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Wasilczyk C. Nanosurgical and Bioengineering Treatment of Human Anterior Cruciate Ligament Tears with Ultrasound-Guided Injection of Modified Platelet-Rich Plasma Using Human Cell Memory Based on Clinical, Ultrasound, MRI, and Nanoscope Analyses: A Double-Blind Randomized Trial. J Clin Med 2024; 13:2475. [PMID: 38731004 PMCID: PMC11084372 DOI: 10.3390/jcm13092475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/17/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Anterior cruciate ligament (ACL) tears account for 40% to 50% of all ligamentous knee injuries. Most patients with ACL ruptures undergo surgical treatment. There is currently no objective, well-documented, repeatable, and standardized nonsurgical method for ACL tear treatment. This study aimed to investigate ACL outcomes in patients who underwent a novel nanosurgery and bioengineering treatment (NSBT) for an ACL tear. Methods: This was a double-blind randomized trial including 44 patients with a history of traumatic knee injury and a confirmed ACL tear. The final sample comprised 40 patients who met all the eligibility criteria. The patients were divided into two groups: the treatment group (n = 30) and the control group (n = 10). The treatment group underwent nanosurgery with an ultrasound-guided injection of modified platelet-rich plasma (PRP) using human cell memory (RP-hCM). The control group was treated with an ultrasound-guided PRP injection into the joint capsule. At baseline and post-treatment, all patients underwent both ultrasonography and magnetic resonance imaging (MRI), and the following clinical variables were assessed: the WOMAC score, the Lysholm knee score, the visual analog scale score, and knee instability. In most patients, the clinical outcome was verified using nanoscopy. Results: The median WOMAC, VAS, and LKS scores, as well as knee instability, improved significantly 12 weeks after the procedure in the treatment group (p < 0.001). We found a significantly larger improvement in the assessed parameters in the treatment group compared to the control group (p < 0.001). In the treatment group, all the patients had good and very good clinical outcomes, while 90% of the patients had a normal ACL signal in a follow-up MRI scan. In the control group, a physical examination revealed no changes in knee stability after treatment. Conclusions: This study showed that there is a significant difference in patient experience and the duration of recovery for patients with ACL tears treated with NSBT. The novel nonsurgical method was shown to be repeatable, objective, well documented, standardized, and highly effective.
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Affiliation(s)
- Cezary Wasilczyk
- Medical Department, Wasilczyk Medical Clinic, ul. Kosiarzy 37/80, 02-953 Warszawa, Poland
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2
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Sanborn RM, Badger GJ, Fleming BC, Kiapour AM, Fadale PD, Hulstyn MJ, Owens BD, Proffen B, Sant N, Portilla G, Freiberger C, Henderson R, Barnett S, Costa M, Chrostek C, Ecklund K, Micheli LJ, Murray MM, Yen YM, Kramer DE. Preoperative Risk Factors for Subsequent Ipsilateral ACL Revision Surgery After an ACL Restoration Procedure. Am J Sports Med 2023; 51:49-57. [PMID: 36412922 DOI: 10.1177/03635465221137873] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) revision surgery is challenging for both patients and surgeons. Understanding the risk factors for failure after bridge-enhanced ACL restoration (BEAR) may help with patient selection for ACL restoration versus ACL reconstruction. PURPOSE To identify the preoperative risk factors for ACL revision surgery within the first 2 years after BEAR. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data from the prospective BEAR I, II, and III trials were used to determine the preoperative risk factors for ACL revision surgery. All patients with a complete ACL tear (aged 13-47 years, depending on the trial), who met all other inclusion/exclusion criteria and underwent a primary BEAR procedure within 30 to 50 days from the injury (dependent on the trial), were included. Demographic data (age, sex, body mass index), baseline patient-reported outcomes (International Knee Documentation Committee [IKDC] subjective score, Marx activity score), preoperative imaging results (ACL stump length, notch size, tibial slope), and intraoperative findings (knee hyperextension, meniscal status) were evaluated to determine their contribution to the risk of ipsilateral ACL revision surgery. RESULTS A total of 123 patients, with a median age of 17.6 years (interquartile range, 16-23 years), including 67 (54%) female patients, met study criteria. Overall, 18 (15%) patients required ACL revision surgery in the first 2 years after the BEAR procedure. On bivariate analyses, younger age (P = .011), having a contact injury at the time of the initial tear (P = .048), and increased medial tibial slope (MTS; P = .029) were associated with a higher risk of ipsilateral revision surgery. Multivariable logistic regression analyses identified 2 independent predictors of revision: patient age and MTS. The odds of ipsilateral revision surgery were decreased by 32% for each 1-year increase in age (odds ratio, 0.684 [95% CI, 0.517-0.905]; P = .008) and increased by 28% for each 1° increase in MTS (odds ratio, 1.280 [95% CI, 1.024-1.601]; P = .030). Sex, baseline IKDC or Marx score, knee hyperextension, and meniscal status were not significant predictors of revision. CONCLUSION Younger age and higher MTS were predictors of ipsilateral ACL revision surgery after the BEAR procedure. Younger patients with higher tibial slopes should be aware of the increased risk for revision surgery when deciding to undergo ACL restoration.
