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Chen K, Aggarwal S, Baker H, Athiviraham A. Biologic Augmentation of Isolated Meniscal Repair. Curr Rev Musculoskelet Med 2024; 17:223-234. [PMID: 38652368 PMCID: PMC11156815 DOI: 10.1007/s12178-024-09898-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE OF REVIEW The limited blood supply and intrinsic healing capacity of the meniscus contributes to suboptimal tissue regeneration following injury and surgical repair. Biologic augmentation techniques have been utilized in combination with isolated meniscal repair to improve tissue regeneration. Several innovative strategies such as Platelet-Rich Plasma (PRP), fibrin clots, mesenchymal stem cells (MSCs), bone marrow stimulation, meniscal scaffolds, and meniscal wrapping, are being explored to enhance repair outcomes. This article provides a comprehensive review of recent findings and conclusions regarding biologic augmentation techniques. RECENT FINDINGS Studies on PRP reveal mixed outcomes, with some suggesting benefits in reducing failure rates of isolated meniscal repair, while others question its efficacy. Fibrin clots and PRF (Platelet-rich fibrin), although promising, show inconsistent results and lack sufficient evidence for definitive conclusions. MSCs demonstrate potential in preclinical studies, but clinical trials have been limited and inconclusive. Bone marrow stimulation appears effective in certain contexts, but its broader applicability remains uncertain. Meniscal scaffolds, including CMI (Collagen Meniscal Implants) and Actifit (polyurethane scaffolds), show encouraging short- and mid-term outcomes but have not consistently surpassed traditional methods in the long term. Meniscal wrapping is infrequently studied but demonstrates positive short-term results with certain applications. The review reveals a diverse range of outcomes for biologic augmentation in meniscal repair. While certain techniques show promise, particularly in specific scenarios, the overall efficacy of these methods has yet to reach a consensus. The review underscores the necessity for standardized, high-quality research to establish the definitive effectiveness of these biologic augmentation methods.
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Affiliation(s)
- Kevin Chen
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Sarthak Aggarwal
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Hayden Baker
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, 5841 S. Maryland Ave MC 3079, Chicago, IL, 60637, USA
| | - Aravind Athiviraham
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, 5841 S. Maryland Ave MC 3079, Chicago, IL, 60637, USA.
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Gopinatth V, Batra AK, Chahla J, Smith MV, Matava MJ, Brophy RH, Knapik DM. Degenerative Meniscus Tears Treated Nonoperatively With Platelet-Rich Plasma Yield Variable Clinical and Imaging Outcomes: A Systematic Review. Arthrosc Sports Med Rehabil 2024; 6:100916. [PMID: 38525288 PMCID: PMC10960087 DOI: 10.1016/j.asmr.2024.100916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/14/2024] [Indexed: 03/26/2024] Open
Abstract
Purpose To perform a systematic review on clinical and radiologic outcomes for meniscus tears treated nonoperatively with platelet-rich plasma (PRP). Methods A literature search was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using keywords and Boolean operators in SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials in April 2023. Inclusion criteria were limited to Level I to IV human studies reporting on outcomes of meniscus tears treated nonoperatively with PRP. Results A total of 6 studies, consisting of 184 patients, were identified. There was 1 Level I study and 5 Level IV studies. Mean patient age was 47.8 ± 7.9 years, with 62% (n = 114/184) being female. The medial meniscus was treated in 95.7% (n = 157/164) of patients. Mean follow-up ranged from 75.9 days to 31.9 months. Meniscus tears were generally described as chronic, degenerative, or intrasubstance. In 4 studies, magnetic resonance imaging revealed variable improvement in meniscus grade with complete healing in 0% to 44% of patients and partial healing in 0% to 40% of patients. Four of 5 studies reported significant statistical improvement in pain from baseline to final follow-up. Studies reporting on clinical outcomes showed significant improvements Lysholm score (2 studies), Knee injury and Osteoarthritis Outcome Score total score (2 studies), and Tegner score (1 study). Successful return to sport occurred in 60% to 100% of patients. Two studies reported that most patients were either very satisfied or satisfied following treatment. Conclusions The use of PRP injections for the treatment of meniscus tears led to variable results based on postoperative magnetic resonance evaluation and improvements in clinical outcomes, although the clinical significance remains unclear. The heterogeneity of PRP protocols, short-term follow-up, and lack of comparative studies limit findings. Level of Evidence Level IV, systematic review of Level I to IV studies.
