed before the treatment and after two, six, and twelve months with the HHS, WOMAC, and VAS scores. No major adverse events were recorded. Overall, the improvement was limited with both treatments. Significant improvements in VAS (p = 0.031) and HHS (p = 0.011) were documented at two months for C-PRP. Patients with a low OA grade (Tonnis 1-2) showed a significantly higher HHS improvement with C-PRP than A-PRP at twelve months (p = 0.049). C-PRP injections are safe but offered only a short-term clinical improvement. The comparative analysis did not demonstrate benefits compared with A-PRP in the overall population, but the results are influenced by OA severity, with C-PRP showing more benefits when advanced OA cases were excluded. Further studies are needed to confirm the most suitable indications and potential of this biological injective approach.

Custom Massive Allograft in a Case of Pelvic Bone Tumour: Simulation of Processing with Computerised Numerical Control vs. Robotic Machining.

The use of massive bone allografts after the resection of bone tumours is still a challenging process. However, to overcome some issues related to the processing procedures and guarantee the best three-dimensional matching between donor and recipient, some tissue banks have developed a virtual tissue database based on the scanning of the available allografts for using their 3D shape during virtual surgical planning (VSP) procedures. To promote the use of future VSP bone-shaping protocols useful for machining applications within a cleanroom environment, in our work, we simulate a massive bone allograft machining with two different machines: a four-axes (computer numerical control, CNC) vs. a five-axes (robot) milling machine. The allograft design was based on a real case of allograft reconstruction after pelvic tumour resection and obtained with 3D Slicer and Rhinoceros software. Machining simulations were performed with RhinoCAM and graphically and mathematically analysed with CloudCompare and R, respectively. In this case, the geometrical differences of the allograft design are not clinically relevant; however, the mathematical analysis showed that the robot performed better than the four-axes machine. The proof-of-concept presented here paves the way towards massive bone allograft cleanroom machining. Nevertheless, further studies, such as the simulation of different types of allografts and real machining on massive bone allografts, are needed.

Quality Control Platform for the Standardization of a Regenerative Medicine Product.

Adipose tissue is an attractive source of stem cells due to its wide availability. They contribute to the stromal vascular fraction (SVF), which is composed of pre-adipocytes, tissue-progenitors, and pericytes, among others. Because its direct use in medical applications is increasing worldwide, new quality control systems are required. We investigated the ability of the Non-Equilibrium Earth Gravity Assisted Dynamic Fractionation (NEEGA-DF) method to analyze and separate cells based solely on their physical characteristics, resulting in a fingerprint of the biological sample. Adipose tissue was enzymatically digested, and the SVF was analyzed by NEEGA-DF. Based on the fractogram (the UV signal of eluting cells versus time of analysis) the collection time was set to sort alive cells. The collected cells (F-SVF) were analyzed for their phenotype, immunomodulation ability, and differentiation potential. The SVF profile showed reproducibility, and the alive cells were collected. The F-SVF showed intact adhesion phenotype, proliferation, and differentiation potential. The methodology allowed enrichment of the mesenchymal component with a higher expression of mesenchymal markers and depletion of debris, RBCs, and an extracellular matrix still present in the digestive product. Moreover, cells eluting in the last minutes showed higher circularity and lower area, proving the principles of enrichment of a more homogenous cell population with better characteristics. We proved the NEEGA-DF method is a "gentle" cell sorter that purifies primary cells obtained by enzymatic digestion and does not alter any stem cell function.

Fiber Thickness and Porosity Control in a Biopolymer Scaffold 3D Printed through a Converted Commercial FDM Device.