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Affiliation(s)
- Ryan M Sanborn
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gary J Badger
- Department of Medical Biostatistics, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ata M Kiapour
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Paul D Fadale
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Michael J Hulstyn
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Brett D Owens
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Benedikt Proffen
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Nicholas Sant
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Gabriela Portilla
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Christina Freiberger
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Rachael Henderson
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Samuel Barnett
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Meggin Costa
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Cynthia Chrostek
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Kirsten Ecklund
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Lyle J Micheli
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Martha M Murray
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Yi-Meng Yen
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Dennis E Kramer
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Kunze KN, Pakanati JJ, Vadhera AS, Polce EM, Williams BT, Parvaresh KC, Chahla J. The Efficacy of Platelet-Rich Plasma for Ligament Injuries: A Systematic Review of Basic Science Literature With Protocol Quality Assessment. Orthop J Sports Med 2022; 10:23259671211066504. [PMID: 35155701 PMCID: PMC8832618 DOI: 10.1177/23259671211066504] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/27/2021] [Indexed: 02/01/2023] Open
Abstract
Background: Despite the existence of many clinical studies on platelet-rich plasma (PRP) interventions for ligamentous pathology, basic science consensus regarding the indications, mechanisms, and optimal composition of PRP for treating ligament injuries is lacking. Purpose: To (1) compare the efficacy of PRP in animal models of ligament injury with placebo and (2) describe the potential variability in PRP preparation using accepted classification systems. Study Design: Systematic review. Methods: The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Embase, and Ovid MEDLINE were queried in April 2020 for in vivo and in vitro basic science studies regarding PRP use for ligament injury. Study design, results, PRP composition, and analyzed cellular and molecular markers were extracted, and outcomes relative to control models were documented. Bias was assessed using the SYRCLE risk-of-bias tool. Results: Included were 43 articles (31 in vivo and 12 in vitro studies) investigating the anterior cruciate ligament/cranial cruciate ligament (n = 32), medial collateral ligament (n = 6), suspensory ligament (n = 3), patellar ligament (n = 1), and Hock ligament (n = 1). Platelet concentration was reported in 34 studies (77.3%); leukocyte composition, in 12 (27.3%); and red blood cell counts, in 7 (15.9%). With PRP treatment, 5 of 12 in vitro studies demonstrated significant increases in cell viability, 6 of 12 in gene expression, 14 of 32 in vivo studies reported superior ligament repair via histological evaluation, and 13 in vivo studies reported superior mechanical properties. Variability in PRP preparation methods was observed across all articles, and only 1 study reported all necessary information to be classified by the 4 schemes we used to evaluate reporting. Among the in vivo studies, detection and performance bias were consistently high, whereas selection, attrition, reporting, and other biases were consistently low. Conclusion: Conflicting data on the cellular and molecular effects of PRP for ligament injuries were observed secondary to the finding that included studies were heterogeneous, limiting interpretation across studies and the ability to draw meaningful conclusions. Clinical trials and any causal relationship between PRP use in ligament injuries and its potential for regeneration and healing should be pursued with caution if based solely on basic science data.
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Affiliation(s)
- Kyle N. Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Jeevana J. Pakanati
- Rosalind Franklin University, Chicago Medical School, Chicago, Illinois, USA
| | - Amar S. Vadhera
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Evan M. Polce
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Brady T. Williams
- Department of Orthopaedic Surgery, University of Colorado, Aurora, Colorado, USA
| | - Kevin C. Parvaresh
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Skeletally immature patient showed lower graft maturity than skeletally mature patient after ACL reconstruction with a rounded rectangular femoral tunnel. Sci Rep 2021; 11:19968. [PMID: 34620936 PMCID: PMC8497465 DOI: 10.1038/s41598-021-99532-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 09/21/2021] [Indexed: 11/24/2022] Open
Abstract
To compare the clinical results and ligamentization of anterior cruciate ligament reconstruction (ACLR) between skeletally immature and mature patients. Two-hundred-and-two patients who underwent primary ACLR were evaluated retrospectively. The clinical outcomes were compared between skeletally immature (immature group 1, n = 27) and mature (control group 1, n = 175) groups. Graft ligamentization of the reconstructed anterior cruciate ligament (ACL) using magnetic resonance imaging (MRI) signal intensity at 6 months postoperatively was compared between immature group 2 (n = 16), which included participants from immature group 1, and control group 2 (n = 32), created by recruiting data-matched controls from control group 1. Immature group 1 had significantly higher revision (14.8%) and pivot shift test positive (22.2%) rates than control group 1 (2.9% and 4.0%, respectively) (P = 0.020 and 0.003, respectively). The signal intensity in immature group 2 were significantly higher at the mid-substance and distal site of the reconstructed ACL than those in control group 2 (P = 0.003 and 0.034, respectively). Skeletally immature patients had higher graft revision and residual rotational laxity rates. Reconstructed ACL in skeletally immature patients showed higher signal intensity on MRI at 6 months postoperatively.
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5
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van der List JP, Mintz DN, DiFelice GS. The Locations of Anterior Cruciate Ligament Tears in Pediatric and Adolescent Patients: A Magnetic Resonance Study. J Pediatr Orthop 2019; 39:441-448. [PMID: 31503221 DOI: 10.1097/bpo.0000000000001041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Recently, a resurgence of interest has been noted in anterior cruciate ligament (ACL) preservation in pediatric and adolescent patients. Different tear types, defined by their tear location, require different preservation techniques: proximal and distal avulsion tears can be treated with arthroscopic primary repair, whereas primary repair with biological scaffold has been proposed for midsubstance tears. The goal of this study was to assess the distribution of different tear types in pediatric and adolescent patients, as these are currently unknown. METHODS A retrospective search in an institutional radiographic database was performed for patients under 18.0 years undergoing knee magnetic resonance imaging (MRI) for ACL tears between June 2005 and June 2016. Patients with reports of chronic tears, partial tears, and multiligamentous injuries were excluded.Tear locations were graded using MRI as: proximal avulsion (distal remnant length >90% of total length; type I), proximal (75% to 90%; type II), midsubstance (25% to 75%; type III), distal (10% to 25%; type IV), and distal avulsion (<10%; type V). RESULTS A total of 274 patients (59% girls; mean±SD age, 15.1±2.1 y; range, 6.9 to 18.0 y) were included. Frequency of type I tears was 15%, type II 23%, type III 52%, type IV 1%, and type V 8% (of which 7% had bony avulsion).Prevalence of tear types varied with age. At age 6 to 10 years, 93% were type V (bony) avulsion tears. At age 11 to 13 years, 32% were type I, 16% type II, 32% type III, and 16% type V. At age 14 to 17 years, type III tears were more common (57%) than type I (14%), type II (25%) and type V (2%) tears. CONCLUSIONS It was noted that the ACL was torn at different locations depending on the patients' age. These data provide more information on the potential application for ACL preservation in pediatric and adolescent patients. Future studies correlating these findings with arthroscopy are needed before using MRI for preoperative planning of ACL preservation surgery. LEVEL OF EVIDENCE Diagnostic level III.