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Affiliation(s)
- Varun Gopinatth
- Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | - Anjay K. Batra
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Matthew V. Smith
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Matthew J. Matava
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Robert H. Brophy
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Derrick M. Knapik
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
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El Zouhbi A, Yammine J, Hemdanieh M, Korbani ET, Nassereddine M. Utility of Platelet-Rich Plasma Therapy in the Management of Meniscus Injuries: A narrative review. Orthop Rev (Pavia) 2024; 16:94240. [PMID: 38505136 PMCID: PMC10950196 DOI: 10.52965/001c.94240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/18/2024] [Indexed: 03/21/2024] Open
Abstract
Menisci are crucial for knee joint functions and meniscal tears are common injuries, especially in sports activities. Platelet-rich plasma (PRP), which enhances healing, has emerged as a promising additive treatment for meniscus injuries, utilizing the regenerative properties of platelets and growth factors for improved clinical outcomes. In studies with a follow-up period of less than one year, the use of platelet-rich plasma (PRP) therapy for meniscus injuries showed significant improvements in knee symptoms and daily activity. Patients experienced enhanced outcomes in terms of pain reduction and increased sports activity, with MRI scans indicating stable meniscus conditions after six months. Studies with a follow-up of more than one year, however, did not find significant differences between groups treated with PRP and groups not treated with PRP in terms of various outcome measures, including pain and knee function. The vascularization of the menisci is vital for their proper function, and insufficient blood supply can affect healing of meniscal injuries. PRP therapy is used to enhance meniscal healing by introducing growth factors and anti-inflammatory agents. PRP therapy may enable athletes with meniscal tears to return to sports more quickly and has less rehabilitation duration. While PRP seems promising as an alternative to failed treatment or as an adjunct to treatment in the short term, its long-term effectiveness remains inconclusive. Patient preferences, commitment to therapy rehabilitation, and cost should all be considered on an individual basis.
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Affiliation(s)
- Anas El Zouhbi
- Faculty of Medicine American University of Beirut, Beirut, Lebanon
| | - Jeffrey Yammine
- Faculty of Medicine American University of Beirut, Beirut, Lebanon
| | - Maya Hemdanieh
- Division of Orthopedic Surgery American University of Beirut Medical Center, Beirut, Lebanon
| | - Elie Toni Korbani
- Division of Orthopedic Surgery American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Nassereddine
- Division of Orthopedic Surgery American University of Beirut Medical Center, Beirut, Lebanon
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Migliorini F, Schäfer L, Bell A, Weber CD, Vecchio G, Maffulli N. Meniscectomy is associated with a higher rate of osteoarthritis compared to meniscal repair following acute tears: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2023; 31:5485-5495. [PMID: 37812251 PMCID: PMC10719156 DOI: 10.1007/s00167-023-07600-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/20/2023] [Indexed: 10/10/2023]
Abstract
PURPOSE Meniscal tears are common and may impair knee function and biomechanics. This meta-analysis compared meniscal repair versus resection in patients with symptomatic meniscal tears in terms of patient-reported outcomes measures (PROMs), joint width, surgical failure, and rate of progression to osteoarthritis (OA) at conventional radiography. METHODS This study was conducted according to the 2020 PRISMA statement. In August 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. Two reviewers independently performed the analysis and a methodological quality assessment of the included studies. All the clinical investigations which compared repair versus resection of meniscal tears were accessed. RESULTS Data from 20 studies (31,783 patients) were collected. The mean BMI was 28.28 ± 3.2 kg/m2, and the mean age was 37.6 ± 14.0 years. The mean time elapsed from injury to surgery was 12.1 ± 10.2 months and the mean medial joint width was 4.9 ± 0.8 mm. Between studies comparability at baseline was found in age, women, BMI, time from injury to surgery and length of the follow-up, PROMs, medial joint width, and stage of OA. The resection group demonstrated a greater Lysholm score (P = 0.02). No difference was found in the International Knee Documentation Committee (P = 0.2). Nine studies reported data on the rate of failures at a mean of 63.00 ± 24.7 months. No difference was found between the two groups in terms of persistent meniscal symptoms (P = 0.8). Six studies reported data on the rate of progression to total knee arthroplasty at a mean of 48.0 ± 14.7 months follow-up. The repair group evidenced a lower rate of progression to knee arthroplasty (P = 0.0001). Six studies reported data on the rate of advanced knee OA at a mean of 48.0 ± 14.7 months of follow-up. The repair group evidenced a lower rate of advanced knee OA (P = 0.0001). No difference was found in the mean joint space width (P = 0.09). CONCLUSION Meniscal repair is associated with a lower progression to knee osteoarthritis at approximately six years of follow-up compared to partial meniscectomy. No difference in PROMs, medial joint width, and failures were evidenced. LEVEL OF EVIDENCE Level III, meta-analysis.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University, 39100, Bolzano, Italy.
