Quantitative Volumetric Measurements of Bone Grafting Sites Within the Lower Extremity on Computed Tomography Scans.

The anterior iliac crest is one of the most used options; however, pain and other complications have been reported. Other options for bone harvest in the lower extremity, such as the proximal tibia and calcaneus, can be useful sites for bone grafting. Computed tomography angiography images of the lower extremity were analyzed using 3-D Slicer™ medical imaging software, creating an advanced 3-dimensional model. Bone volume (cm3) and bone mineral density (Hounsfield units) were measured from the cancellous bone in the anterior iliac crest, posterior iliac crest, proximal tibia, and the calcaneus. Fifteen studies were included. The total volume measured it was of 61.88 ± 14.15 cm3, 19.35 ± 4.16 cm3, 32.48 ± 7.49 cm3, 26.40 ± 7.18 cm3, for the proximal tibia, anterior and posterior iliac crest, and calcaneus, respectively. Regarding Hounsfield units, the densities were 116 ± 58.77, 232.4 ± 68.65, 214.4 ± 74.45, 170.5 ± 52.32, for proximal tibia, anterior and posterior iliac crest, and calcaneus. The intraclass correlation coefficients were in average >0.94. In conclusion, the proximal tibia has more cancellous bone than the anterior and posterior iliac crest. The calcaneus has more cancellous bone than the anterior iliac crest. Bone mineral density was highest in the anterior iliac crest and in proximal tibia was the lowest value.

The Effects of the Combination of Rhein and Platelet-Rich Plasma on Human Articular Chondrocytes.

BACKGROUND: The presence of side effects and low bioavailability of rhein has limited its use in the treatment of osteoarthritis. We aimed to evaluate the in vitro response of human articular chondrocytes to the presence of the combination of platelet-rich plasma (PRP) and rhein. METHODS: Solutions of rhein were prepared to assess solubility and select a working concentration. A stimulus with interleukin-1ß (IL-ß, 10 ng/mL) was induced for 24 h on human chondrocytes. Five treatment groups were established: control, IL-ß control, PRP, rhein, and PRP + rhein. Cell viability, cell migration, nitric oxide (NO) production, tumor necrosis factor-α (TNF-α), and gene expression analyses were carried out. RESULTS: A concentration of 50 mg/L was selected after a dose-response curve assay. Both NO and tumor TNF-α production significantly decreased after PRP and PRP + rhein treatments at 24 and 48 h. The wound healing assay revealed a significant stimulation of migration after 72 h with the PRP and PRP + rhein treatments. Expression of IL-1ß, IL-6, MMP-13, and ADAMTS-5 was significantly downregulated, particularly after treatment with the combination of PRP + rhein. CONCLUSIONS: Much of the determinations denoted a better performance of the combination of PRP and rhein in decreasing the levels of the different targets evaluated; however, this was not great enough to detect a significant difference in comparison with the PRP treatment alone.

The use of platelet-rich plasma in studies with early knee osteoarthritis versus advanced stages of the disease: a systematic review and meta-analysis of 31 randomized clinical trials.

INTRODUCTION: Reports have concluded that platelet-rich plasma (PRP) is an effective and safe biological approach to treating knee osteoarthritis (OA). However, the effectiveness of PRP in advanced stages of the disease is not entirely clear. The purpose of this study was to evaluate whether the use of PRP would be as effective in studies with early-moderate knee OA patients compared to studies including patients with end-stage OA, based on the Kellgren-Lawrence classification. MATERIALS AND METHODS: A comprehensive search in MEDLINE, EMBASE, Scopus, and Web of Science databases was conducted to identify randomized controlled trials (RCTs) comparing the effect of PRP injections versus other intra-articular treatments on pain and functionality. A meta-analysis was conducted using a random-effects model and the generic inverse variance method. RESULTS: We included 31 clinical trials that reported data of 2705 subjects. Meta-analysis revealed an overall significant improvement of both pain [MD, - 1.05 (95% CI - 1.41 to - 0.68); I2 = 86%; P ≤ 0.00001] and function [SMD, - 1.00 (95% CI - 1.33, to - 0.66); I2 = 94%; P ≤ 0.00001], favoring PRP. Subanalysis for pain and functional improvement showed a significant pain relief in studies with 1-3 and 1-4 Kellgren-Lawrence OA stages and a significant functional improvement in studies with 1-2, 1-3 and 1-4 knee OA stages, favoring PRP. CONCLUSION: Our results indicate that including patients with advanced knee OA does not seem to affect the outcomes of clinical trials in which the effectiveness of the PRP in knee OA is assessed.