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Affiliation(s)
| | - Douglas N Mintz
- Radiology and Imaging, Hospital for Special Surgery, New York, NY
| | - Gregory S DiFelice
- Departments of Orthopedic Surgery, Orthopaedic Trauma and Sports Medicine
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6
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Heath EL, Salmon LJ, Cooper R, Pappas E, Roe JP, Pinczewski LA. 5-Year Survival of Pediatric Anterior Cruciate Ligament Reconstruction With Living Donor Hamstring Tendon Grafts. Am J Sports Med 2019; 47:41-51. [PMID: 30476437 DOI: 10.1177/0363546518804502] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It is well accepted that there is a higher incidence of repeat anterior cruciate ligament (ACL) injuries in the pediatric population after ACL reconstruction (ACLR) with autograft tissue compared with adults. Hamstring autograft harvest may contribute to the risk for repeat ACL injuries in this high functional demand group. A novel method is the use of a living donor hamstring tendon (LDHT) graft from a parent; however, there is currently limited research on the outcomes of this technique, particularly beyond the short term. PURPOSE/HYPOTHESIS The purpose was to determine the medium-term survival of the ACL graft and the contralateral ACL (CACL) after primary ACLR with the use of an LDHT graft from a parent in those aged less than 18 years and to identify factors associated with subsequent ACL injuries. It was hypothesized that ACLR with the use of an LDHT provides acceptable midterm outcomes in pediatric patients. STUDY DESIGN Case series; Level of evidence, 4. METHODS Between 2005 and 2014, 247 (of 265 eligible) consecutive patients in a prospective database, having undergone primary ACLR with the use of an LDHT graft and aged less than 18 years, were included. Outcomes were assessed at a minimum of 2 years after surgery including data on ACL reinjuries, International Knee Documentation Committee (IKDC) scores, and current symptoms, as well as factors associated with the ACL reinjury risk were investigated. RESULTS Patients were reviewed at a mean of 4.5 years (range, 24-127 months [10.6 years]) after ACLR with an LDHT graft. Fifty-one patients (20.6%) sustained an ACL graft rupture, 28 patients (11.3%) sustained a CACL rupture, and 2 patients sustained both an ACL graft rupture and a CACL rupture (0.8%). Survival of the ACL graft was 89%, 82%, and 76% at 1, 2, and 5 years, respectively. Survival of the CACL was 99%, 94%, and 86% at 1, 2, and 5 years, respectively. Survival of the ACL graft was favorable in patients with Tanner stage 1-2 at the time of surgery versus those with Tanner stage 3-5 at 5 years (87% vs 69%, respectively; hazard ratio, 3.7; P = .01). The mean IKDC score was 91.7. A return to preinjury levels of activity was reported by 59.1%. CONCLUSION After ACLR with an LDHT graft from a parent in those aged less than 18 years, a second ACL injury (ACL graft or CACL injury) occurred in 1 in 3 patients. The 5-year survival rate of the ACL graft was 76%, and the 5-year survival rate of the CACL was 86%. High IKDC scores and continued participation in sports were maintained over the medium term. Importantly, there was favorable survival of the ACL graft in patients with Tanner stage 1-2 compared with patients with Tanner stage 3-5 over 5 years. Patients with Tanner stage 1-2 also had a significantly lower incidence of second ACL injuries over 5 years compared with those with Tanner stage 3-5, occurring in 1 in 5 patients. Thus, an LDHT graft from a parent is an appropriate graft for physically immature children.