| | - Luise Schäfer
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany
| | - Christian David Weber
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Gianluca Vecchio
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, Italy
| | - Nicola Maffulli
- Faculty of Medicine and Psychology, University Hospital Sant' Andrea, University La Sapienza, 00185, Rome, Italy
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Stoke On Trent, ST4 7QB, UK
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, London, E1 4DG, UK
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Sánchez M, Jorquera C, Bilbao AM, García S, Beitia M, Espregueira-Mendes J, González S, Oraa J, Guadilla J, Delgado D. High survival rate after the combination of intrameniscal and intraarticular infiltrations of platelet-rich plasma as conservative treatment for meniscal lesions. Knee Surg Sports Traumatol Arthrosc 2023; 31:4246-4256. [PMID: 37302993 DOI: 10.1007/s00167-023-07470-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/30/2023] [Indexed: 06/13/2023]
Abstract
PURPOSE To evaluate the efficacy of applying a combination of intrameniscal and intraarticular infiltrations of Platelet-Rich Plasma (PRP) in patients with meniscal tears, analyzing its failure rate and clinical evolution, as well as factors that may influence the positive response to this treatment. METHODS Three hundred and ninety-two cases out of 696 met the inclusion criteria and were included in this work. Survival and patient-reported outcome measure (PROM) were collected and analyzed. Survival rate was defined as the percentage of patients who did not undergo meniscus surgery during their follow-up time. Patients were asked to complete the Knee injury and Osteoarthritis Outcome Score (KOOS) at baseline, 6 months and 18 months. Other patient- and pathology-related variables were collected. Blood and PRP samples were randomly tested as a quality control measure. Survival and comparative statistical tests, and multivariate regression were performed for the analysis of the variables. RESULTS The PRP applied had a platelet concentration factor of 1.9X in respect to blood levels, with no leukocytes or erythrocytes. Thirty-eight patients required surgical intervention after treatment reaching a survival rate of 90.3% with an estimated mean survival time of 54.4 months. The type of injury (P = 0.002) and the presence of chondropathy were risk factors for surgical intervention after PRP treatment (P = 0.043). All KOOS scores showed a significant statistical increase from baseline to 6 months (N = 93) and 18 months (N = 66) (P < 0.0001). The number of cases with minimal clinically important improvement (MCII) at 6 months and 18 months post-treatment was 65 (69.9%) and 43 (65.2%), respectively. CONCLUSION The combination of intrameniscal and intraarticular PRP infiltrations is a valid conservative treatment for meniscal injuries avoiding the need for surgical intervention. Its efficacy is higher in horizontal tears and decreases when joint degeneration is present. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Mikel Sánchez
- Arthroscopic Surgery Unit, Hospital Vithas Vitoria, Vitoria-Gasteiz, Spain
- Advanced Biological Therapy Unit, Hospital Vithas Vitoria, C/Beato Tomás de Zumárraga 10, 01008, Vitoria-Gasteiz, Spain
| | - Cristina Jorquera
- Advanced Biological Therapy Unit, Hospital Vithas Vitoria, C/Beato Tomás de Zumárraga 10, 01008, Vitoria-Gasteiz, Spain
| | - Ane Miren Bilbao
- Arthroscopic Surgery Unit, Hospital Vithas Vitoria, Vitoria-Gasteiz, Spain
| | - Saínza García
- Advanced Biological Therapy Unit, Hospital Vithas Vitoria, C/Beato Tomás de Zumárraga 10, 01008, Vitoria-Gasteiz, Spain
| | - Maider Beitia
- Advanced Biological Therapy Unit, Hospital Vithas Vitoria, C/Beato Tomás de Zumárraga 10, 01008, Vitoria-Gasteiz, Spain
| | - João Espregueira-Mendes
- Clínica Espregueira-FIFA Medical Centre of Excellence, Porto, Portugal
- Dom Henrique Research Centre, Porto, Portugal
- School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
- 3B's Research Group-Biomaterials, Biodegradables and Biomimetics, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, University of Minho, Barco, Guimarães, Portugal
| | - Sergio González
- Arthroscopic Surgery Unit, Hospital Vithas Vitoria, Vitoria-Gasteiz, Spain
| | - Jaime Oraa
- Arthroscopic Surgery Unit, Hospital Vithas Vitoria, Vitoria-Gasteiz, Spain
