Better outcomes using suture button compared to screw fixation in talofibular syndesmotic injuries of the ankle: a level I evidence-based meta-analysis

INTRODUCTION

The present meta-analysis evaluated current level I clinical trials which compared the use of a suture button (SB) versus syndesmotic screw (SS) fixation techniques for syndesmosis injuries of the ankle. The outcomes of interest were to compare patient-reported outcome measures (PROMs) and complications. It was hypothesised that SB might achieve better PROMs along with a lower rate of complications.

METHODS

This study was conducted according to the 2020 PRISMA statement. In August 2023, PubMed, Web of Science, Google Scholar, and Embase were accessed. All the randomised controlled trials (RCTs) which compared SB versus SS fixation for syndesmosis injuries of the ankle were accessed. Data concerning the American Orthopaedic Foot & Ankle Society (AOFAS), and Olerud-Molander score (OMS) were collected at baseline and at last follow-up. Data on implant failure, implant removal, and joint malreduction were also retrieved.

RESULTS

Data from seven RCTs (490 patients) were collected. 33% (161 of 490) were women. The mean length of the follow-up was 30.8 ± 27.4 months. The mean age of the patients was 41.1 ± 4.1 years. Between the two groups (SB and SS), comparability was found in the mean age, and men:women ratio. The SS group evidenced lower OMS (P = 0.0006) and lower AOFAS (P = 0.03). The SS group evidenced a greater rate of implant failure (P = 0.0003), implant removal (P = 0.0005), and malreduction (P = 0.04).

CONCLUSION

Suture button fixation might perform better than the syndesmotic screw fixation in syndesmotic injuries of the ankle.

Long head of biceps tendon augmentation for massive rotator cuff tears improves clinical results regardless of the number of tendons involved

PURPOSE

Management of massive rotator cuff tears (MRCTs) remains debated, and various arthroscopic and open techniques have been described for their management. Nevertheless, the optimal strategy remains unclear. The present study evaluated the clinical results in patients managed arthroscopically for MRCTs augmented with the long head biceps tendon (LHBT) at a minimum 1-year follow-up, considering different type of tears, demographic data and number of torn tendons.

METHODS

Patients treated in a secondary referral centre from January 2021 to April 2022 were enroled prospectively. Inclusion criteria were pain, inability to fully elevate the affected shoulder, irreparable tears and active and motivated patients. All patients were managed within 2 months from diagnosis in a single centre by the same surgeons. Preoperative shoulder radiographs and magnetic resonance imaging (MRI) were collected, and clinical assessment was also performed using the Numerical analogue scale (NAS), Constant score (CS) American Shoulder and Elbow Surgeons Shoulder Score (ASES). Tissue retraction and tendon fatty infiltration were evaluated using Patte and Fuchs scale, respectively. Clinical assessment was performed using the same scales at 3-6 months and 1-year follow-up.

RESULTS

A total of 55 patients (31 female and 24 male) with a mean age of 60 ± 7.1 years were enroled for a mean follow-up of 18.2 ± 4.3 months. The mean preoperative NAS was 7.8 ± 0.6, CS was 20.5 ± 7.6 and ASES was 22.6 ± 9.2, increasing, respectively, to 0.3 ± 0.6, 91.5 ± 6.9 and 94.2 ± 6.7. No adverse side effects (infection, rejection, allergy) were reported during the study period. All patients were evaluated after surgery at 3 and 6 months and 1 year with statistically significant improvement for each score at the first and last follow-up (p < 0.05).

CONCLUSIONS

The use of LHBT augmentation in patients with MRCTs in appropriately selected patients is safe and effective and can lead to pain relief and acceptable clinical outcomes. Furthermore, its use carries low donor site morbidity and is cost effective. Comparative studies, including randomised controlled trials, with other proposed techniques are needed to confirm these findings.

LEVEL OF EVIDENCE

Level IV.

Predictors of success of pharmacological management in patients with chronic lower back pain: systematic review

BACKGROUND

Conservative management is recommended as the first therapeutic step in chronic low back pain (LBP), but there is no available evidence regarding the possible effect of patients' baseline characteristics on the therapeutic outcomes. A systematic review of the literature was performed to investigate this point.