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Affiliation(s)
- Emma L Heath
- North Sydney Orthopaedic and Sports Medicine Centre, Wollstonecraft, New South Wales, Australia
| | - Lucy J Salmon
- North Sydney Orthopaedic and Sports Medicine Centre, Wollstonecraft, New South Wales, Australia
| | - Robert Cooper
- School of Medicine, University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Evangelos Pappas
- Department of Physiotherapy, University of Sydney, Sydney, New South Wales, Australia
| | - Justin P Roe
- North Sydney Orthopaedic and Sports Medicine Centre, Wollstonecraft, New South Wales, Australia
| | - Leo A Pinczewski
- North Sydney Orthopaedic and Sports Medicine Centre, Wollstonecraft, New South Wales, Australia.,School of Medicine, University of Notre Dame Australia, Sydney, New South Wales, Australia
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7
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Ardern CL, Ekås G, Grindem H, Moksnes H, Anderson AF, Chotel F, Cohen M, Forssblad M, Ganley TJ, Feller JA, Karlsson J, Kocher MS, LaPrade RF, McNamee M, Mandelbaum B, Micheli L, Mohtadi NG, Reider B, Roe JP, Seil R, Siebold R, Silvers-Granelli HJ, Soligard T, Witvrouw E, Engebretsen L. 2018 International Olympic Committee Consensus Statement on Prevention, Diagnosis, and Management of Pediatric Anterior Cruciate Ligament Injuries. Orthop J Sports Med 2018; 6:2325967118759953. [PMID: 29594177 PMCID: PMC5865521 DOI: 10.1177/2325967118759953] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
In October 2017, the International Olympic Committee hosted an international expert group of physical therapists and orthopaedic surgeons who specialize in treating and researching pediatric anterior cruciate ligament (ACL) injuries. The purpose of this meeting was to provide a comprehensive, evidence-informed summary to support the clinician and help children with ACL injury and their parents/guardians make the best possible decisions. Representatives from the following societies attended: American Orthopaedic Society for Sports Medicine; European Paediatric Orthopaedic Society; European Society for Sports Traumatology, Knee Surgery, and Arthroscopy; International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; Pediatric Orthopaedic Society of North America; and Sociedad Latinoamericana de Artroscopia, Rodilla, y Deporte. Physical therapists and orthopaedic surgeons with clinical and research experience in the field and an ethics expert with substantial experience in the area of sports injuries also participated. This consensus statement addresses 6 fundamental clinical questions regarding the prevention, diagnosis, and management of pediatric ACL injuries. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision making with children and the potential long-term ramifications of the injury.
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Affiliation(s)
| | - Clare L. Ardern
- Clare L. Ardern, PT, PhD, Division of Physiotherapy, Linköping University, Linköping, Sweden (ORCID ID: 0000-0001-8102-3631) ()
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8
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Ardern CL, Ekås G, Grindem H, Moksnes H, Anderson AF, Chotel F, Cohen M, Forssblad M, Ganley TJ, Feller JA, Karlsson J, Kocher MS, LaPrade RF, McNamee M, Mandelbaum B, Micheli L, Mohtadi N, Reider B, Roe J, Seil R, Siebold R, Silvers-Granelli HJ, Soligard T, Witvrouw E, Engebretsen L. 2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries. J ISAKOS 2018. [DOI: 10.1136/jisakos-2018-000200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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9
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Ardern CL, Ekås GR, Grindem H, Moksnes H, Anderson AF, Chotel F, Cohen M, Forssblad M, Ganley TJ, Feller JA, Karlsson J, Kocher MS, LaPrade RF, McNamee M, Mandelbaum B, Micheli L, Mohtadi N, Reider B, Roe J, Seil R, Siebold R, Silvers-Granelli HJ, Soligard T, Witvrouw E, Engebretsen L. 2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries. Br J Sports Med 2018; 52:422-438. [PMID: 29478021 PMCID: PMC5867447 DOI: 10.1136/bjsports-2018-099060] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2018] [Indexed: 12/25/2022]
Abstract
In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric ACL injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery & Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.
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Affiliation(s)
- Clare L Ardern
- Division of Physiotherapy, Linköping University, Linköping, Sweden.,School of Allied Health, La Trobe University, Melbourne, Australia
| | - Guri Ranum Ekås
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.,Oslo Sports Trauma Research Centre (OSTRC), Norwegian School of Sport Sciences, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hege Grindem
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Håvard Moksnes
- Oslo Sports Trauma Research Centre (OSTRC), Norwegian School of Sport Sciences, Oslo, Norway
| | | | - Franck Chotel
- Department of Pediatric Orthopaedic Surgery, Hôpital Femme Mere Enfant, Lyon, France
| | - Moises Cohen
- Orthopedic Department, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Magnus Forssblad
- Stockholm Sports Trauma Research Center, Karolinska Institute, Stockholm, Sweden
| | - Theodore J Ganley
- Department of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Julian A Feller
- OrthoSport Victoria Research Unit, Epworth Healthcare, Melbourne, Australia.,College of Science, Health & Engineering, La Trobe University, Melbourne, Australia
| | - Jón Karlsson
- Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Minider S Kocher
- Division of Sports Medicine, Boston Children's Hospital, Boston, USA.,Harvard Medical School, Boston, USA
| | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, USA.,The Steadman Clinic, Vail, USA
| | | | - Bert Mandelbaum
- Santa Monica Orthopaedic and Sports Medicine Group, Los Angeles, USA
| | - Lyle Micheli
- Division of Sports Medicine, Boston Children's Hospital, Boston, USA.,Harvard Medical School, Boston, USA.,The Micheli Center for Sports Injury Prevention, Waltham, USA
| | | | - Bruce Reider
- Department of Orthopaedics and Rehabilitation Medicine, University of Chicago, Chicago, USA
| | - Justin Roe
- North Sydney Orthopaedic & Sports Medicine Centre, Sydney, Australia
| | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg, Luxembourg.,Sports Medicine Research Laboratory, Luxembourg Institute of Health, Luxembourg
| | - Rainer Siebold
- Institute for Anatomy and Cell Biology, Ruprecht-Karls-University, Heidelberg, Germany.,HKF International Center for Hip, Knee, Foot Surgery and Sports Traumatology, ATOS Klinik, Heidelberg, Germany
| | | | - Torbjørn Soligard
- Medical & Scientific Department, International Olympic Committee, Chateau de Vidy, Lausanne, Switzerland.,Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Erik Witvrouw
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
| | - Lars Engebretsen
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.,Oslo Sports Trauma Research Centre (OSTRC), Norwegian School of Sport Sciences, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Medical & Scientific Department, International Olympic Committee, Chateau de Vidy, Lausanne, Switzerland
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10
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Ardern CL, Ekås G, Grindem H, Moksnes H, Anderson A, Chotel F, Cohen M, Forssblad M, Ganley TJ, Feller JA, Karlsson J, Kocher MS, LaPrade RF, McNamee M, Mandelbaum B, Micheli L, Mohtadi N, Reider B, Roe J, Seil R, Siebold R, Silvers-Granelli HJ, Soligard T, Witvrouw E, Engebretsen L. 2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries. Knee Surg Sports Traumatol Arthrosc 2018; 26:989-1010. [PMID: 29455243 PMCID: PMC5876259 DOI: 10.1007/s00167-018-4865-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/05/2018] [Indexed: 12/11/2022]
Abstract
In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric anterior cruciate ligament (ACL) injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery and Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America, and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis, and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.