| | - Jorge Guadilla
- Arthroscopic Surgery Unit, Hospital Vithas Vitoria, Vitoria-Gasteiz, Spain
| | - Diego Delgado
- Advanced Biological Therapy Unit, Hospital Vithas Vitoria, C/Beato Tomás de Zumárraga 10, 01008, Vitoria-Gasteiz, Spain.
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Migliorini F, Pilone M, Bell A, Celik M, Konrads C, Maffulli N. Outside-in repair technique is effective in traumatic tears of the meniscus in active adults: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:4257-4264. [PMID: 37314454 PMCID: PMC10471662 DOI: 10.1007/s00167-023-07475-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 05/31/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE Meniscal injuries are common. Outside-in meniscal repair is one of the techniques advocated for the management of traumatic meniscal tears. This systematic review investigated the outcomes of the outside-in repair technique for the management of traumatic tears of the menisci. The outcomes of interest were to investigate whether PROMs improved and to evaluate the rate of complications. METHODS Following the 2020 PRISMA statement, in May 2023, PubMed, Web of Science, Google Scholar, and Embase were accessed with no time constraints. All the clinical investigations which reported data on meniscal repair using the outside-in technique were considered for inclusion. Only studies which reported data on acute traumatic meniscal tears in adults were considered. Only studies which reported a minimum of 24 months of follow-up were eligible. RESULTS Data from 458 patients were extracted. 34% (155 of 458) were women. 65% (297 of 458) of tears involved the medial meniscus. The mean operative time was 52.9 ± 13.6 min. Patients returned to their normal activities at 4.8 ± 0.8 months. At a mean of 67-month follow-up, all PROMs of interest improved: Tegner scale (P = 0.003), Lysholm score (P < 0.0001), International Knee Documentation Committee (P < 0.0001). 5.9% (27 of 458) of repairs were considered failures. Four of 186 (2.2%) patients experienced a re-injury, and 5 of 458 (1.1%) patients required re-operation. CONCLUSION Meniscal repair using the outside-in technique can be effectively performed to improve the quality of life and the activity level of patients with acute meniscal tears. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
- Department of Orthopaedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100 Bolzano, Italy
| | - Marco Pilone
- Residency Program in Orthopedics and Traumatology, University of Milan, Milan, Italy
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, SA Italy
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152 Simmerath, Germany
| | - Michael Celik
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Christian Konrads
- Department of Orthopaedics and Traumatology, Helios Hanseatic Hospital Stralsund, Stralsund, Germany
- Medical Faculty, University of Tübingen, 72076 Tübingen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, SA Italy
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, ST4 7QB Stoke On Trent, England
- Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, E1 4DG London, England
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Migliorini F, Asparago G, Oliva F, Bell A, Hildebrand F, Maffulli N. Greater rate of return to play and re-injury following all-inside meniscal repair compared to the inside-out technique: a systematic review. Arch Orthop Trauma Surg 2023; 143:6273-6282. [PMID: 37284879 PMCID: PMC10491517 DOI: 10.1007/s00402-023-04933-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 05/25/2023] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Inside-out and all-inside arthroscopic meniscal repairs are widely performed. However, it remains unclear which method promotes greater clinical outcomes. This study compared inside-out versus all-inside arthroscopic meniscal repair in terms of patient-reported outcome measures (PROMs), failures, return to play, and symptoms. METHODS This systematic review was conducted in accordance with the PRISMA guidelines. Two authors independently performed the literature search by accessing the following databases: PubMed, Google Scholar, and Scopus in February 2023. All clinical studies which investigated the outcomes of all-inside and/or inside-out meniscal repair were considered. RESULTS Data from 39 studies (1848 patients) were retrieved. The mean follow-up was 36.8 (9 to 120) months. The mean age of the patients was 25.8 ± 7.9 years. 