Stem cell therapy for the treatment of early stage avascular necrosis of the femoral head: a systematic review.

BACKGROUND: Avascular necrosis (AVN) of the femoral head (FH) is believed to be caused by a multitude of etiologic factors and is associated with significant morbidity in younger populations. Eventually, the disease progresses and results in FH collapse. Thus, a focus on early disease management aimed at joint preservation by preventing or delaying progression is key. The use of stem cells (SC) for the treatment of AVN of the FH has been proposed. We undertook a systematic review of the medical literature examining the use of SC for the treatment of early stage (precollapse) AVN of the FH, in both pre-clinical and clinical studies. METHODS: Data collected included: Pre-clinical studies - model of AVN, variety and dosage of SC, histologic and imaging analyses. Clinical studies - study design, classification and etiology of AVN, SC dosage and treatment protocol, incidence of disease progression, patient reported outcomes, volume of necrotic lesion and hip survivorship. RESULTS: In pre-clinical studies, the use of SC uniformly demonstrated improvements in osteogenesis and angiogenesis, yet source of implanted SC was variable. In clinical studies, groups treated with SC showed significant improvements in patient reported outcomes; however hip survivorship was not affected. Discrepancies regarding dose of SC, AVN etiology and disease severity were present. CONCLUSIONS: Routine use of this treatment method will first require further research into dose and quality optimization as well as confirmed improvements in hip survivorship.

The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature.

BACKGROUND: A number of factors have been identified as influencing total knee arthroplasty outcomes, including patient factors such as gender and medical comorbidity, technical factors such as alignment of the prosthesis, and provider factors such as hospital and surgeon procedure volumes. Recently, strategies aimed at optimizing provider factors have been proposed, including regionalization of total joint arthroplasty to higher volume centers, and adoption of volume standards. To contribute to the discussions concerning the optimization of provider factors and proposals to regionalize total knee arthroplasty practices, we undertook a systematic review to investigate the association between surgeon volume and primary total knee arthroplasty outcomes. METHODS: We performed a systematic review examining the association between surgeon volume and primary knee arthroplasty outcomes. To be included in the review, the study population had to include patients undergoing primary total knee arthroplasty. Studies had to report on the association between surgeon volume and primary total knee arthroplasty outcomes, including perioperative mortality and morbidity, patient-reported outcomes, or total knee arthroplasty implant survivorship. There were no restrictions placed on study design or language. RESULTS: Studies were variable in defining surgeon volume ('low': <3 to <52 total knee arthroplasty per year; 'high': >5 to >70 total knee arthroplasty per year). Mortality rate, survivorship and thromboembolic events were not found to be associated with surgeon volume. We found a significant association between low surgeon volume and higher rate of infection (0.26% - 2.8% higher), procedure time (165 min versus 135 min), longer length of stay (0.4 - 2.13 days longer), transfusion rate (13% versus 4%), and worse patient reported outcomes. CONCLUSIONS: Findings suggest a trend towards better outcomes for higher volume surgeons, but results must be interpreted with caution.

Patient satisfaction after total knee and hip arthroplasty.

Patient satisfaction is an important outcome measurement in TKA/THA surgery. Patient satisfaction can be evaluated from 2 perspectives, determinants of satisfaction and components of satisfaction.(5) In total joint arthroplasty, improvements in satisfaction can be achieved by examining these perspectives. Patient satisfaction is one of the many PROMs used in orthopedic surgery and is an integral part of the growing sentiment to evaluate surgery from the patient's perspective as well as from the surgeon's. The importance of measuring outcomes from the patient perspective is integral to today's patient-centered models of care.