METHODS

In February 2024, all the level I studies investigating the role of pharmacological management for chronic LBP were accessed. Data concerning the patient demographic at baseline were collected: number of patients and related mean BMI and age, duration of the symptoms, duration of the follow-up, percentage of females, Numeric Rating Scale (NRS), the Roland Morris Disability Questionnaire (RMQ), Oswestry Disability Index (ODI). The outcomes at the last follow-up were evaluated through NRS, RMQ, and ODI. A multiple linear model regression diagnostic through the Pearson Product-Moment Correlation Coefficient (r) was used.

RESULTS

Data from 47 articles (9007 patients) were obtained. The analysis yielded the following significant associations: age at baseline and NRS at follow-up (r = - 0.22; P = 0.04), NRS at baseline with NRS (r = 0.26; P = 0.03) and RMQ (r = - 0.58; P = 0.02) at follow-up, RMQ at baseline and the same at follow-up (r = 0.69; P = 0.0001).

CONCLUSION

Older age, higher BMI, presence of comorbidities, higher ODI and a long history of symptoms or surgical treatments do not reduce the efficacy of pharmacological management of chronic LBP. However, pharmacological therapy is not an effective option for patients with high baseline RMQ.

LEVEL OF EVIDENCE

I systematic review of RCTs.

TENDINopathy Severity assessment-Achilles (TENDINS-A): evaluation of reliability and validity in accordance with COSMIN recommendations

OBJECTIVE

To evaluate the construct validity (structural validity and hypothesis testing), reliability (test-retest reliability, measurement error and internal consistency) and minimal important change (MIC) of the 13-item TENDINopathy Severity assessment-Achilles (TENDINS-A).

METHODS

Participants with Achilles pain completed an online survey including: demographics, TENDINS-A, Foot and Ankle Outcome Score (FAOS) and Victorian Institute of Sport Assessment-Achilles (VISA-A). Exploratory factor analysis (EFA) assessed dimensionality. Confirmatory factor analysis (CFA) assessed structural validity (root mean square error of approximation (RMSEA); Comparative Fit Index (CFI); Tucker-Lewis Index (TLI); standardised root measure square (SRMS)). Correlations between TENDINS-A and the FAOS or VISA-A assessed hypothesis testing. Intraclass correlation (ICC) assessed test-retest reliability. Cronbach's alpha assessed internal consistency. SE of the measurement (SEM) assessed measurement error. A distribution-based approach assessed MIC.

RESULTS

79 participants (51% female) with a mean (SD) age=42.6 (13.0) years, height=175.0 (11.7) cm and body mass=82.0 (19.1) kg were included. EFA identified three meaningful factors, proposed as pain, symptoms and function. The best model identified using CFA for TENDINS-A had structural validity (RMSEA=0.101, CFI=0.959, TLI=0.947, SRMS=0.068), which included three factors (pain, symptoms and function), but excluded three items from the original TENDINS-A. TENDINS-A exhibited moderate positive correlation with FAOS (r=0.598, p<0.001) and a moderate negative correlation with VISA-A (r=-0.639, p<0.001). Reliability of the TENDINS-A was excellent (ICC=0.930; Cronbach's α=0.808; SEM=6.54 units), with an MIC of 12 units.

CONCLUSIONS

Our evaluation of the revised 10-item TENDINS-A determined it has construct validity and excellent reliability, compared with the VISA-A and FAOS which lack content and construct validity. The TENDINS-A is recommended as the preferred patient-reported outcome measure to assess disability in people with Achilles tendinopathy.

Groin Pain Syndrome Italian Consensus Conference update 2023

Groin pain syndrome (GPS) is a controversial topic in Sports Medicine. The GPS Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes was organized by the Italian Society of Arthroscopy in Milan, on 5 February 2016. In this Consensus Conference (CC) GPS etiology was divided into 11 different categories for a total of 63 pathologies. The GPS Italian Consensus Conference update 2023 is an update of the 2016 CC. The CC was based on a sequential, two-round online Delphi survey, followed by a final CC in the presence of all panelists. The panel was composed of 55 experts from different scientific and clinical backgrounds. Each expert discussed 6 different documents, one of which regarded the clinical and imaging definition of sports hernias, and the other 5 dealt with 5 new clinical situations thought to result in GPS. The panelists came to an agreement on the definition of a sports hernia. Furthermore, an agreement was reached, recognizing 4 of the 5 possible proposed pathologies as causes to GPS. On the contrary, the sixth pathology discussed did not find consensus given the insufficient evidence in the available scientific literature. The final document includes a new clinical and imaging definition of sports hernia. Furthermore, the etiology of GPS was updated compared to the previous CC of 2016. The new taxonomic classification includes 12 categories (versus 11 in the previous CC) and 67 pathologies (versus 63 in the previous CC).

