Faculty Bibliography

BACKGROUND/UNASSIGNED:Biological adjuvants are used after a musculoskeletal injury to improve healing, decrease inflammation, and restore joint homeostasis. Work on 1 such adjuvant, platelet-rich plasma (PRP), has suggested a positive effect when introduced during cartilage repair. However, it remains unknown whether healing osteochondral injuries benefit from serial PRP injections. PURPOSE/UNASSIGNED:To evaluate the effects of serial PRP injections versus a single PRP injection on reparative cartilaginous tissue, subchondral bone remodeling, and the expression of inflammatory cytokines in joint synovium. STUDY DESIGN/UNASSIGNED:Controlled laboratory study. METHODS/UNASSIGNED:A total of 48 New Zealand White rabbits were randomly assigned to receive 1 (1P), 2 (2P), or 3 (3P) PRP injections. Cylindrical full-thickness cartilage defects (2.9 × 2.9 mm) with microdrillings (0.6-mm diameter) were created on the medial condyles of both knees. PRP was injected into the right knee after closure (groups 1P, 2P, and 3P), at 2 weeks after surgery (groups 2P and 3P), and at 4 weeks after surgery (group 3P). The left knees did not receive any PRP injections. A total of 6 rabbits in each group were euthanized at 3, 6, and 12 weeks postoperatively. Cartilage repair tissue was assessed using the Goebel macroscopic and modified International Cartilage Regeneration & Joint Preservation Society (ICRS) histological scoring systems. Subchondral bone remodeling was evaluated by micro-computed tomography analysis (micro-CT). Inflammatory cytokine levels were assessed by quantitative polymerase chain reaction. RESULTS/UNASSIGNED:No significant differences were found for the mean macroscopic score between the PRP groups at 12 weeks (control, 6.1 ± 3.3; group 1P, 3.4 ± 2.7; group 2P, 4.2 ± 2.9; group 3P, 0.7 ± 1.5). All PRP groups had a significantly higher mean modified ICRS histological score compared with the control group, but no significant difference was found among the PRP groups. No significant differences were seen in outcomes for the tested micro-CT parameters or cytokine expression levels. CONCLUSION/UNASSIGNED:Serial PRP injections conferred no apparent advantage over single injections according to evaluations of the macroscopic and histological appearance of the cartilaginous tissue, subchondral bone healing, and inflammatory cytokine expression levels in the synovium. CLINICAL RELEVANCE/UNASSIGNED:The use of PRP as a biological adjuvant to bone marrow stimulation for osteochondral lesions has the potential to enhance the quality of regenerative cartilaginous tissue. We recommend only a single PRP injection if the use of PRP is indicated by the operating surgeon as an adjuvant therapy for osteochondral lesions.

BACKGROUND:There appears to be a close relationship between deformities at the knee joint and at the hindfoot in patients with knee osteoarthritis (OA). Despite this intrinsic link, there is a dearth of studies investigating alterations in hindfoot alignment following total knee arthroplasty (TKA) in patients with knee OA. AIM/OBJECTIVE:To evaluate changes in alignment of the hindfoot following TKA, foot and ankle clinical outcomes in terms of subjective clinical scoring tools following surgical intervention, and to analyse the level of evidence (LOE) and quality of evidence (QOE) of the included studies. METHODS:MEDLINE, EMBASE and Cochrane Library databases were systematically reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting changes in the postoperative alignment of the hindfoot following TKA were included. The level and QOE were recorded and assessed. RESULTS:Eleven studies with a total of 1142 patients (1358 knees) met the inclusion/ exclusion criteria. Six studies were of LOE II and 5 studies were of LOE III. Patients with preoperative varus knee deformity and valgus hindfoot deformity demonstrated improvement in hindfoot alignment post TKA. Patients with preoperative varus knee deformity and varus hindfoot deformity demonstrated no improvement in hindfoot alignment following TKA. Twelve different radiographic parameters were used to measure the alignment of the hindfoot across the included studies, with the tibio-calcaneal angle most frequently utilised (27.3%). CONCLUSION/CONCLUSIONS:This systematic review demonstrated that the hindfoot may display compensatory changes in alignment following TKA in patients with knee OA. However, the marked heterogeneity between the included studies and poor QOE limits any meaningful cross sectional comparisons between studies. Further, well designed studies are necessary to determine the changes and outcomes of hindfoot alignment following TKA.

