Platelet-rich plasma augmentation in anterior cruciate ligament reconstruction: Evidence is still too scattered. A scoping review of randomised controlled trials

PURPOSE

Platelet-rich plasma (PRP) augmentation has been proposed to improve the results of anterior cruciate ligament reconstruction (ACLR). The present study aims to quantify the available evidence to support the use of PRP as biological augmentation in ACLR surgery.

METHODS

A systematic literature search was conducted on the PubMed, Cochrane, Web of Science and Embase databases on 10 March 2023. Inclusion criteria were randomised controlled trials (RCTs), written in English, addressing PRP augmentation in ACLR surgery, with no time limitation. A scoping review was performed to map the body of literature by examining the evidence related to specific aspects of patients' treatment and evaluation. Risk of bias evaluation was performed with the Cochrane risk-of-bias tool for randomised trials Version 2 (RoB 2), while the quality assessment was performed with the use of the Coleman Score.

RESULTS

Out of 983 articles retrieved, 23 RCTs on 943 knees were included in this scoping review. PRP was administered in a liquid form in nine studies and clotted in 11 studies, while in three studies both liquid and clotted PRP were used. Hamstring auto/allografts were used in 14 studies, patellar tendon auto/allografts were used in eight studies and one study described ACLR with peroneus longus allografts. The map of the evidence documented high heterogeneity also in terms of surgical technique, objective and subjective outcome measures and radiological assessment, as well as follow-up times ranging from 1 day to 2 years, with virtually no overlapping data among studies neither in terms of treatments nor evaluations. Risk of bias evaluation showed an overall low quality of the included studies.

CONCLUSIONS

The available literature addressing PRP augmentation in ACLR is largely scattered. PRP was produced and applied following different procedures, and high variability was detected across the included studies for every aspect of ACLR surgery and evaluation. Currently, a meaningful comparison of the available studies is not possible as the quantification of the literature results is biased by their heterogeneity. Future studies should provide more standardisation to investigate the benefits of biological augmentation in ACL surgery and confirm the promising yet weak evidence of PRP potential as well as the most suitable application modality, before routine use in clinical practice.

LEVEL OF EVIDENCE

Levels I and II, scoping review.

Robotic-assisted unicompartmental knee arthroplasty improves functional outcomes, complications, and revisions

Aims

Robotic-assisted unicompartmental knee arthroplasty (R-UKA) has been proposed as an approach to improve the results of the conventional manual UKA (C-UKA). The aim of this meta-analysis was to analyze the studies comparing R-UKA and C-UKA in terms of clinical outcomes, radiological results, operating time, complications, and revisions.

Methods

The literature search was conducted on three databases (PubMed, Cochrane, and Web of Science) on 20 February 2024 according to the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Inclusion criteria were comparative studies, written in the English language, with no time limitations, on the comparison of R-UKA and C-UKA. The quality of each article was assessed using the Downs and Black Checklist for Measuring Quality.

Results

Among the 3,669 articles retrieved, 21 studies on 19 series of patients were included. A total of 3,074 patients (59.5% female and 40.5% male; mean age 65.2 years (SD 3.9); mean BMI 27.4 kg/m2 (SD 2.2)) were analyzed. R-UKA obtained a superior Knee Society Score improvement compared to C-UKA (mean difference (MD) 4.9; p < 0.001) and better Forgotten Joint Score postoperative values (MD 5.5; p = 0.032). The analysis of radiological outcomes did not find a statistically significant difference between the two approaches. R-UKA showed longer operating time (MD 15.6; p < 0.001), but reduced complication and revision rates compared to C-UKA (5.2% vs 10.1% and 4.1% vs 7.2%, respectively).

Conclusion

This meta-analysis showed that the robotic approach for UKA provided a significant improvement in functional outcomes compared to the conventional manual technique. R-UKA showed similar radiological results and longer operating time, but reduced complication and revision rates compared to C-UKA. Overall, R-UKA seems to provide relevant benefits over C-UKA in the management of patients undergoing UKA.

Intra-articular corticosteroid injections provide a clinically relevant benefit compared to placebo only at short-term follow-up in patients with knee osteoarthritis: A systematic review and meta-analysis

PURPOSE

To quantify the clinical relevance of intra-articular corticosteroid effects compared to placebo for the injective treatment of knee osteoarthritis (OA).

METHODS

The PubMed, Cochrane Library and Web of Science databases were searched on May 3, 2023. This study was conducted in accordance with the PRISMA guidelines. The inclusion criteria were randomized controlled trials (RCTs), published in English, with no time limitation regarding publication date, comparing intra-articular corticosteroids and placebo injections for knee OA. The effects were quantified at short- (≤6 weeks), mid- (>6 weeks and ≤3 months), and long-term (≥6 months) follow-ups. The minimal clinically important difference (MCID) for the outcomes (visual analogue scale for pain - VAS: 1.4, Western Ontario and McMaster University Osteoarthritis Index - WOMAC: 9) was used to interpret the clinical improvement provided by intra-articular corticosteroid injections compared to placebo. The quality of each article was assessed using the Cochrane RoB 2 tool and the GRADE guidelines.

RESULTS

Among the 1030 articles retrieved, 11 RCTs (842 patients) were included. A comparison of the two groups revealed statistically significant differences in the improvement of VAS and WOMAC scores in terms of the mean difference (MD); this difference was in favour of corticosteroids at short-term (p < 0.001, MD = -1.6 and p < 0.001, MD = -9.9, respectively) and mid-term follow-ups (p = 0.001, mean MD = -1.3 and p = 0.005, MD = -4.9, respectively). No difference was observed at the long-term follow-up. The MDs between the improvements in the two groups reached the MCID values for the VAS and WOMAC only at the short-term follow-up. The RoB 2 tool and the GRADE evaluations showed the presence of risk of bias and limited quality of evidence.