Functional alignment in robotic-assisted total knee arthroplasty: a systematic review

PURPOSE

The present study systematically reviewed current evidence on functional alignment (FA) in robotic total knee arthroplasty (TKA), discussing advantages and limitations, possible pitfalls, and prospects.

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 with no additional filters or time constraints. All the clinical studies investigating functional alignment in robotic TKA were accessed. Only studies published in peer-reviewed journals were considered. The risk of bias was evaluated following the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions. Non-randomized controlled trials (non-RCTs) were evaluated using the Risk of Bias in Nonrandomised Studies of Interventions (NRSI) (ROBINS-I) tool.

RESULTS

Data from 1198 patients (seven studies) were retrieved. The mean length of the follow-up was 17.1 ± 6.4 months. The mean age was 67.2 ± 5.4 years, and the mean BMI was 30.9 ± 2.7 kg/m2.

CONCLUSION

FA might improve resection accuracy, implant alignment, and gap balancing in TKA, and additional high-quality clinical trials are necessary to properly establish the superiority of FA to other alignment techniques in TKA. Long-term clinical trials are needed to investigate the impact of FA on implant survivorship.

LEVEL OF EVIDENCE

Level IV, systematic review and meta-analysis.

Wharton's jelly and osteoarthritis of the knee

INTRODUCTION

The existing treatment modalities for knee osteoarthritis (OA) do not actually address the pathology. Biological therapies, including those using material derived from perinatal tissues, represent a ground-breaking approach to alleviating the symptoms of OA of the knee.

SOURCE OF DATA

Current scientific literature published in PubMed (MEDLINE), Embase and Scopus databases. Trials registered in various clinical trial databases.

AREAS OF AGREEMENT

Perinatal tissues including Wharton's jelly (WJ) and associated mesenchymal stem cells (MSCs) can be used for the management of knee OA.

AREAS OF CONTROVERSY

The efficacy of WJ and associated MSCs in the management of knee OA is still controversial.

GROWING POINTS

The use of WJ and associated MSCs in the management of knee OA is safe and appears to be effective.

AREAS TIMELY FOR DEVELOPING RESEARCH

The present published evidence suggests that WJ tissue and associated MSCs offer an encouraging alternative for the management of knee OA. The published in vitro, preclinical and clinical investigations demonstrate the therapeutic potential of WJ and promote further research in this field to provide symptomatic relief to patients suffering from OA, aiming also to regenerate the osteoarthritic hyaline cartilage, with disease-modifying effects. Future adequately powered randomized controlled trials should be undertaken to establish whether WJ is helpful in the management of OA of the knee.

Management of rotator cuff injuries using allogenic platelet-rich plasma

Rotator cuff injuries are a major cause of shoulder pain, affecting the quality of life and producing a significant burden on healthcare systems. Conservative management modalities are prioritized, resorting to surgery only when required. The field of regenerative medicine involving the use of biologics, such as platelet-rich plasma (PRP), has evolved and shown potential for managing rotator cuff injuries. Nonetheless, limitations including subpar outcomes have led clinicians to question the efficacy of autologous PRP. To circumvent this, the possibility of utilizing a standardized and well-characterized allogenic PRP for RCI has been explored. In this manuscript, we qualitatively present the evidence from in vitro, pre-clinical, clinical and ongoing studies investigating the applications of allogenic PRP in the context of rotator cuff disorders. Administration of allogenic PRP is safe and potentially efficacious to manage rotator cuff injuries, though more adequately powered randomized controlled trials with longer follow-ups are warranted to further establish the efficacy of allogenic PRP and justify its routine clinical use.

Return to Sport at Preinjury Level is Common After Surgical Treatment of SLAP Lesions: A Systematic Review and a Meta-analysis

BACKGROUND

Patients undergoing surgery for Superior-Labrum-anterior-to-posterior (SLAP) lesions are often worried about their return to sport performance. This systematic review determined the rate of return to sport and return to sport at the previous level (RTSP) after surgery for SLAP lesion.