BACKGROUND:Hemiarthroplasty using a polyvinyl alcohol (PVA) hydrogel synthetic implant has been suggested as a good alternative to arthrodesis for the treatment of hallux rigidus. However, failure rates as high as 20% have been recorded. PURPOSE:To characterize the pathological processes in bone, cartilage, and the synovial membrane after PVA hemiarthroplasty in an ovine model with 6 months of follow-up. STUDY DESIGN:Controlled laboratory study. METHODS:A unilateral osteochondral defect (8-mm diameter × 10-mm depth) was made in the medial femoral condyle in 6 sheep. Animals were randomized to receive a PVA implant (n = 4) or to have an empty defect (n = 2) and were monitored for 6 months. Patellofemoral radiographs were obtained at monthly intervals, and quantitative computed tomography was performed at the end of the study. After death, the joints were macroscopically evaluated and scored. Osteochondral and synovial membrane histological findings were assessed using modified Osteoarthritis Research Society International (OARSI) and aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) scoring systems. Immunohistochemistry using Iba1 was performed to evaluate activated macrophage infiltration. RESULTS:Overall, 2 sheep with PVA implants were euthanized at 1 and 5 months because of uncontrollable pain and lameness (failed implants). Quantitative computed tomography showed that sheep with failed implants had 2.1-fold more osteolysis than those with successful implants. The sheep with failed implants had osteoarthritis with extensive glycosaminoglycan loss and cartilage fibrillation of the condyle and opposing tibial surface on histological examination. A foreign body reaction with severe chronic lymphoplasmacytic and granulomatous inflammation with giant cells was detected surrounding the implant. The synovial membrane ALVAL score was 9 of 19 and 14 of 19 in failed implants with synovial hyperplasia and lymphoplasmacytic and macrophage infiltration. In contrast, the synovial membrane in successful implants and empty defects was normal (ALVAL score = 0/19). Immunolabeling for Iba1 in failed implants confirmed extensive and dense macrophage infiltration within the condyle and synovial membrane, with the highest immunoreactive score (9/9). CONCLUSION:PVA hydrogel implants had a 50% failure rate with uncontrollable pain, severe osteolysis, inflammation, and foreign body reactions. CLINICAL RELEVANCE:The failure rate and pathological characteristics of the PVA implants suggest that their use should not be continued in human patients without further in vivo safety studies.

BACKGROUND:The purpose of the present study was to evaluate the efficacy of biological adjuvants in patients managed with hindfoot arthrodesis. METHODS:A systematic review of the PubMed and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with use of specific search terms and eligibility criteria. Assessment of evidence was threefold: level of evidence by criteria as described in The Journal of Bone & Joint Surgery, quality of evidence according to the Newcastle-Ottawa scale, and conflicts of interest. Meta-analysis was performed with fixed-effects models for studies of low heterogeneity (I2 < 25%) and with random-effects models for studies of moderate to high heterogeneity (I2 ≥ 25%). RESULTS:A total of 1,579 hindfeet were recruited across all studies, and 1,527 hindfeet were recorded as having completed treatment and follow-up visits. The duration of follow-up ranged from 2.8 to 43 months. Twelve of the 17 included studies comprised patients with comorbidities associated with reduced healing capacity. Based on the random-effects model for nonunion rates for autograft versus allograft, the risk ratio was 0.82 (95% CI, 0.13 to 5.21; I2 = 56%; p = 0.83) in favor of lower nonunion rates for autograft. Based on the random-effects model for rhPDGF/β-TCP versus autograft, the risk ratio was 0.90 (95% CI, 0.74 to 1.10; I2 = 59%; p = 0.30) in favor of lower nonunion rates for rhPDGF/β-TCP. CONCLUSIONS:There is a lack of data to support the meaningful use of biological adjuvants as compared with autograft/allograft for hindfoot arthrodesis. The meta-analysis favored the use of autograft when compared with allograft but favored rhPDGF/β-TCP when compared with autograft in the short term. LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE/OBJECTIVE:To assess the feasibility of needle arthroscopy for management of suspected bacterial arthritis in native joints. METHODS:During a pilot period, patients presenting with symptoms suggestive of native joint bacterial arthritis were eligible for initial management with needle arthroscopy. Procedures were performed in the operating theatre or at the patient bedside in the emergency department or inpatient ward. As our primary outcome measure, it was assessed whether needle arthroscopic lavage resulted in a clear joint. In addition, the need for conversion to standard arthroscopy or arthrotomy, the need for conversion from local to general anaesthesia, complications and the need for additional surgical intervention at follow-up during admission were recorded. RESULTS:Eleven joints in 10 patients (four males, age range 35 - 77) were managed with needle arthroscopy. Needle arthroscopic lavage resulted in a clear joint in all cases. Conversion to standard arthroscopy or arthrotomy was not needed. Seven procedures were performed at the patient bedside using local anaesthesia. These procedures were well tolerated and conversion to general or spinal anaesthesia was not required. There were no procedure complications. One patient received multiple needle arthroscopic lavages. No further surgical interventions beside the initial needle arthroscopic lavage were required for successful management in other cases. CONCLUSIONS:Needle arthroscopy can be a feasible tool in the initial management of complaints suggestive for native joint bacterial arthritis, providing an effective, quick and well-tolerable intervention in the operating theatre or at the patient bedside, with the potential to relief health systems from need for scarce operating theatre time.