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Affiliation(s)
- Clare L. Ardern
- 0000 0001 2162 9922grid.5640.7Division of Physiotherapy, Linköping University, Linköping, Sweden ,0000 0001 2342 0938grid.1018.8School of Allied Health, La Trobe University, Melbourne, Australia
| | - Guri Ekås
- 0000 0004 0389 8485grid.55325.34Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway ,0000 0000 8567 2092grid.412285.8Oslo Sports Trauma Research Centre (OSTRC), Norwegian School of Sport Sciences, Oslo, Norway ,0000 0004 1936 8921grid.5510.1Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hege Grindem
- 0000 0000 8567 2092grid.412285.8Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Håvard Moksnes
- 0000 0000 8567 2092grid.412285.8Oslo Sports Trauma Research Centre (OSTRC), Norwegian School of Sport Sciences, Oslo, Norway
| | | | - Franck Chotel
- grid.414103.3Department of Pediatric Orthopaedic Surgery, Hôpital Femme Mere Enfant, Lyon, France
| | - Moises Cohen
- 0000 0001 0514 7202grid.411249.bOrthopedic Department, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Magnus Forssblad
- 0000 0004 1937 0626grid.4714.6Stockholm Sports Trauma Research Center, Karolinska Institute, Stockholm, Sweden
| | - Theodore J. Ganley
- 0000 0001 0680 8770grid.239552.aDepartment of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, USA
| | - Julian A. Feller
- 0000 0001 0459 5396grid.414539.eOrthoSport Victoria Research Unit, Epworth Healthcare, Melbourne, Australia ,0000 0001 2342 0938grid.1018.8College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
| | - Jón Karlsson
- 0000 0000 9919 9582grid.8761.8Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mininder S. Kocher
- 0000 0004 0378 8438grid.2515.3Division of Sports Medicine, Boston Children’s Hospital, Boston, USA ,000000041936754Xgrid.38142.3cHarvard Medical School, Boston, USA
| | - Robert F. LaPrade
- 0000 0001 0367 5968grid.419649.7Steadman Philippon Research Institute, Vail, USA ,0000 0001 0027 3736grid.419648.6The Steadman Clinic, Vail, USA
| | - Mike McNamee
- 0000 0001 0658 8800grid.4827.9College of Engineering, Swansea University, Swansea, UK
| | - Bert Mandelbaum
- Santa Monica Orthopaedic and Sports Medicine Group, Los Angeles, USA
| | - Lyle Micheli
- 0000 0004 0378 8438grid.2515.3Division of Sports Medicine, Boston Children’s Hospital, Boston, USA ,000000041936754Xgrid.38142.3cHarvard Medical School, Boston, USA ,The Micheli Center for Sports Injury Prevention, Waltham, USA
| | - Nicholas Mohtadi
- 0000 0004 1936 7697grid.22072.35University of Calgary Sports Medicine Centre, Calgary, Canada
| | - Bruce Reider
- 0000 0004 1936 7822grid.170205.1Department of Orthopaedics and Rehabilitation Medicine, University of Chicago, Chicago, USA
| | - Justin Roe
- 0000 0004 0382 8241grid.420075.4North Sydney Orthopaedic and Sports Medicine Centre, Sydney, Australia
| | - Romain Seil
- 0000 0004 0578 0421grid.418041.8Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg, Luxembourg City, Luxembourg ,0000 0004 0621 531Xgrid.451012.3Sports Medicine Research Laboratory, Luxembourg Institute of Health, Luxembourg City, Luxembourg
| | - Rainer Siebold
- 0000 0001 2190 4373grid.7700.0Institute for Anatomy and Cell Biology, Ruprecht-Karls-University, Heidelberg, Germany ,HKF International Center for Hip, Knee, Foot Surgery and Sportstraumatology, ATOS Klinik, Heidelberg, Germany
| | | | - Torbjørn Soligard
- 0000 0004 0626 1762grid.469323.9Medical and Scientific Department, International Olympic Committee, Chateau de Vidy, Lausanne, Switzerland ,0000 0004 1936 7697grid.22072.35Faculty of Kinesiology, Sports Injury Prevention Centre, University of Calgary, Calgary, Alberta Canada
| | - Erik Witvrouw
- 0000 0001 2069 7798grid.5342.0Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Healthscience, Ghent University, Ghent, Belgium
| | - Lars Engebretsen
- 0000 0004 0389 8485grid.55325.34Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway ,0000 0000 8567 2092grid.412285.8Oslo Sports Trauma Research Centre (OSTRC), Norwegian School of Sport Sciences, Oslo, Norway ,0000 0004 1936 8921grid.5510.1Institute of Clinical Medicine, University of Oslo, Oslo, Norway ,0000 0004 0626 1762grid.469323.9Medical and Scientific Department, International Olympic Committee, Chateau de Vidy, Lausanne, Switzerland
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Seil R, Weitz FK, Pape D. Surgical-experimental principles of anterior cruciate ligament (ACL) reconstruction with open growth plates. J Exp Orthop 2015; 2:11. [PMID: 26914879 PMCID: PMC4538715 DOI: 10.1186/s40634-015-0027-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 04/08/2015] [Indexed: 11/10/2022] Open
Abstract
Objective To review surgical and animal experimental studies performed with open growth plates in relation with pediatric anterior cruciate ligament (ACL) reconstruction. Backround When it comes to the treatment of ACL injured children, there is a lack of current international guidelines, leaving the treating physicians with a therapeutic dilemma. A variety of surgical and animal experimental studies have been undertaken over the last decades in relation with open growth plates and ACL-reconstruction. Method Based on our own previous animal experimental data, we highlighted 15 specific points concerning pediatric ACL-reconstruction and reviewed additional literature concerning these individual items. Results Pediatric ACL-reconstruction could be proven to be safe in animal models. Growth abnormalities, risk factors and factors, which were specifically related to biological healing processes in children, were identified. From them surgical principles for safe pediatric ACL replacements can be deducted. Applying these principles through a correct technical execution of surgery may prevent clinically significant growth changes. Conclusion Over the last 2 decades it has been shown that a technically correct pediatric ACL reconstruction has little risk in creating clinically significant growth abnormalities. Animal experiments support this hypothesis despite the fact that the gained knowledge cannot be fully generalized to humans. More long time follow-up is needed to fully understand the complete risk factors related to ACL surgery with open growth plates. Electronic supplementary material The online version of this article (doi:10.1186/s40634-015-0027-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg, Clinique d'Eich. 78, rue d'Eich, L-1460, Luxembourg, Luxembourg. .,Sports Medicine Research Laboratory, Luxembourg Institute of Health, 78 rue d'Eich, L-1460, Luxembourg, Luxembourg.