MATERIALS AND METHODS

The PRISMA guidelines were followed. Meta-analysis of data through forest plot projections was conducted. Studies were divided and analyzed according to the type of interventions (isolated slap repair or SLAP repair with rotator cuff debridement and biceps tenodesis).

RESULTS

The mean overall rate of return to sport after the procedures was 90.6% and the mean overall rate of return to sport at the previous level after the procedures was 71.7%. RTSP rates of the whole population were 71% (95% CI: 60%-80%), 66% (95% CI: 49%-79%), and 78% (95% CI: 67%-87%) for isolated SLAP repair, SLAP repair with the rotator cuff debridement and biceps tenodesis, respectively. A lack of subgroup analysis for the specific performance demand or type of lesion related to the surgical technique used might induce a high risk of bias.

DISCUSSION

Return to sports at the previous level after surgically treated superior labrum anterior to posterior lesion is possible and highly frequent, with the highest rates of RTSP in patients treated with biceps tenodesis. More studies and better-designed trials are needed to enrich the evidence on indications of SLAP surgical treatment in relation to specific sports-level demand.

LEVEL OF EVIDENCE

Level-IV.

All-epiphyseal anterior cruciate ligament reconstruction yields superior sports performances than the trans-epiphyseal technique in skeletally immature patients: a systematic review

BACKGROUND

Anterior cruciate ligament (ACL) tears in skeletally immature patients are increasingly common. Evidence comparing the outcomes of all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients is limited, and the current literature could benefit from a comprehensive systematic review. The present study compared all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients. The outcomes of interest were to compare joint laxity, patient-reported outcome measures (PROMs), return to sport, and complications.

METHODS

This study was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. In November 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. No additional filters were used in the database search. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles that clearly stated the surgical technique (all- or trans-epiphyseal) were eligible. Only articles with a minimum of 6 months of follow-up were included. Only articles that clearly stated that surgeries were conducted in children with open physis were eligible.

RESULTS

Data from 1489 patients (1493 procedures) were collected, of which 32% (490 of 1489 patients) were female. The mean length of follow-up was 46.6 months. The mean age of the patients was 12.7 years. No difference was found in joint laxity (Table 3): positive pivot shift (P = 0.4), positive Lachman test (P = 0.3), and mean arthrometer laxity (P = 0.1). No difference was found in PROMs (Table 4): International Knee Documentation Committee (IKDC) (P = 0.3), Lysholm (P = 0.4), and Tegner (P = 0.7). The trans-epiphyseal technique was associated with a greater rate of patients unable to return to sports (1% versus 7%, P = 0.0001) and with a longer time to return to sports (7.7 versus 8.6 months, P = 0.01). Though the trans-epiphyseal technique was associated with a lower rate of return to sport, this difference was not statistically significant (P = 0.8). No difference was evidenced in the rate of patients who had reduced their league or level of sports activity (P = 0.6) or in the rate of patients who had returned to their previous league or level of sports activity (P = 0.7). No difference was found in the rate of complication: re-tear (P = 0.8), reoperation (P = 0.7), increased laxity (P = 0.9), and persistent instability sensation (P = 0.3).

CONCLUSION

Trans-epiphyseal ACL reconstruction was associated with a greater rate of patients unable to return to sport and with a longer time to return to sport compared with the all-epiphyseal technique in skeletally immature patients. Level of evidence Level III, systematic review.

The pandemic is gone but its consequences are here to stay: avascular necrosis following corticosteroids administration for severe COVID-19

BACKGROUND

In patients with COVID-19 infection and respiratory insufficiency, corticosteroid (CCS) administration is recommended. Among the wide range of complications and interactions, time-limited high-dose CCS administration might promote avascular necrosis (AVN) in a cumulative dose. This systematic review updated the current evidence and characterises the trend of AVN following time-limited high-dose CCS administration in patients who had severe COVID-19, discussing management strategies and outcomes.

METHODS

This systematic review was conducted according to the 2020 PRISMA statement. In October 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Scopus restricting the search to the years 2019 to 2023. All the clinical studies which investigated the association between time-limited high-dose CCS administration in patients with severe COVID-19 infection and AVN were accessed.

RESULTS

A total of 245 patients (9 studies) who experienced AVN following COVID-19 were included in the present investigation. 26% (63 of 245 included patients) were women. The mean age of the patients was 42.9 ± 17.7 years. Four studies focused on AVN of the hip and two on the knee, and the other studies included patients with AVN from mixed areas of the body (spine, pelvis, and shoulder). The mean time elapsed from COVID-19 infection to the development of symptomatic AVN was 79.4 ± 59.2 days (range, 14 to 166 days).