The purpose of this study was to provide an overview of the available evidence on peroneal tendon tears and the outcomes after surgical intervention. A systematic review of the literature was performed using MEDLINE, Embase, and Cochrane. Criteria for inclusion were clinical studies reporting outcomes after treatment for peroneal tendon tear within the last 10 years. Nine studies evaluating 336 patients (146 males/190 females) and 336 ankles were included in this review. The mean age of included patients was 46.3 years (range, 46-56.9 years). The weighted mean follow-up was 23.82 months (range 9.2-78 months. Five surgical interventions were reported: primary repair with tenodesis, primary repair without tenodesis, FDL tendon transfer, FHL tendon transfer, and allograft reconstruction. Four studies recorded the AOFAS score, with a weighted mean preoperative score of 69.58 and a weighted mean postoperative score of 88.82. Six studies measured the VAS score showing an improvement from a mean weighted preoperative score of 4.68 to a mean weighted postoperative score of 1.2. FAAM score was measured in 3 studies, which showed an improvement from 41.1 preoperatively to 84.4 postoperatively. The average overall complication rate was 38.7% (130/336) with the most commonly reported minor complication being ankle pain, which made up 46.2% of all minor complications (56/121). Primary repair without tenodesis was associated with a higher complication rate compared to any other surgical intervention (p=.001176). The current systematic review showed that overall clinical outcomes were positive in lieu of the different modalities of surgical intervention for peroneal tendon tears.

PURPOSE/OBJECTIVE:The purpose of this study is to evaluate the effectiveness of Extracellular Matrix Cartilage Allograft (EMCA) as an adjuvant to bone marrow stimulation (BMS) compared to BMS alone in the treatment of osteochondral lesions of the talus (OLT). METHODS:or Fisher exact test for categorical variables. RESULTS:Twenty-four patients underwent BMS with EMCA (BMS-EMCA group) and 24 patients underwent BMS alone (BMS group). The mean age was 40.8 years (range, 19 to 60 years) in BMS-EMCA group and 47.8 years (range, 24 to 60 years) in BMS group (p=0.060). The mean follow-up time was 20.0 months (range, 12-36 months) in BMS-EMCA group and 26.9 months (range, 12 to 55 months) in BMS group (p=0.031). Both groups showed significant improvements in all FAOS subscales. No significant differences between groups were found in all postoperative FAOS. The mean MOCART score in BMS-EMCA group was higher (76.3 vs 66.3), but not statistically significant (p=0.176). The MRI analysis showed that 87.5% of BMS-EMCA group had complete infill of the defect with repair tissue, however less than half (46.5%) of BMS group had complete infill (p=0.015). CONCLUSION/CONCLUSIONS:BMS with EMCA is an effective treatment strategy for the treatment of OLT and provides better cartilage infill in the defect on MRI. However, this did not translate to improved functional outcomes compared with BMS alone in the short-term. Additionally, according to the minimal clinically important difference (MCID) analysis, there was no significant difference in clinical function scoring between either group postoperatively. LEVEL OF EVIDENCE/METHODS:Level III retrospective comparative study.

