Faculty Bibliography

Anterior cruciate ligament CAW reconstruction is one of the most commonly performed orthopaedic procedures. Venous thromboembolism is a rare, but potentially serious complication of ACL reconstructions and having a thorough understanding of the potential risk factors could help to minimize the incidence of postoperative deep vein thrombosis or pulmonary embolism. We review some of the literature on the risk factors, diagnosis and treatment of deep vein thrombosis or pulmonary embolism. Although current data does not support the routine use of thromboprophylaxis in all patients undergoing ACL reconstruction, it is important for the clinician to be aware that some consideration should be given for initiating pharmacological prophylaxis in some patients who may be at increased risk for thromboembolic disease. Oper Tech Sports Med 24:73-76 (C) 2015 Published by Elsevier Inc.

Staphylococcus aureus nasal colonization is a risk factor for surgical site infection. We conducted a retrospective case-control study of 1,708 consecutively enrolled patients to identify criteria that places orthopaedic surgery patients undergoing spine and total joint arthroplasty surgery at risk for nasal colonization by MRSA and MSSA. Multivariate analysis showed obesity and asthma as significant risk fac - tors for MRSA colonization. The identification of these two risk factors for MRSA colonization may help decolonization programs target patients with these factors for treatment prior to surgery, which could potentially lead to reductions in the rates of surgical site infections.

PURPOSE: The aims of this study were (1) to perform a systematic review of meta-analyses evaluating platelet-rich plasma (PRP) injection in the treatment of knee joint cartilage degenerative pathology, (2) to provide a framework for analysis and interpretation of the best available evidence to provide recommendations for use (or lack thereof) of PRP in the setting of knee osteoarthritis (OA), and (3) to identify literature gaps where continued investigation would be suggested. METHODS: Literature searches were performed for meta-analyses examining use of PRP versus corticosteroids, hyaluronic acid, oral nonsteroidal anti-inflammatory drugs, or placebo. Clinical data were extracted, and meta-analysis quality was assessed. The Jadad algorithm was applied to determine meta-analyses that provided the highest level of evidence. RESULTS: Three meta-analyses met the eligibility criteria and ranged in quality from Level II to Level IV evidence. All studies compared outcomes of treatment with intra-articular platelet-rich plasma (IA-PRP) versus control (intra-articular hyaluronic acid or intra-articular placebo). Use of PRP led to significant improvements in patient outcomes at 6 months after injection, and these improvements were seen starting at 2 months and were maintained for up to 12 months. It is unclear if the use of multiple PRP injections, the double-spinning technique, or activating agents leads to better outcomes. Patients with less radiographic evidence of arthritis benefit more from PRP treatment. The use of multiple PRP injections may increase the risk of self-limited local adverse reactions. After application of the Jadad algorithm, 3 concordant high-quality meta-analyses were selected and all showed that IA-PRP provided clinically relevant improvements in pain and function compared with the control treatment. CONCLUSIONS: IA-PRP is a viable treatment for knee OA and has the potential to lead to symptomatic relief for up to 12 months. There appears to be an increased risk of local adverse reactions after multiple PRP injections. IA-PRP offers better symptomatic relief to patients with early knee degenerative changes, and its use should be considered in patients with knee OA. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

PURPOSE: To conduct a systematic review of overlapping meta-analyses comparing treatment of knee osteoarthritis (OA) with intra-articular viscosupplementation (intra-articular hyaluronic acid [IA-HA]) versus oral nonsteroidal anti-inflammatory drugs (NSAIDs), intra-articular corticosteroids (IA-corticosteroids), intra-articular platelet-rich plasma (IA-PRP), or intra-articular placebo (IA-placebo) to determine which meta-analyses provide the best current evidence and identify potential causes of discordance. METHODS: Literature searches were performed for meta-analyses examining use of IA-HA versus NSAIDs, IA-corticosteroids, IA-PRP, or IA-placebo. Clinical data were extracted, and meta-analysis quality was assessed. The Jadad algorithm was applied to determine which meta-analyses provided the highest level of evidence. RESULTS: Fourteen meta-analyses met the eligibility criteria and ranged in quality from Level I to IV evidence. In studies reporting patient numbers, there were a total of 20,049 patients: 13,698 receiving IA-HA, 355 receiving NSAIDs, 294 receiving IA-corticosteroids, and 5,702 receiving IA-placebo. Ten studies examined the effects of IA-HA versus IA-placebo; of these, 5 found that IA-HA improved pain and 4 found that IA-HA improved function. No clinically relevant differences in the efficacy of IA-HA versus NSAIDs regarding pain and function were found. Regarding IA-HA versus IA-PRP, IA-HA improved knee function at 2 and 6 months after injection but the effects were less robust than those of IA-PRP. Regarding IA-HA versus IA-corticosteroids, the positive effects of IA-HA were greater at 5 to 13 weeks and persisted for up to 26 weeks. After application of the Jadad algorithm, 2 concordant high-quality meta-analyses were selected and both showed that IA-HA provided clinically relevant improvements in pain and function compared with IA-placebo. CONCLUSIONS: This systematic review of overlapping meta-analyses comparing IA-HA with other nonoperative treatment modalities for knee OA shows that the current highest level of evidence suggests that IA-HA is a viable option for knee OA. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. IA-HA has a good safety profile, and its use should be considered in patients with early knee OA. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