3D printing has opened exciting new opportunities for the in vitro fabrication of biocompatible hybrid pseudo-tissues. Technologies based on additive manufacturing herald a near future when patients will receive therapies delivering functional tissue substitutes for the repair of their musculoskeletal tissue defects. In particular, bone tissue engineering (BTE) might extensively benefit from such an approach. However, designing an optimal 3D scaffold with adequate stiffness and biodegradability properties also guaranteeing the correct cell adhesion, proliferation, and differentiation, is still a challenge. The aim of this work was the rewiring of a commercial fuse deposition modeling (FDM) 3D printer into a 3D bioplotter, aiming at obtaining scaffold fiber thickness and porosity control during its manufacturing. Although it is well-established that FDM is a fast and low-price technology, the high temperatures required for printing lead to limitations in the biomaterials that can be used. In our hands, modifying the printing head of the FDM device with a custom-made holder has allowed to print hydrogels commonly used for embedding living cells. The results highlight a good resolution, reproducibility and repeatability of alginate/gelatin scaffolds obtained via our custom 3D bioplotter prototype, showing a viable strategy to equip a small-medium laboratory with an instrument for manufacturing good-quality 3D scaffolds for cell culture and tissue engineering applications.

Ultrasound-guided injection of platelet-rich plasma or cord blood platelet-rich plasma in nonunion: a randomized controlled trial.

Aim: To compare the ability of autologous platelet-rich plasma (PRP) and cord blood PRP (PRPc) to accelerate bone healing. Patients & methods: 71 patients with mechanically stable nonunion were treated weekly (3 consecutive weeks) with ultrasound-guided percutaneous injections of PRP or PRPc in a controlled randomized clinical trial. The primary outcome was healing (12 months) and secondary outcomes were radiological evolution (2 and 6 months) and changes in pain intensity (6 months). Results & conclusion: Bone consolidation was assessed over time without significant differences between PRP and PRPc treatment. In patients with persistent nonunion, pain perception decreased more after PRP treatment. PRPc appears to be a valid alternative when specific clinical conditions suggest avoiding the use of autologous blood products.

Although the regenerative capacity of bone tissue is well recognized, the fracture repair process may be impaired by unfavorable conditions resulting in delayed union or complete nonunion. In this scenario, the use of autologous blood derivates to accelerate bone healing has been proposed. The aim of this study was to compare the therapeutic efficacy of autologous platelet-rich plasma (PRP) and cord blood PRP (PRPc) in bone nonunion. PRPc contains high levels of cytokines and growth factors, has low immunogenicity and can be successfully stored until use. This study verified that bone consolidation was similar in PRP and PRPc treatments, thus supporting PRPc as a valid therapeutic option when clinical conditions discourage the use of autologous blood derivates.

Current concepts in hip-spine relationships: making them practical for total hip arthroplasty.

Hip, spine, and pelvis move in coordination with one another during activity, forming the lumbopelvic complex (LPC). These movements are characterized by the spinopelvic parameters sacral slope, pelvic tilt, and pelvic incidence, which define a patient's morphotype. LPC kinematics may be classified by various systems, the most comprehensive of which is the Bordeaux Classification. Hip-spine relationships in total hip arthroplasty (THA) may influence impingement, dislocation, and edge loading. Historical 'safe zones' may not apply to patients with impaired spinopelvic mobility; adjustment of cup inclination and version and stem version may be necessary to achieve functional orientation and avert complications. Stem design, bearing surface (including dual mobility), and head size are part of the armamentarium to treat abnormal hip-spine relationships. Special attention should be directed to patients with adult spine deformity or fused spine because they are at increased risk of complications after THA.

Brillouin and Raman Micro-Spectroscopy: A Tool for Micro-Mechanical and Structural Characterization of Cortical and Trabecular Bone Tissues.