CONCLUSION

It is possible that even time-limited high-dose CCS administration in patients with severe COVID-19 infection increased the incidence of AVN. The mean time elapsed from COVID-19 infection to the development of symptomatic AVN was approximately 80 days. Given the high risk of bias in all the included studies, the quality of recommendations of the present investigation is low, and no reliable conclusion can be inferred.

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines

BACKGROUND

Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes.

METHODS

A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines.

RESULTS

Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol.

CONCLUSION

Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.

Endoscopic peroneus brevis tendon transfer for chronic ruptures of the Achilles tendon: surgical technique

Chronic Achilles tendon rupture is usually defined as a rupture diagnosed 4-6 weeks after injury. The management of chronic Achilles tendon rupture (CATR) is a topic of hot debate, and no consensus has been achieved. Surgical management of CATR is recommended. Several approaches, techniques, and grafts have been described. Open techniques carry a high risk of wound breakdown, infection, and necessitate long rehabilitation times. Surgical techniques with smaller incisions to reduce the risk of scar fibrosis, pain, and infection are becoming common. The ipsilateral tendon of the hallux flexor longus and the peroneus brevis is commonly used. Endoscopic transfer of the peroneus brevis tendon is an innovative alternative to other procedures, with comparable results of other autografts even in elite athletes. The tendon of the peroneus brevis is harvested by tendoscopy before performing a calcaneal tendon endoscopy and fixing the graft in a calcaneal tunnel using an interference screw. After surgery, an anterior splint is placed for 3 weeks with immediate forefoot weight bearing. The rehabilitation starts on the 15th postoperative day.

Diagnosis and management of Achilles tendon ailments: the Scottish mist

The diagnosis and management of Achilles tendon ailments continue to be widely discussed by the scientific community. Also, the nomenclature used to describe the tendinopathic lesion in patients changed over the last decades together with the evolution in the knowledge of the physiopathology of Achilles tendinopathy, and unfortunately, through ignorance and possibly laziness, confusion still abounds. To emerge from these foggy paths, some clarifications are still necessary. The present Editorial tries to clarify some of these issues.

Rotator cuff tears

Rotator cuff tears are the most common upper extremity condition seen by primary care and orthopaedic surgeons, with a spectrum ranging from tendinopathy to full-thickness tears with arthritic change. Some tears are traumatic, but most rotator cuff problems are degenerative. Not all tears are symptomatic and not all progress, and many patients in whom tears become more extensive do not experience symptom worsening. Hence, a standard algorithm for managing patients is challenging. The pathophysiology of rotator cuff tears is complex and encompasses an interplay between the tendon, bone and muscle. Rotator cuff tears begin as degenerative changes within the tendon, with matrix disorganization and inflammatory changes. Subsequently, tears progress to partial-thickness and then full-thickness tears. Muscle quality, as evidenced by the overall size of the muscle and intramuscular fatty infiltration, also influences symptoms, tear progression and the outcomes of surgery. Treatment depends primarily on symptoms, with non-operative management sufficient for most patients with rotator cuff problems. Modern arthroscopic repair techniques have improved recovery, but outcomes are still limited by a lack of understanding of how to improve tendon to bone healing in many patients.

Demographic characteristics influencing the stem subsidence in total hip arthroplasty: an imaging study

INTRODUCTION

The present study evaluated whether patient demographic characteristics influence the subsidence of the stem in total hip arthroplasty (THA). The following characteristics were evaluated: age, height, weight, and sex. The association between the time elapsed from the THA implantation and the amount of stem subsidence was also investigated.

METHODS

The records of patients who underwent THA in the period between 2016 and 2023 were accessed. All patients underwent two-staged bilateral THA using cementless DePuy collarless Corail (DePuy Synthes, Raynham, MA, USA) stems. The following parameters were measured and compared to assess stem subsidence: distance from the proximal femur at the stem bone interface and the medial apex of the regular triangle built within the trochanter minor (point A); distance from the medial apex of the regular triangle built within the trochanter minor and the distal portion of the femoral stem (point B).