Comparison of Anterior Iliac Crest Versus Proximal Tibia Autologous Bone Graft Harvesting: A Systematic Review and Meta-Analysis.

Anterior iliac crest (AIC) is the preferred option for bone grafting; however, pain and complications are reported. Proximal tibia (PT) is a sourceful site for bone grafting with lower complications. MEDLINE, EMBASE, and Scopus were searched to identify studies comparing AIC and PT autograft procedure. The main outcome was pain and complication rate. As well as cadaveric and cell-based studies were analyzed for quantity and quality of AIC and PT autograft. A meta-analysis was performed using the generic inverse variance method with random or fixed effects model depending on heterogeneity between studies. Heterogeneity was tested with the I2 statistic index. Fifteen studies were included in the meta-analysis. Six studies and 248 patients were included for clinical outcomes. A significant pain reduction favoring PT at 24 hours was detected after meta-analysis and corresponding sensitivity analysis. The estimated effect size ranged from -2.31 to -2.93 cm, with confidence intervals aligned to the left indicating a robust steady decrease in pain across studies. This effect was not observed after 1 month. A total of 18 complications were reported, 13 in the AIC group and 5 in the PT group. Four cadaveric studies were included, 3 favored PT on the quantity of bone graft harvested. Five cell-based studies were included, only one study favored AIC for quality of bone graft. Our study concludes that PT bone harvest is a reliable option for bone grafting regarding morbidity, complications, volume graft obtained, and cellular and molecular properties. However, the current evidence is still insufficient to draw definitive conclusions, especially in terms of bone healing. PROSPERO Register: CRD42020198150.

Spinal epidural hematoma in antiphospholipid syndrome: case report and review of the literature.

INTRODUCTION: Spinal epidural hematomas are a surgical emergency, the delay in diagnosis can develop devastating sequelae due to its acute and progressive course. If not treated properly, it may lead to death or permanent neurological deficit. It is a rare condition that can occur in patients with hematologic pathology. CASE PRESENTATION: We report a case report and literature review of a patient with antiphospholipid syndrome, who undergoes a diagnostic lumbar puncture for probable fungal meningitis. Developed a spinal acute epidural hematoma with neurological involvement that is evidenced in MRI. Urgent surgical decompression was performed with good results. DISCUSSION: Despite the low incidence of an epidural hematoma in patients who undergo lumbar puncture, it is important to perform a thorough evaluation in any patient with coagulation abnormalities prior and after a lumbar puncture, by reason of the inherent possibility of developing an epidural hematoma at the site of the procedure. In the same way, early diagnosis and aggressive treatment is necessary in patients who develop progressive neurological symptoms to limit the damage and improve the prognosis for neurological recovery.

Double-Row Rotator Cuff Repair Enhanced With Platelet-Rich Therapy Reduces Retear Rate: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

PURPOSE: To assess retear rates in arthroscopic double-row rotator cuff repair (double-row RCR) with and without platelet-rich therapy (PRT). METHODS: Systematic review and meta-analysis of randomized controlled trials (RCTs). MEDLINE, Embase, and Scopus databases were searched for RCTs involving use of PRT exclusively in arthroscopic double-row RCR. A random-effects model and the generic inverse variance method were used for quantitative data synthesis. Heterogeneity was tested with the I2 statistic index. RESULTS: The 9 RCTs included in the meta-analysis demonstrated a risk reduction of 49% for retears in patients receiving PRT (risk ratio [RR] 0.51; 95% confidence interval [CI] 0.35 to 0.76; P = .0008; I2 = 0%). Divided by tear sizes, retear risk reduction of 47% (RR 0.53; 95% CI 0.30 to 0.95; P = .03; I2 = 0%) was found in small to medium tears and 51% (RR 0.49; 95% CI 0.29 to 0.84; P = .009; I2 = 0%) in large to massive tears. Linked double-row RCR resulted in risk reduction of 51% for retears in comparison with nonlinked repairs. CONCLUSION: Double-row RCR plus PRT significantly reduced retear rates in all sizes of rotator cuff tears. Linked double-row RCR and applying the PRT during the surgical procedure and in the tendon-bone interface reproduced the best outcomes. Clinically, all patients improved, and no statistically significant difference was seen in clinical and functional scores between the intervention groups. All patients achieved optimal values for patient-reported outcomes measures. LEVEL OF EVIDENCE: I, systematic review and meta-analysis of level I studies.