Human bone is a specialized tissue with unique material properties, providing mechanical support and resistance to the skeleton and simultaneously assuring capability of adaptation and remodelling. Knowing the properties of such a structure down to the micro-scale is of utmost importance, not only for the design of effective biomimetic materials but also to be able to detect pathological alterations in material properties, such as micro-fractures or abnormal tissue remodelling. The Brillouin and Raman micro-spectroscopic (BRmS) approach has the potential to become a first-choice technique, as it is capable of simultaneously investigating samples' mechanical and structural properties in a non-destructive and label-free way. Here, we perform a mapping of cortical and trabecular bone sections of a femoral epiphysis, demonstrating the capability of the technique for discovering the morpho-mechanics of cells, the extracellular matrix, and marrow constituents. Moreover, the interpretation of Brillouin and Raman spectra merged with an approach of data mining is used to compare the mechanical alterations in specimens excised from distinct anatomical areas and subjected to different sample processing. The results disclose in both cases specific alterations in the morphology and/or in the tissue chemical make-up, which strongly affects bone mechanical properties, providing a method potentially extendable to other important biomedical issues.

Fresh Osteochondral Allograft Transplantation in Osteochondritis Dissecans in the Knee Joint.

Osteochondritis dissecans (OCD) is a chronic and painful joint condition that can occur from childhood through to adult life. Microtrauma, vascular insufficiency, or abnormal endochondral ossification are the most common causes of OCD. Reconstructive techniques for OCD of the knee are typically necessary when either non-operative or reparative/regenerative operative treatments fail, or when the OCD is irreversible. To analyze the clinical outcomes and failure rates of fresh osteochondral allograft transplantation (FOCA) used as a reconstructive strategy in OCD patients, an in-depth search was carried out on the PubMed, Scopus, and Web of Science databases concerning the existing evidence related to the use of FOCA for OCD patients in the knee joint. A total of 646 studies were found through the search and 2 studies were added after a cross-referenced examination of the articles within the bibliography. Six studies with a total of 303 OCD lesions treated with FOCA, with a mean follow-up of 6.3 years, were included. Although a limited number of low-level evidence studies on this topic are available in previous research, satisfactory clinical results and survival rates of the reconstruction are reported. However, to better define the real advantages of FOCA in the healing process of OCD lesions, comparative studies with different techniques are needed.

Cementless Ceramic-on-Ceramic Total Hip Replacement in Children and Adolescents.

Background: total hip replacement (THR) is a rare surgical option in children and adolescents with disabling hip diseases. The aim of this study is to report results from a retrospective cohort of patients aged 18 years or less who underwent cementless Ceramic-on-Ceramic (CoC) THR at a single institution, investigating clinical and radiographic outcomes, survival rates, and reasons for revision of the implants. Materials and methods: we queried the Registry of Prosthetic Orthopedic Implants (RIPO) to identify all children and adolescents undergoing THR between 2000 and 2019 at a single Institution. Inclusion criteria were patients undergoing cementless CoC THR, aged less than 18 years at surgery, followed for at least 2 years. Sixty-eight patients (74 hips) matched all the inclusion criteria and were enrolled in the study. We assessed the clinical and radiographic outcomes, the rate of complications, the survival rate, and reasons for revision of the implants. Results: The mean follow-up was 6.6 ± 4.4 years (range 2-20). The most frequent reason for THR was post-traumatic or chemotherapy-induced avascular necrosis (38%). The overall survival rate of the cohort was 97.6% (95% CI: 84.9-99.7%) at 5 years of follow-up, 94.4% (95% CI: 79.8-98.6%) at 10 years and 15 years of follow-up. Two THR in two patients (2.7%) required revision. With the numbers available, Cox regression analysis could not detect any significant interaction between preoperative or intraoperative variables and implant survivorship (p-value 0.242 to 0.989)." The average HOOS was 85 ± 14.3 (range 30.6-100). Overall, 23 patients (48%) reported excellent HOOS scores (>90 points), 21 patients (44%) reported acceptable HOOS scores (60-90 points) while 4 patients (8%) reported poor outcomes (<60 points). Twenty-one patients (43%) were regularly involved into moderate- to high-intensity sport activities (UCLA ≥ 6). Conclusions: Cementless CoC THR is a successful procedure in children and teenagers, having demonstrated high implant survivorship and low rates of complications and failure. A meticulous preoperative planning and implant selection is mandatory, to avoid implant malposition, which is the main reason of failure and revision in these cases. Further studies are needed to assess the impact of the THR on the psychosocial wellbeing of teenagers, as well as risks and benefits and cost-effectiveness in comparison to the hip preserving surgical procedures.