RESULTS

Overall, 294 patients were included. 62% (182 of 294 patients) were women. 45% (134 of 296 THAs) were on the right side. The mean age was 64.9 ± 10.4 years. The mean BMI was 28.3 ± 5.1 kg/m2. The mean length of the follow-up was 14.4 ± 11.0 months. The mean subsidence in point A was 2.1 mm (P < 0.0001), and that in point B was 3.1 mm (P < 0.0001). There was evidence of a weak positive association between patient weight (P < 0.0001), age (P = 0.03), follow-up (P = 0.002) and the amount of stem subsidence. Patient height did not demonstrate any association with the amount of stem subsidence (P = 0.07). There was no difference in stem subsidence between women and men (P = 0.9).

CONCLUSION

Stem subsidence in THA using cementless DePuy collarless Corail implants is approximately 2.6 mm after 14.4 months. Greater patient weight, age, and longer time elapsed from THA implantation were associated with greater stem subsidence. Patient height and sex did not demonstrate any influence on the amount of stem subsidence. These results must be considered in light of the limitations of the present study.

Predictors of postoperative hospital length of stay after total knee arthroplasty

INTRODUCTION

We aimed to collect and analyse clinical and functional variables of patients undergoing rehabilitation after total knee arthroplasty (TKA), to identify the variables that influence the postoperative hospital length of stay (LOS).

METHODS

We conducted a retrospective analysis of prospectively collected data of 1,082 consecutive patients (746 females and 336 males) who underwent primary TKA and rehabilitation in our orthopaedic institute between January 2013 and July 2017. Clinical and anthropometric data were analysed using a multivariate linear regression model.

RESULTS

The average LOS was 5.08 ± 2.52 days in the Department of Orthopaedic Surgery and 12.67 ± 5.54 days in the Sports Rehabilitation Unit. Factors such as age, female sex and the presence of comorbidities were predictive of a longer stay. The presence of caregiver assistance at home was associated with shorter LOS. There was no evidence of a statistically significant positive association between body mass index and LOS.

CONCLUSION

An in-depth and early knowledge of factors that influence LOS may enable the multidisciplinary team to plan a patient-tailored rehabilitation path and better allocate resources to maximise patients' functional recovery, while reducing LOS and the overall cost of the procedure.

Anterior cruciate ligament reconstruction in skeletally immature patients is effective: A systematic review

PURPOSE

The present study evaluated the outcomes of anterior cruciate ligament (ACL) reconstruction in children with open physes. The outcomes of interest were to compare the increase in joint laxity and PROMs from baseline to the last follow-up, the rate and features of the return to sport and the rate of complications.

METHODS

This study was conducted according to the 2020 PRISMA guidelines. In October 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles which clearly stated that surgeries were conducted in children with open physis were eligible.

RESULTS

Data from 53 studies (1691 procedures) were collected. 35% (597 out of 1691 patients) were women. The mean length of the follow-up was 44.7 ± 31.3 months. The mean age of the patients was 12.7 ± 1.1 years old. All PROMs significantly improved from the baseline values to those at the last follow-up. The mean time to return to sport was 8.3 ± 1.9 months. 89% (690 out of 771 patients) returned to sports, 15% (109 out of 721 patients) reduced their level of sports activity or league, and 84% (651 out of 771 patients) returned to their previous level of sport. 9% (112 out of 1213) of patients experienced re-tear of the reconstructed ACL, and 11% (75 out of 660) of patients underwent a further ACL reoperation. No patients (0 out of 83) demonstrated increased laxity at the last follow-up, and persistent sensation of instability was reported by 5% (11 out of 235) of patients.

CONCLUSION

ACL reconstruction in skeletally immature patients is effective and safe, and is associated with fast recovery and a high rate of return to sport.

LEVEL OF EVIDENCE

Level IV.

Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) in patients who have undergone total knee arthroplasty: a systematic review

BACKGROUND

The present systematic review investigated the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) of several frequent and established PROMs used to assess patients who have undergone TKA. This study was conducted according to the 2020 PRISMA statement.

METHODS

In September 2023, PubMed, Web of Science, and Embase were accessed with no time constraint All clinical studies investigating tools to assess the clinical relevance of PROMs used to evaluate patients having received TKA were accessed. Only studies which evaluated the MCID, PASS, or SCB were eligible. The PROMs of interest were the Forgotten Joint Score-12 (FJS-12), the Oxford Knee Score (OKS), the Knee Injury and Osteoarthritis Outcome Score (KOOS) and its related subscales activity of daily living (ADL), pain, quality of life (QoL), sports and recreational activities, and symptoms, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score, the Knee Society Score (KSS) and related function score, and the Short Form-12 (SF-12) and Short Form-36 (SF-36).