Anti­inflammatory and anti­catabolic effect of non­animal stabilized hyaluronic acid and mesenchymal stem cell­conditioned medium in an osteoarthritis coculture model.

Previous clinical studies have reported the clinical effectiveness of non­animal stabilized hyaluronic acid (NASHA) and adipose­derived mesenchymal stromal/stem cells (MSC) in the treatment of knee osteoarthritis (OA). Unlike MSC secreted mediators, in vitro anti­inflammatory effects of NASHA have not been evaluated. We aimed to evaluate and compare the anti­inflammatory effect of NASHA and MSC conditioned medium (stem cell­conditioned medium; SC­CM), in an explant­based coculture model of OA. Cartilage and synovial membrane from seven patients undergoing total knee arthroplasty were used to create a coculture system. Recombinant IL­1ß was added to the cocultures to induce inflammation. Four experimental groups were generated: i) Basal; ii) IL­1ß; iii) NASHA (NASHA + IL­1ß); and iv) SC­CM (SC­CM + IL­1ß). Glycosaminoglycans (GAG) released in the culture medium and of nitric oxide (NO) production were quantified. Gene expression in cartilage and synovium of IL­1ß, matrix metallopeptidase 13 (MMP13), ADAM metallopeptidase with thrombospondin type 1 motif 5 (ADAMTS5) and tissue inhibitor of metalloproteinases 1 (TIMP1) was measured by reverse transcription­quantitative PCR. Media GAG concentration was decreased in cocultures with NASHA and SC­CM (48 h, P<0.05; 72 h, P<0.01) compared with IL­1ß. Production of NO was significantly lower only in SC­CM after 72 h (P<0.01). In cartilage, SC­CM inhibited the expression of IL­1ß, MMP13 and ADAMTS5, while NASHA had this effect only in MMP13 and ADAMTS5. In synovium, SC­CM decreased the expression level of MMP13 and ADAMTS5, while NASHA only decreased ADAMTS5 expression. Both NASHA and SC­CM increased TIMP1 expression in cartilage and synovium. Treatments with NASHA and SC­CM were shown to be a therapeutic option that may help counteract the catabolism produced by the inflammatory state in knee OA. The anti­inflammatory mediators produced by MSC promote a lower expression of inflammatory targets in our study model.

Effect of Normal Saline Injections on Lateral Epicondylitis Symptoms: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

BACKGROUND: Lateral epicondylitis, or tennis elbow, is a painful degenerative disorder that commonly occurs in adults between 40 and 60 years of age. Normal saline (NS) injections have been used as placebo through a large number of randomized controlled trials (RCTs) focused on the treatment of lateral epicondylitis. PURPOSE: This meta-analysis of RCTs aimed to assess the therapeutic effect of NS injections on lateral epicondylitis symptoms and compare results with established minimal clinically important difference criteria. STUDY DESIGN: Systematic review and meta-analysis. METHODS: MEDLINE, Embase, Web of Science, and Scopus databases were searched for clinical trials reporting pain and joint function with the visual analog scale, Patient-Rated Tennis Elbow Evaluation, and Disabilities of the Arm, Shoulder and Hand in patients with lateral epicondylitis. The meta-analysis was conducted with a random effects model and generic inverse variance method. Heterogeneity was tested with the I2 statistic index. RESULTS: A total of 15 RCTs included in this meta-analysis revealed a significant improvement in pain (mean difference, 3.61 cm [95% CI, 2.29-4.92 cm]; P < .00001; I2 = 88%; visual analog scale) and function (mean difference, 25.65 [95% CI, 13.30-37.99]; P < .0001; I2 = 82%; Patient-Rated Tennis Elbow Evaluation / Disabilities of the Arm, Shoulder and Hand) after NS injection (≥6 months). CONCLUSION: NS injections yielded a statistically significant and clinically meaningful improvement in pain and functional outcomes in patients with lateral epicondylitis. New research should focus on better methods to diminish the potential confounders that could lead to this effect because NS injections could mask the real effect of an active therapeutic intervention in RCT. REGISTRATION: CRD42019127547 (PROSPERO).

Intraarticular injection of platelet-rich plasma in knee osteoarthritis: single versus triple application approach. Pilot study.