28% (521 of 1848 patients) were women. No difference was found in PROMs: Tegner Activity Scale (P = 0.4), Lysholm score (P = 0.2), and International Knee Document Committee score (P = 0.4) among patients undergoing meniscal repair with all inside or inside-out techniques. All-inside repairs showed a greater rate of re-injury (P = 0.009) but also a greater rate of return to play at the pre-injury level (P = 0.0001). No difference was found in failures (P = 0.7), chronic pain (P = 0.05), reoperation (P = 0.1) between the two techniques. No difference was found in the rate of return to play (P = 0.5) and to daily activities (P = 0.1) between the two techniques. CONCLUSION Arthroscopic all-inside meniscal repair may be of special interest in patients with a particular interest in a fast return to sport, while, for less demanding patients, the inside-out suture technique may be recommended. High-quality comparative trials are required to validate these results in a clinical setting. LEVEL OF EVIDENCE Level III, systematic review.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy.
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, Simmerath, Germany.
| | - Giovanni Asparago
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy
| | - Francesco Oliva
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, Simmerath, Germany
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, ST4 7QB, Stoke On Trent, England
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, E1 4DG, London, England
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Pesare E, Vicenti G, Kon E, Berruto M, Caporali R, Moretti B, Randelli PS. Italian Orthopaedic and Traumatology Society (SIOT) position statement on the non-surgical management of knee osteoarthritis. J Orthop Traumatol 2023; 24:47. [PMID: 37679552 PMCID: PMC10485223 DOI: 10.1186/s10195-023-00729-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/15/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Knee osteoarthritis (OA) is a chronic disease associated with a severe impact on quality of life. However, unfortunately, there are no evidence-based guidelines for the non-surgical management of this disease. While recognising the gap between scientific evidence and clinical practice, this position statement aims to present recommendations for the non-surgical management of knee OA, considering the available evidence and the clinical knowledge of experienced surgeons. The overall goal is to offer an evidenced-based expert opinion, aiding clinicians in the management of knee OA while considering the condition, values, needs and preferences of individual patients. METHODS The study design for this position statement involved a preliminary search of PubMed, Google Scholar, Medline and Cochrane databases for literature spanning the period between January 2021 and April 2023, followed by screening of relevant articles (systematic reviews and meta-analyses). A Società Italiana Ortopedia e Traumatologia (SIOT) multidisciplinary task force (composed of four orthopaedic surgeons and a rheumatologist) subsequently formulated the recommendations. RESULTS Evidence-based recommendations for the non-surgical management of knee OA were developed, covering assessment, general approach, patient information and education, lifestyle changes and physical therapy, walking aids, balneotherapy, transcutaneous electrical nerve stimulation, pulsed electromagnetic field therapy, pharmacological interventions and injections. CONCLUSIONS For non-surgical management of knee OA, the recommended first step is to bring about lifestyle changes, particularly management of body weight combined with physical exercise and/or hydrotherapy. For acute symptoms, non-steroidal anti-inflammatory drugs (NSAIDs), topic or oral, can be used. Opioids can only be used as third-line pharmacological treatment. Glucosamine and chondroitin are also suggested as chronic pharmacological treatment. Regarding intra-articular infiltrative therapy, the use of hyaluronic acid is recommended in cases of chronic knee OA [platelet-rich plasma (PRP) as second line), in the absence of active acute disease, while the use of intra-articular injections of cortisone is effective and preferred for severe acute symptoms.