Randomised, double-blind comparison of a fixed co-formulation of intra-articular polynucleotides and hyaluronic acid versus hyaluronic acid alone in the treatment of knee osteoarthritis: two-year follow-up.

BACKGROUND: A first-year interim analysis of this two-year study suggested that intra-articular injections of highly purified, natural-origin polynucleotides and hyaluronic acid (HA) as a fixed combination (PNHA) might improve knee function and joint pain more effectively than HA alone in patients with knee osteoarthritis (OA). The purpose of the second-year analysis herein described was to verify whether the first-year interim outcomes persist over the whole two-year period. METHODS: Randomised, double-blind, HA-controlled clinical trial in 100 knee OA patients (98 randomised, 79 completing the study) in a high-specialisation tertiary care setting. The hypothesised difference of efficacy between PNHA and HA for the original sample size estimate is 20%. Treatment cycle: three intra-articular knee injections of either PNHA or HA, at baseline and weekly for two weeks. EVALUATIONS: Western Ontario and McMaster Universities (WOMAC) score and Knee Society Score (KSS) as, respectively, primary and secondary endpoints, evaluated at baseline and after 2, 6, 12, and 24 months; synovial fluid levels of mediators (at baseline and the end of the treatment cycle). Adverse effects investigated at each control visit. STATISTICAL ANALYSIS: Kruskal-Wallis test for independent samples (nonparametric one-way analysis of variance) after correction of means for age, Body Mass Index and Kellgren-Lawrence grade. If significant, pairwise post-hoc Sidak multiple comparisons. RESULTS: KSS total score and KSS pain item: significant improvement in both groups, with significantly more pain improvement in patients treated with PNHA (2-point reduction) than HA (1-point reduction). Both groups experienced significant long-term reductions in WOMAC total scores: significantly stronger in PNHA-treated patients after 24 months with a steady difference of 16% favouring PNHA in WOMAC pain subscore. No clinically significant adverse events in either group. CONCLUSIONS: The outcomes of the 2-year study confirmed that a short cycle of intra-articular treatment (3 weekly double-blind injections) with polynucleotides (long-acting viscosupplementation properties, chondrocyte activation, pain-relieving properties) in fixed combination with high molecular weight hyaluronic acid is more effective in improving knee function and pain in knee OA patients than HA alone. PNHA may be elective for viscosupplementation in knee OA patients with fastidious and resistant pain and worsening disease. TRIAL REGISTRATION: NCT02417610 . Registration, 15/04/2015. ClinicalTrials.gov database link.

Extra-Corporeal Membrane Oxygenation Cadaver Donors: What about Tissues Used as Allografts?

Several studies demonstrated the efficacy of post-mortem extracorporeal membrane oxygenation (ECMO) on donors in preserving organ function addressing organ transplantation. Nevertheless, no common and shared evidence was reached about the possibility of using ECMO donors in tissue harvesting. Therefore, this work aimed first to review the current scientific literature about ECMO donors, and then to focus on the use of ECMO tissues as allografts, mainly addressing musculoskeletal tissues, which are of the most interest for reconstruction. A search was conducted on the current scientific literature, focusing on the keywords "ECMO" and "Donor". Several online databases were used, including PubMed, Scopus, and Web of Science. From the preliminary search, 478 articles were obtained, out of which 173 specifically reported the use of ECMO for donation and transplantation purposes. Literature reported extensive analyses of ECMO organs-overall from the abdomen-both in pre- and post-transplantation studies. On the other hand, ECMO tissues were explanted only in a very limited number of cases; moreover, no information was referred about their status and use. A revision of the current scientific literature highlighted the lack of information concerning ECMO tissues and the necessity to perform preclinical, ex vivo studies to compare allografts from ECMO donors, with respect to standard donors, and, thus, to verify whether they can be harvested and implanted safely and with efficacy.