| | - Frederick K Weitz
- Department of Pediatric Surgery, University of Tampere, Teiskontie 35, 33521, Tampere, Finland.
| | - Dietrich Pape
- Department of Orthopaedic Surgery, Centre Hospitalier Luxembourg, Clinique d'Eich. 78, rue d'Eich, L-1460, Luxembourg, Luxembourg. .,Sports Medicine Research Laboratory, Luxembourg Institute of Health, 78 rue d'Eich, L-1460, Luxembourg, Luxembourg.
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PRP Augmentation for ACL Reconstruction. BIOMED RESEARCH INTERNATIONAL 2015; 2015:371746. [PMID: 26064903 PMCID: PMC4430629 DOI: 10.1155/2015/371746] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 08/15/2014] [Indexed: 12/19/2022]
Abstract
Current research is investigating new methods to enhance tissue healing to speed up recovery time and decrease the risk of failure in Anterior Cruciate Ligament (ACL) reconstructive surgery. Biological augmentation is one of the most exploited strategies, in particular the application of Platelet Rich Plasma (PRP). Aim of the present paper is to systematically review all the preclinical and clinical papers dealing with the application of PRP as a biological enhancer during ACL reconstructive surgery. Thirty-two studies were included in the present review. The analysis of the preclinical evidence revealed that PRP was able to improve the healing potential of the tendinous graft both in terms of histological and biomechanical performance. Looking at the available clinical evidence, results were not univocal. PRP administration proved to be a safe procedure and there were some evidences that it could favor the donor site healing in case of ACL reconstruction with patellar tendon graft and positively contribute to graft maturation over time, whereas the majority of the papers did not show beneficial effects in terms of bony tunnels/graft area integration. Furthermore, PRP augmentation did not provide superior functional results at short term evaluation.
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New and emerging strategies in platelet-rich plasma application in musculoskeletal regenerative procedures: general overview on still open questions and outlook. BIOMED RESEARCH INTERNATIONAL 2015; 2015:846045. [PMID: 26075269 PMCID: PMC4436449 DOI: 10.1155/2015/846045] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 01/09/2015] [Accepted: 01/13/2015] [Indexed: 02/07/2023]
Abstract
Despite its pervasive use, the clinical efficacy of platelet-rich plasma (PRP) therapy and the different mechanisms of action have yet to be established. This overview of the literature is focused on the role of PRP in bone, tendon, cartilage, and ligament tissue regeneration considering basic science literature deriving from in vitro and in vivo studies. Although this work provides evidence that numerous preclinical studies published within the last 10 years showed promising results concerning the application of PRP, many key questions remain unanswered and controversial results have arisen. Additional preclinical studies are needed to define the dosing, timing, and frequency of PRP injections, different techniques for delivery and location of delivery, optimal physiologic conditions for injections, and the concomitant use of recombinant proteins, cytokines, additional growth factors, biological scaffolds, and stems cells to develop optimal treatment protocols that can effectively treat various musculoskeletal conditions.
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Fleming BC, Proffen BL, Vavken P, Shalvoy MR, Machan JT, Murray MM. Increased platelet concentration does not improve functional graft healing in bio-enhanced ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2015; 23:1161-70. [PMID: 24633008 PMCID: PMC4167989 DOI: 10.1007/s00167-014-2932-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 03/04/2014] [Indexed: 12/19/2022]
Abstract
PURPOSE The use of an extracellular matrix scaffold (ECM) combined with platelets to enhance healing of an anterior cruciate ligament (ACL) graft ("bio-enhanced ACL reconstruction") has shown promise in animal models. However, the effects of platelet concentration on graft healing remain unknown. The objectives of this study were to determine whether increasing the platelet concentration in the ECM scaffold would (1) improve the graft biomechanical properties and (2) decrease cartilage damage after surgery. METHODS Fifty-five adolescent minipigs were randomized to five treatment groups: untreated ACL transection (n = 10), conventional ACL reconstruction (n = 15) and bio-enhanced ACL reconstruction using 1× (n = 10), 3× (n = 10) or 5× (n = 10) platelet-rich plasma. The graft biomechanical properties, anteroposterior (AP) knee laxity, graft histology and macroscopic cartilage integrity were measured at 15 weeks. RESULTS The mean linear stiffness of the bio-enhanced ACL reconstruction procedure using the 1× preparation was significantly greater than traditional reconstruction, while the 3× and 5× preparations were not. The failure loads of all the ACL-reconstructed groups were equivalent but significantly greater than untreated ACL transection. There were no significant differences in the Ligament Maturity Index or AP laxity between reconstructed knees. Macroscopic cartilage damage was relatively minor, though significantly less when the ECM-platelet composite was used. CONCLUSIONS Only the 1× platelet concentration improved healing over traditional ACL reconstruction. Increasing the platelet concentration from 1× to 5× in the ECM scaffold did not further improve the graft mechanical properties. The use of an ECM-platelet composite decreased the amount of cartilage damage seen after ACL surgery.