OBJECTIVE: To compare the clinical effectiveness of the triple intra-articular injection of platelet-rich plasma (PRP) with respect to the single injection in patients with mild osteoarthritis of the knee. METHODS: A total of 35 patients with a clinical and radiographic diagnosis of osteoarthritis grade I and II were analyzed. They were randomized into two groups: single application (18 patients) and triple application (17 patients). Both groups were evaluated using the Visual Analogue Scale (VAS), the Western Ontario and McMaster Universities (WOMAC) index, and the Health Survey 12v2 (SF-12) at baseline and at 6, 12, 24, 36 and 48 weeks post-treatment. RESULTS: Both treatments significantly decreased the level of pain (VAS) (single, from 7.3±2.1 to 4.6±2.7 and triple, from 6.6±2.4 to 0.9±1.4; p lt 0.05) and the total WOMAC (single, from 44.2±19.7 to 26.7±24.9 and triple, from 41.4±15.5 to 7.2±7.3; p lt 0.05) at the end of the study. The triple application showed better improvement in the VAS (p= 0.0007) and the total WOMAC (p= 0.0209) scores when comparing the final results between groups. CONCLUSION: The triple infiltration of PRP in patients with mild knee osteoarthritis is clinically more effective than the single application at 48 weeks of follow-up.

Effect of collagen supplementation on osteoarthritis symptoms: a meta-analysis of randomized placebo-controlled trials.

PURPOSE: Osteoarthritis (OA) is one of the most common causes of disability and a prevalent chronic disease. The use of collagen is growing due to the satisfactory results in the treatment of OA. However, the possible beneficial effects of collagen for the treatment of OA are currently controversial. The aim of the present meta-analysis was to evaluate the effect of collagen-based supplements on OA symptoms. METHODS: PubMed-Medline, Scopus, and Google Scholar databases were searched for randomized placebo-controlled trials evaluating the effect of orally administered collagen on OA symptoms using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale and/or the Visual Analog Scale (VAS). Meta-analysis was conducted using a random-effects model and a generic inverse variance method. Heterogeneity was tested using the I2 statistic index. RESULTS: Collagen treatment showed a significant reduction in the score of total WOMAC index (WMD - 8.00; 95% CI - 13.04, - 2.95; p = 0.002). After subgroup analysis of the WOMAC subscores, the collagen supplementation revealed a significant decrease in the stiffness subscore (WMD - 0.41; 95% CI - 0.74, - 0.08; p = 0.01), whereas the pain (WMD - 0.22; 95% CI - 1.58, 1.13; p = 0.75) and functional limitation (WMD - 0.62; 95% CI - 5.77, 4.52; p = 0.81) subscores did not have significant differences. Finally, a significant reduction was found in the VAS score after collagen administration (WMD - 16.57; 95% CI - 26.24, - 6.89; p < 0.001). CONCLUSION: The results of this meta-analysis showed that collagen is effective in improving OA symptoms by the decrease of both total WOMAC index and VAS score.

Comparison of the Clinical Effectiveness of Single Versus Multiple Injections of Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis: A Systematic Review and Meta-analysis.

BACKGROUND: Reports have concluded that platelet-rich plasma (PRP) is an effective and safe biological approach in the treatment of knee osteoarthritis (OA). However, no consensus has been established regarding the number of injections required to observe a therapeutic effect. PURPOSE: To compare the clinical effectiveness reported in randomized controlled trials (RCTs) of single versus multiple PRP injections in the treatment of knee OA. STUDY DESIGN: Systematic review; Level of evidence, 1. METHODS: A comprehensive search was conducted for RCTs published between 1970 and 2019 that compared the effect of single versus multiple PRP injections on pain and functionality in patients with knee OA. Searched databases included MEDLINE, Scopus, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. A data extraction form was designed to obtain bibliographic information of the study as well as patient, intervention, comparison, and outcomes of interest data. A random-effects model was used to pool quantitative data from the primary outcomes. RESULTS: We included 5 clinical trials with a low-moderate risk of bias that reported data for 301 patients. Meta-analysis showed that, at 6 months after the intervention, single and multiple (double or triple) injections had similar pain improvement, with no significant differences (standardized mean difference [SMD], 0.61 [95% CI, -1.09 to 2.31]; I 2 = 97%; P = .48). A significant improvement in knee functionality was observed in favor of multiple injections (SMD, 2.29 [95% CI, 0.45-4.12]; I 2 = 97%; P = .01). Subanalysis showed that the significant improvement was only evident for the results of single versus triple injections (SMD, 3.12 [95% CI, 0.64-5.60]; I 2 = 97%; P = .01). CONCLUSION: According to our results, a single injection was as effective as multiple PRP injections in pain improvement; however, multiple injections seemed more effective in joint functionality than a single injection at 6 months. We consider that the available evidence is still insufficient, and future research on this specific topic is needed to confirm our results.