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Affiliation(s)
- Elisa Pesare
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 70100, Bari, Italy
| | - Giovanni Vicenti
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 70100, Bari, Italy.
| | - Elisaveta Kon
- Biomechanics and Technology Innovation Laboratory, II Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Bologna, Italy
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Massimo Berruto
- ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini, CTO, Milan, Italy
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, University of Milan, and IRCCS S Matteo Foundation, Pavia, Italy
| | - Biagio Moretti
- Orthopaedic & Trauma Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 70100, Bari, Italy
| | - Pietro S Randelli
- Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università Degli Studi Di Milano, Via Mangiagalli 31, 20133, Milan, Italy
- U.O.C. 1° Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, 20122, Milan, Italy
- Research Center for Adult and Pediatric Rheumatic Diseases (RECAP-RD), Department of Biomedical Sciences for Health, Università Degli Studi Di Milano, Via Mangiagalli 31, 20133, Milan, Italy
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Rodeo SA. Orthobiologics: Current Status in 2023 and Future Outlook. J Am Acad Orthop Surg 2023:00124635-990000000-00683. [PMID: 37130369 DOI: 10.5435/jaaos-d-22-00808] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 03/21/2023] [Indexed: 05/04/2023] Open
Abstract
Orthobiologic agents, including platelet-rich plasma, connective tissue progenitor cells derived from bone marrow, adipose, and other tissues, and purified cytokines and small peptides, have tremendous potential to target deficiencies in soft-tissue healing. The principal limitation currently is the variability in the composition and biologic activity of orthobiologic formulations, making it difficult to choose the optimal treatment for a specific tissue or pathology. Current data suggest that orthobiologics are "symptom-modifying," but there is little evidence that they can lead to true tissue regeneration ("structure-modifying"). A critically important need at this time is to identify sentinel markers of potency and biologic activity for different orthobiologic formulations so that we can match the treatment to the desired biologic effect for a specific tissue or pathology. Improved understanding of the underlying cellular and molecular mechanisms of tissue degeneration and repair will allow a precision medicine approach where we can choose the optimal orthobiologic treatment of specific orthopaedic problems. It is important for the clinician to be aware of the evolving regulatory status of orthobiologic treatments. Emerging therapies such as the use of exosomes and gene therapy approaches hold great promise as improved methods to both treat symptoms and affect tissue regeneration.
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Affiliation(s)
- Scott A Rodeo
- From the Sports Medicine Institute, Hospital for Special Surgery, New York, NY
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Li Z, Weng X. Platelet-rich plasma use in meniscus repair treatment: a systematic review and meta-analysis of clinical studies. J Orthop Surg Res 2022; 17:446. [PMID: 36209223 PMCID: PMC9548158 DOI: 10.1186/s13018-022-03293-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 08/20/2022] [Indexed: 11/15/2022] Open
Abstract
Background There is conflicting clinical evidence whether platelet-rich plasma (PRP) therapies could translate to an increased meniscus healing rate and improved functional outcomes. The objective of this systematic review and meta-analysis was to compare the failure rate and patient-reported functional outcomes in meniscus repair augmented with and without PRP. Methods We comprehensively searched the PubMed, Web of Science, Medline, Embase, and Cochrane Library databases to identify studies that compared the clinical efficacy of meniscus repair performed with PRP versus without PRP. The primary outcome was the meniscus repair failure rate, while the secondary outcomes were knee-specific patient-reported outcomes, including the International Knee Documentation Committee (IKDC) score, Lysholm knee scale, visual analog scale, Tegner activity level score, Western Ontario and McMaster Universities Osteoarthritis Index score, Single Assessment Numeric Evaluation score, and Knee injury and Osteoarthritis Outcome Score. Furthermore, subgroup analyses were performed by stratifying the studies according to the PRP preparation technique to investigate the potential sources of heterogeneity among studies. Results Our meta-analysis included nine studies (two RCTs and seven non-RCTs) with 1164 participants. The failure rate in the PRP group was significantly lower than that in the non-PRP group [odds ratio: 0.64, 95% confidence interval (CI) (0.42, 0.96), P = 0.03]. Furthermore, the PRP group was associated with a statistically significant improvement in the visual analog scale for pain [Mean difference (MD): − 0.76, 95% CI (− 1.32, − 0.21), P = 0.007] and Knee injury and Osteoarthritis Outcome Score-symptom [MD: 8.02, 95% CI (2.99, 13.05), P = 0.002] compared with the non-PRP group. However, neither the IKDC score nor the Lysholm knee scale showed any differences between the two groups. In addition, the results of subgroup analyses favored PRP over platelet-rich fibrin matrix (PRFM) regarding the IKDC score. Conclusions Although meniscus repairs augmented with PRP led to significantly lower failure rates and better postoperative pain control compared with those of the non-PRP group, there is insufficient RCT evidence to support PRP augmentation of meniscus repair improving functional outcomes. Moreover, PRP could be recommended in meniscus repair augmentation compared with PRFM. PRFM was shown to have no benefit in improving functional outcomes.