OBJECTIVE/UNASSIGNED:Patients frequently use the internet as a source to obtain health information. The purpose of this study was to evaluate the quality and readability of online resources on the diagnosis and treatment of ankle osteochondral lesions (OCLs). DESIGN/UNASSIGNED:Three search terms ("ankle cartilage defect," "cartilage injury," "ankle cartilage damage") were entered into 3 search engines (Google, Yahoo, and Bing). The first 20 websites from each search was collected excluding websites intended for health care providers. The quality of the websites were evaluated using the DISCERN instrument, JAMA benchmark, and a Quality rating criteria specific to ankle OCL. The readability was assessed using Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL). Statistical analysis was performed using one-way analysis of variance. RESULTS/UNASSIGNED:A total of 41 websites were reviewed. The mean quality ratings were poor across the assessment tools: DISCERN = 38.5 ± 9.0 (range, 23.7-56.7) out of 80; JAMA = 1.0 ± 1.1 (range, 0-3.3) out of 4; and Quality rating criteria = 11.3 ± 4.6 (range, 4-20.7) out of 24. The mean FRE and FKGL were 40.7 ± 32.0 (range, -152.3 to 60.2) and 13.5 ± 10.8 (range, 8.4-80.7), respectively; higher than the recommended reading level for patients (fifth grade). CONCLUSIONS/UNASSIGNED:The quality and readability of credible sources for ankle OCL were poor, which could lead to misinformation. This study should guide the improvement of online information on ankle OCL.

PURPOSE/OBJECTIVE:(1) To determine the rate of return to play following autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLT) and (2) report subsequent rehabilitation protocols. METHODS:A systematic review of the PubMed, Embase, and The Cochrane Library databases was performed according to the PRISMA guidelines based on specific eligibility criteria. Return to play data was meta-analysed and subsequent rehabilitation protocols were summarised. Level of evidence and quality of evidence (Zaman's criteria) were also evaluated. RESULTS: = 0.140, p = 0.023). The most common time to ankle motion post-surgery was immediately and the most common time to full weight-bearing was 12 weeks. CONCLUSIONS:This systematic review indicated a high rate of return to play following AOT in the athletic population. Size of OLT was not found to be a predictor of return to play, whereas advancing age was a predictor. Rehabilitation protocols were largely inconsistent and were primarily based on individual surgeon protocols. However, the included studies were of low level and quality of evidence. LEVEL OF EVIDENCE/METHODS:Level IV.

Extracorporeal shock wave therapy (ESWT) is a promising treatment for plantar fasciitis (PF), however, treatment results have varied due to inconsistencies among types of shock wave treatment and devices used. This retrospective chart review includes patients who underwent ESWT using the OrthoGold 100â„¢ shock wave device (MTS, Konstanz, Germany) for PF between January, 2013 and September, 2018. There were 108 patients (119 heels) identified, with a mean age of 51.7 ± 16.5 (Range 21-83) years. Patients were treated weekly for 3 weeks, with 2000 impulses per session at an energy flux density between 0.10 and 0.17 mJ/mm². Mean follow-up duration was 11.5 ± 9.7 (Range 3-51) months. Mean pre-ESWT pain visual assessment scale improved from 6.7 ± 1.7 to 2.6 ± 2.7 (p < .001). The Foot and Ankle Outcome Score subscales: pain, function of daily living, function of sports and recreational activities and quality of life domains improved from 53.7 ± 14.9 to 75.7 ± 16.7 (p < .001), from 38 ± 15.2 to 71.8 ± 23 (p < .001), from 55.8 ± 16.4 to 71.4 ± 18 (p < .001), from 42.4 ± 21.5 to 59.4 ± 20.3 (p < .001) and from 44.9 ± 16.4 to 69 ± 23.9 (p < .001), respectively. Eighty-eight (81.5%) patients were satisfied with the procedure at final follow-up. Treatment of PF with unfocused shock waves was well tolerated and led to significant pain reduction, functional improvement, and patient satisfaction.