CONTEXT: Venous thromboembolic (VTE) disease is thought to be an uncommon but serious problem after anterior cruciate ligament (ACL) reconstruction. Rates of VTE after ACL reconstruction are not well documented. OBJECTIVE: To determine the rates of deep vein thrombosis (DVT) and symptomatic pulmonary emboli (PE) after ACL reconstruction. DATA SOURCES: Five publicly available databases (PubMed, Cochrane Database of Systematic Reviews, Scopus, Embase, and CINAHL Complete) were utilized. STUDY SELECTION: All studies that screened patients for DVT and reported rates of DVT and PE after ACL reconstruction were eligible for inclusion. Level 5 evidence, cadaver, biomechanical, and basic science studies; studies reporting only multiligament reconstruction outcomes; studies where rates of DVT and PE could not be separated out from patients undergoing other types of arthroscopic knee procedures; and classification studies were excluded. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: All study, subject, and surgical data were analyzed. Descriptive statistics were calculated. RESULTS: Six studies met the inclusion criteria, with a mean Modified Colman Methodology Score of 30 +/- 8.22. A total of 692 patients (488 men [70.5%]; mean age, 31.6 +/- 2.82 years; mean follow-up, 7 +/- 18.4 months) underwent ACL reconstruction using either semitendinosus-gracilis autograft (77.6%), bone-patellar tendon-bone (BTB) autograft (22%), or allograft (0.4%). No patient received postoperative pharmacological anticoagulation. Fifty-eight patients (8.4%) had a DVT (81% below knee and 19% above knee), while only 1 patient (0.2%) had a symptomatic PE. When reported, 27% of DVT episodes were symptomatic. CONCLUSION: The rate of DVT after ACL reconstruction in patients who did not receive postoperative pharmacological anticoagulation is 8.4%, while the rate of symptomatic PE is 0.2%. Of the DVT episodes that occurred, 73% were asymptomatic.

A thorough knowledge of the principles of antibiotic stewardship is a crucial part of high-quality orthopaedic surgical care. These principles include (1) determining appropriate indications for antibiotic administration, (2) choosing the correct antibiotic based on known or expected pathogens, (3) determining the correct dosage, and (4) determining the appropriate duration of treatment. Antibiotic stewardship programs have a multidisciplinary staff that can help guide antibiotic selection and dosage. These programs also perform active surveillance of antimicrobial use and may reduce Clostridium difficile and other drug-resistant bacterial infections by providing expert guidance on judicious antibiotic usage. The emergence of antibiotic-resistant pathogens, the geographical diversity of these infecting pathogens, and the changing patient population require customization of prophylactic regimens to reduce infectious complications. A multidisciplinary approach to antibiotic stewardship can lead to improved patient outcomes and cost-effective medical care.

CONTEXT: Skeletal muscle is comprised of a highly organized network of cells, neurovascular structures, and connective tissue. Muscle injury is typically followed by a well-orchestrated healing response that consists of the following phases: inflammation, regeneration, and fibrosis. This review presents the mechanisms of action and evidence supporting the effectiveness of various traditional and novel therapies at each phase of the skeletal muscle healing process. EVIDENCE ACQUISITION: Relevant published articles were identified using MEDLINE (1978-2013). STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 3. RESULTS: To facilitate muscle healing, surgical techniques involving direct suture repair, as well as the implantation of innovative biologic scaffolds, have been developed. Nonsteroidal anti-inflammatory drugs may be potentially supplanted by nitric oxide and curcumin in modulating the inflammatory pathway. Studies in muscle regeneration have identified stem cells, myogenic factors, and beta-agonists capable of enhancing the regenerative capabilities of injured tissue. Furthermore, transforming growth factor-beta1 (TGF-beta1) and, more recently, myostatin and the rennin-angiotensin system have been implicated in fibrous tissue formation; several antifibrotic agents have demonstrated the ability to disrupt these systems. CONCLUSION: Effective repair of skeletal muscle after severe injury is unlikely to be achieved with a single intervention. For full functional recovery of muscle there is a need to control inflammation, stimulate regeneration, and limit fibrosis. STRENGTH-OF-RECOMMENDATION TAXONOMY SORT: B.

OBJECTIVE: To determine the role of ANK/Myb-binding protein 1a (MYBBP1a) and sphingosine kinase 1 (SPHK1) interactions in catabolic events of articular chondrocytes. METHOD: ANK/MYBBP1a and SPHK1 interactions were identified using yeast two-hybrid screening and co-immunoprecipitation. To determine the role of these interactions in catabolic events of articular chondrocytes, ank/ank and wild type mouse chondrocytes transfected with full-length or mutant ank expression vectors or femoral heads were treated with interleukin-1beta (IL-1beta) in the absence or presence of SPHK inhibitor. Catabolic marker mRNA levels were analyzed by real time PCR; proteoglycan loss using safranin O staining and MMP-13 immunostaining were determined in femoral head explants; NF-kappaB activity was determined by transfecting chondrocytes with a NF-kappaB-specific luciferase reporter and analyzing nuclear translocation of p65 by immunoblotting; MYBBP1a nuclear or cytoplasmic amounts were determined by immunohistochemistry and immunoblotting. RESULTS: The ANK N-terminal region interacted with SPHK1, whereas a cytoplasmic C-terminal loop interacted with MYBBP1a. Lack of ANK/MYBBP1a and SPHK1 interactions in ank/ank chondrocytes resulted in increased MYBBP1a nuclear amounts and decreased SPHK1 activity, and consequently decreased NF-kappaB activity, catabolic marker mRNA levels, proteoglycan loss, and MMP-13 immunostaining in IL-1beta-treated articular chondrocytes or femoral heads. Transfection with full-length ank expression vector reduced nuclear MYBBP1a amounts and fully restored SPHK and NF-kappaB activities in IL-1beta-treated ank/ank chondrocytes, whereas transfection with P5L or F376del mutant ank reduced nuclear MYBBP1a or increased SPHK activity, respectively, and consequently either transfection only partially restored NF-kappaB activity. CONCLUSION: ANK/MYBBP1a and SPHK1 interactions stimulate catabolic events in IL-1beta-mediated cartilage degradation.