CONCLUSION

This systematic review and meta-analysis demonstrated that intra-articular corticosteroid injections offer clinically perceivable pain relief and functional improvement higher than the placebo effect only at short-term follow-up in patients affected by knee OA, with benefits losing clinical relevance already after 6 weeks. These results, together with the low number and the limited quality of the RCTs comparing this treatment with placebo, question the indication for the use of corticosteroid injections in clinical practice for the treatment of knee OA.

LEVEL OF EVIDENCE

Level I.

Intra-articular injections in sport-active patients with degenerative cartilage lesions or osteoarthritis of the knee: a systematic review

PURPOSE

The aim of this systematic review was to analyse the available clinical evidence on intra-articular knee injections for the treatment of degenerative cartilage lesions and osteoarthritis (OA) in sport-active patients.

METHODS

A literature search was performed in July 2023 according to the PRISMA guidelines on three electronic databases (PubMed, Cochrane, Web of Science). Studies addressing intra-articular injections for degenerative knee cartilage lesions or knee OA in sport-active patients were included. The Downs and Black's "checklist for measuring quality" was used to evaluate risk of bias and quality of the included studies.

RESULTS

Only 10 clinical studies for a total of 296 sport-active patients were included, with a publication trend increasing over time. The studies were 9 case series and 1 RCT; 7 studies focused on hyaluronic acid (HA), 2 studies focused on platelet-rich plasma (PRP), while 1 study compared HA and PRP. Overall, safety and positive clinical findings were for both HA and PRP, although not always with satisfactory results in terms of return to sport. The Downs and Black evaluation showed an overall poor quality of the included studies, with an average score of 21.1 points (range 19-25).

CONCLUSIONS

The available clinical evidence is still limited, with only a few studies published and an overall low-quality of evidence, suggesting a potential role of HA and PRP injections to treat these patients. However, further high-level trials are needed to confirm the real benefits of these treatments for the management of sport-active patients affected by degenerative cartilage lesions or OA of the knee.

Robotic-assisted mechanically aligned total knee arthroplasty does not lead to better clinical and radiological outcomes when compared to conventional TKA: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Robotic-assisted total knee arthroplasty (R-TKA) has emerged as an alternative to improve the results of the conventional manual TKA (C-TKA). The aim of this study was to analyse the high-level studies comparing R-TKA and C-TKA in terms of clinical outcomes, radiological results, perioperative parameters, and complications.

METHODS

The literature search was conducted on three databases (PubMed, Cochrane, and Web of Science) on 1 February 2023 according to the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Inclusion criteria were: randomized controlled trials (RCTs), written in English language, published in the last 15 years, focusing on the comparison of C-TKA and R-TKA results. The quality of each article was assessed using the Cochrane risk-of-bias tool for randomized trials version 2 (RoB 2). The statistical analysis was carried out using random effects (DerSimonian & Laird) for weighted mean difference (MD) of the continuous variables and Peto method for odds ratios of the dichotomous variables.

RESULTS

Among the 2905 articles retrieved, 14 RCTs on 12 series of patients treated with mechanically aligned implants were included. A total of 2255 patients (25.1% males and 74.9% females; mean age 62.9 ± 3.0; mean BMI 28.1 ± 1.3) were analysed. The results of this systematic review and meta-analysis showed that R-TKA did not provide overall superior results compared to C-TKA in mechanically aligned implants in terms of clinical and radiological outcomes. R-TKA showed longer operative time (MD = 15.3 min, p = 0.004) and similar complication rates compared to C-TKA. A statistically significant difference in favour of R-TKA was found in the posterior-stabilized subgroup in terms of radiological outcomes (hip-knee-ankle angle MD = 1.7, p < 0.001) compared to C-TKA, although without resulting in appreciable difference of clinical outcomes.

CONCLUSION

R-TKA did not provide overall superior results compared to C-TKA in terms of clinical and radiological outcomes, showing longer operative time and similar complication rates.

LEVEL OF EVIDENCE

Level I.

Resurfacing Hip Arthroplasty Is a Safe and Effective Alternative to Total Hip Arthroplasty in Young Patients: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed at comparing resurfacing hip arthroplasty (RHA) and total hip arthroplasty (THA) in terms of rate of complications, revisions, functional outcomes, blood loss, operative time and metal ions levels. The search was conducted on three databases (PubMed, Cochrane and Web of Science) updated until 13 October 2022. The inclusion criteria were RCTs) written in the English language, with no time limitation, comparing RHA and THA. Among the retrieved 4748 articles, 18 RCTs were eligible for a total of 776 patients (mean age 53.1 ± 5.0). A meta-analysis was performed. RHA reported significantly lower blood loss compared to THA (p < 0.001) but with longer operative time (p < 0.001). No statistically significant difference was found between RHA and THA in terms of complications (12.08% and 16.24%, respectively) and revisions (6.32% and 6.14%, respectively). Both RHA and THA provide excellent clinical results in a population of young and active patients. Functional outcomes were not significantly different between the groups. Moreover, no significant difference in metal ion levels was found. These findings provide evidence concerning the safety and clinical effectiveness of RHA. Because of its bone-preserving properties, the lack of drawbacks and good outcomes, RHA appears to be a valid alternative to THA in young and active patients.