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Affiliation(s)
- Ziquan Li
- Department of Orthopedic Surgery, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Beijing, 100730, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Xisheng Weng
- Department of Orthopedic Surgery, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Beijing, 100730, China. .,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, 100730, China.
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No evidence in support of arthroscopic partial meniscectomy in adults with degenerative and nonobstructive meniscal symptoms: a level I evidence-based systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 31:1733-1743. [PMID: 35776158 PMCID: PMC10090009 DOI: 10.1007/s00167-022-07040-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/09/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE It is unclear whether the results of arthroscopic partial meniscectomy (APM) are comparable to a structured physical therapy (PT). This systematic review investigated efficacy of APM in the management of symptomatic meniscal damages in middle aged patients. Current available randomised controlled trials (RCTs) which compared APM performed in isolation or combined with physical therapy versus sham arthroscopy or isolated physical therapy were considered in the present systematic review. METHODS This systematic review was conducted according to the 2020 PRISMA statement. All the level I RCTs which investigated the efficacy of AMP were accessed. Studies which included elderlies with severe OA were not eligible, nor were those in which APM was combined with other surgical intervention or in patients with unstable knee or with ligaments insufficiency. The risk of bias was assessed using the software Review Manager 5.3 (The Nordic Cochrane Collaboration, Copenhagen). To rate the quality of evidence of collected outcomes, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used. RESULTS Data from 17 studies (2037 patients) were collected. 48.5% (988 of 2037 patients) were women. The mean age of the patients was 52.7 ± 3.9 years, the mean BMI 27.0 ± 1.3 kg/m2. The current evidence suggests no difference in functional PROMs (quality of the evidence: high), clinical PROMs (quality of the evidence: high), pain (quality of the evidence: high), quality of life (quality of the evidence: high), physical performance measures (quality of the evidence: moderate), and OA progression (quality of the evidence: moderate). CONCLUSIONS The benefits of APM in adults with degenerative and nonobstructive meniscal symptoms are limited. The current evidence reports similarity in the outcome between APM and PT. Further long-term RCTs are required to investigate whether APM and PT produce comparable results using validated and reliable PROMs. Moreover, future RCTs should investigate whether patients who might benefit from APM exist, clarifying proper indications and outcomes. High quality investigations are strongly required to establish the optimal PT regimes. LEVEL OF EVIDENCE Level I.
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Abstract
Meniscal lesions often occur in association with anterior cruciate ligament (ACL) tears at the moment of the injury or, secondarily, as a consequence of knee instability. Both ACL and meniscus lesions are associated with a higher risk of osteoarthritis. Adequate treatment of these lesions reduces the rate of degenerative changes in the affected knee. Meniscal tears should be addressed concomitantly with ACL reconstruction and the treatment must be oriented towards preserving the meniscal tissue anytime this is possible. Several options for approaching a meniscus tear are available. The meniscal suture should always be considered, and, if possible, meniscectomy should be the last choice. “Masterly neglect” is a valuable option in selected cases.
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