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Affiliation(s)
- Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, RI, USA,
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Valentí Azcárate A, Lamo-Espinosa J, Aquerreta Beola JD, Hernandez Gonzalez M, Mora Gasque G, Valentí Nin JR. Comparison between two different platelet-rich plasma preparations and control applied during anterior cruciate ligament reconstruction. Is there any evidence to support their use? Injury 2014; 45 Suppl 4:S36-41. [PMID: 25384473 DOI: 10.1016/s0020-1383(14)70008-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION To compare the clinical, analytical and graft maturation effects of two different platelet-rich plasma (PRP) preparations applied during anterior cruciate ligament (ACL) reconstruction. MATERIALS AND METHODS A total of 150 patients with ACL disruption were included in the study. Arthroscopic ACL reconstruction with patellar tendon allograft was conducted on all knees using the same protocol. One hundred patients were prospectively randomised to either a group to receive double-spinning platelet-enriched gel (PRP) with leukocytes (n=50) or to a non-gel group (n=50). Finally, we included 50 patients treated with a platelet-rich preparation from a single-spinning procedure (PRGF Endoret(®) Technology) without leukocytes. Inflammatory parameters, including C-reactive protein (CRP) and knee perimeters (PER), were measured 24 hours and 10 days after surgery. Postoperative pain score (visual analogue score [VAS]) was recorded the day after surgery. Follow-up visits occurred postoperatively at 3, 6, and 12 months. The International Knee Documentation Committee scale (IKDC) was included to compare functional state, and MRI was conducted 6 months after surgery. RESULTS The PRGF group showed a statistically significant improvement in swelling and inflammatory parameters compared with the other two groups at 24 hours after surgery (p<0.05). The results did not show any significant differences between groups for MRI and clinical scores. CONCLUSIONS PRGF used in ACL allograft reconstruction was associated with reduced swelling; however, the intensity and uniformity of the graft on MRI were similar in the three groups, and there was no clinical or pain improvement compared with the control group. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Andrés Valentí Azcárate
- Orthopedic Surgery and Traumatology Department, Clínica Universidad de Navarra, Pamplona, Spain.
| | - Jose Lamo-Espinosa
- Orthopedic Surgery and Traumatology Department, Clínica Universidad de Navarra, Pamplona, Spain
| | | | | | - Gonzalo Mora Gasque
- Orthopedic Surgery and Traumatology Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Juan Ramón Valentí Nin
- Orthopedic Surgery and Traumatology Department, Clínica Universidad de Navarra, Pamplona, Spain
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Abstract
Platelet-rich plasma (PRP) has become a popular treatment for acute and chronic soft tissue injuries. Although the majority of research has focused on its use in tendinopathy, PRP may have potential in meniscus and ligament healing. Some level II studies support a possible benefit for anterior cruciate ligament (ACL) allograft maturation, and preliminary animal studies point to a potential role for PRP in primary ACL repair. However, randomized controlled trials have not demonstrated a benefit of PRP for ACL tendon allograft-tunnel integration. To date, 2 studies document the use of PRP for meniscal applications, but this field is largely unexplored. With respect to ligament and meniscal applications, the current literature suggests PRP may be promising for primary ACL repair in skeletally immature patients, ACL graft maturation, and repair of meniscal tears in the avascular zone.
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Murray MM, Fleming BC. Biology of anterior cruciate ligament injury and repair: Kappa delta ann doner vaughn award paper 2013. J Orthop Res 2013; 31:1501-6. [PMID: 23818453 PMCID: PMC3750083 DOI: 10.1002/jor.22420] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 06/06/2013] [Indexed: 02/04/2023]
Abstract
Anterior cruciate ligament (ACL) injuries are currently treated by removing the injured ligament and replacing it with a tendon graft. Recent studies have examined alternative treatment methods, including repair and regeneration of the injured ligament. In order to make such an approach feasible, a basic understanding of ACL biology and its response to injury is needed. Identification of obstacles to native ACL healing can then be identified and potentially resolved using tissue engineering strategies-first, with in vitro screening assays, and then with in vivo models of efficacy and safety. This Perspectives paper outlines this path of discovery for optimizing ACL healing using a bio-enhanced repair technique. This journey required constructing indices of the functional tissue response, pioneering physiologically based methods of biomechanical testing, developing, and validating clinically relevant animal models, and creating and optimizing translationally feasible scaffolds, surgical techniques, and biologic additives. Using this systematic translational approach, "bio-enhanced" ACL repair has been advanced to the point where it may become an option for future treatment of acute ACL injuries and the prevention of subsequent post-traumatic osteoarthritis associated with this injury.
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Affiliation(s)
- Martha Meaney Murray
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Division of Sports Medicine, Boston, MA
| | - Braden C. Fleming
- Department of Orthopaedics, Bioengineering Labs, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI,Center for Biomedical Engineering, Brown University, Providence, RI
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Yuan T, Zhang CQ, Wang JHC. Augmenting tendon and ligament repair with platelet-rich plasma (PRP). Muscles Ligaments Tendons J 2013. [PMID: 24367773 DOI: 10.11138/mltj/2013.3.3.139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tendon and ligament injuries (TLI) commonly occur in athletes and non-athletes alike, and remarkably debilitate patients' athletic and personal abilities. Current clinical treatments, such as reconstruction surgeries, do not adequately heal these injuries and often result in the formation of scar tissue that is prone to re-injury. Platelet-rich plasma (PRP) is a widely used alternative option that is also safe because of its autologous nature. PRP contains a number of growth factors that are responsible for its potential to heal TLIs effectively. In this review, we provide a comprehensive report on PRP. While basic science studies in general indicate the potential of PRP to treat TLIs effectively, a review of existing literature on the clinical use of PRP for the treatment of TLIs indicates a lack of consensus due to varied treatment outcomes. This suggests that current PRP treatment protocols for TLIs may not be optimal, and that not all TLIs may be effectively treated with PRP. Certainly, additional basic science studies are needed to develop optimal treatment protocols and determine those TLI conditions that can be treated effectively.
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Affiliation(s)
- Ting Yuan
- Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh, School of Medicine, Pittsburgh, USA ; Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai, China
| | - Chang-Qing Zhang
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai, China
| | - James H-C Wang
- Laboratory, Department of Orthopaedic Surgery, University of Pittsburgh, School of Medicine, Pittsburgh, USA
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Cheng M, Johnson V, Murray MM. Effects of age and platelet-rich plasma on ACL cell viability and collagen gene expression. J Orthop Res 2012; 30:79-85. [PMID: 21748791 PMCID: PMC3202019 DOI: 10.1002/jor.21496] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 06/15/2011] [Indexed: 02/04/2023]
Abstract
Platelet-rich plasma (PRP) has shown in vivo potential to stimulate anterior cruciate ligament (ACL) healing at early time points in large animal models. However, in animal models, the healing potential of the ACL is dependent on animal age. In this study, we hypothesized that there are age-dependent differences in ACL cell metabolism, collagen gene expression, and the ability of the cells to respond to growth factors in PRP. To test this hypothesis, ACL cells were obtained from skeletally immature, adolescent and adult pigs, and cultured in a collagen type I hydrogel with or without PRP for 14 days. When cultured in collagen-only hydrogel, ACL cells from adult pigs had a 19% lower apoptotic rate as compared to immature pigs (p = 0.001) and a 25% higher cellular metabolic activity as compared to adolescent pigs (p = 0.006). The addition of PRP to the collagen hydrogel resulted in a significantly increased cellular metabolic activity, reduced apoptotic rate, and stimulation of collagen production in the cells from the immature and adolescent animals (p < 0.05 for all comparisons) but had less effect on adult cells. These findings suggest that skeletal maturity may influence ACL cells' metabolic activity, apoptosis, collagen production, and response to PRP.
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Affiliation(s)
| | | | - M. M. Murray
- Corresponding author: Martha Meaney Murray, MD. (), Department of Orthopaedic, Surgery, Children’s Hospital of Boston, 300 Longwood Ave., Boston, MA 02115 USA, Phone: 617 355 7132; Fax: 617 730 0459
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Palmer M, Stanford E, Murray MM. The Effect of Synovial Fluid Enzymes on the Biodegradability of Collagen and Fibrin Clots. MATERIALS 2011; 4:1469-1482. [PMID: 21949586 PMCID: PMC3176731 DOI: 10.3390/ma4081469] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Recently there has been a great deal of interest in the use of biomaterials to stimulate wound healing. This is largely due to their ability to centralize high concentrations of compounds known to promote wound healing at a needed location. Joints present a unique challenge to using scaffolds because of the presence of enzymes in synovial fluid which are known to degrade materials that would be stable in other parts of the body. The hypothesis of this study was that atelocollagen scaffolds would have greater resistance to enzymatic degradation than scaffolds made of gelatin, fibrin and whole blood. To test this hypothesis, collagen and fibrin-based scaffolds were placed in matrix metallopeptidase-1 (MMP-1), elastase, and plasmin solutions at physiologic concentrations, and the degradation of each scaffold was measured at varying time points. The atelocollagen scaffolds had a significantly greater resistance to degradation by MMP-1, elastase and plasmin over the fibrin based scaffolds. The results suggest that atelocollagen-based scaffolds may provide some protection against premature degradation by synovial fluid enzymes over fibrin-based matrices.
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Affiliation(s)
| | | | - Martha M. Murray
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-617-355-7132; Fax: +1-617-730-0459
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Henson F, Getgood A. The use of scaffolds in musculoskeletal tissue engineering. Open Orthop J 2011; 5 Suppl 2:261-6. [PMID: 21886690 PMCID: PMC3149868 DOI: 10.2174/1874325001105010261] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 04/16/2011] [Accepted: 04/24/2011] [Indexed: 12/19/2022] Open
Abstract
The use of bioengineering scaffolds remains an integral part of the tissue engineering concept. A significant amount of basic science and clinical research has been focused on the regeneration of musculoskeletal tissues including bone, articular cartilage, meniscus, ligament and tendon. This review aims to provide the reader with a summary of the principals of using material scaffolds in musculoskeletal tissue engineering applications and how these materials may eventually come to be incorporated in clinical practice.
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Affiliation(s)
- Frances Henson
- Department of Veterinary Medicine, University of Cambridge, Cambridge, CB3 0ES, UK
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