RESULTS

Data from 29,737 patients were collected. The overall risk of bias was low to moderate. The great variability of thresholds for MCID, SCB and PASS between questionnaires but also between investigated aspects was noted, whereby MCIDs for the SF-36 appear lower than for knee-specific questionnaires.

CONCLUSION

Despite its critical role from a patient's perspective, the dimension of SCB is still neglected in the literature. Moreover, thresholds for the different concepts need to be condition-specific. We encourage authors to specifically report such data in future studies and to adhere to previously reported definitions to allow future comparison. Level of evidence Level IV, systematic review and meta-analysis.

Antithrombotic prophylaxis following total hip arthroplasty: a level I Bayesian network meta-analysis

BACKGROUND

Several clinical investigations have compared different pharmacologic agents for the prophylaxis of venous thromboembolism (VTE). However, no consensus has been reached. The present investigation compared enoxaparin, fondaparinux, aspirin and non-vitamin K antagonist oral anticoagulants (NOACs) commonly used as prophylaxis following total hip arthroplasty (THA). A Bayesian network meta-analysis was performed, setting as outcomes of interest the rate of deep venous thrombosis (DVT), pulmonary embolism (PE) and major and minor haemorrhages.

METHODS

This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension statement for reporting systematic reviews incorporating network meta-analyses of healthcare interventions. All randomised controlled trials (RCTs) comparing two or more drugs used for the prophylaxis of VTE following THA were accessed. PubMed, Web of Science and Google Scholar databases were accessed in March 2023 with no time constraint.

RESULTS

Data from 31,705 patients were extracted. Of these, 62% (19,824) were women, with age, sex ratio, and body mass index (BMI) being comparable at baseline. Apixaban 5 mg, fondaparinux, and rivaroxaban 60 mg were the most effective in reducing the rate of DVT. Dabigatran 220 mg, apixaban 5 mg, and aspirin 100 mg were the most effective in reducing the rate of PE. Apixaban 5 mg, ximelagatran 2 mg and aspirin 100 mg were associated with the lowest rate of major haemorrhages, while rivaroxaban 2.5 mg, apixaban 5 mg and enoxaparin 40 mg were associated with the lowest rate of minor haemorrhages.

CONCLUSION

Administration of apixaban 5 mg demonstrated the best balance between VTE prevention and haemorrhage control following THA. Level of evidence Level I, network meta-analysis of RCTs.

Level I of evidence does not support manual lymphatic drainage for total knee arthroplasty: a meta-analysis

It is unclear whether manual lymphatic drainage (MLD) following primary total knee arthroplasty (TKA) is effective in reducing pain and swelling and improving knee function. The present study investigated the efficacy of MLD after TKA. The outcomes of interest are the range of motion (ROM), pain (visual analogue scale, VAS), and circumference of the lower leg. This meta-analysis was conducted according to the 2020 PRISMA statement. In November 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase, with no time constraint. Only level I evidence studies, according to the Oxford Centre of Evidence-Based Medicine, were considered. All the randomised controlled trials (RCTs) comparing patients who have received MLD versus a group of patients who did not undergo MLD following primary TKA were accessed. Data from four RCTs (197 TKAs) were retrieved. 67% (132 of 197 patients) were women. The mean length of follow-up was 7.0 ± 5.8 weeks. The mean age of the patients was 69.6 ± 2.7 years, and the mean BMI was 28.7 ± 0.9 kg/m2. At baseline, between-group comparability was evidenced in the male:female ratio, mean age, mean BMI, knee flexion, and VAS. No difference was found in flexion (P = 0.7) and VAS (P = 0.3). No difference was found in the circumference of the thigh (P = 0.8), knee (P = 0.4), calf (P = 0.4), and ankle (P = 0.3). The current level I of evidence does not support the use of MLD in primary TKA.

Small interfering RNAs in the management of human osteoporosis

BACKGROUND

Osteoporosis results in reduced bone mass and consequent bone fragility. Small interfering RNAs (siRNAs) can be used for therapeutic purposes, as molecular targets or as useful markers to test new therapies.

SOURCES OF DATA

A systematic search of different databases to May 2023 was performed to define the role of siRNAs in osteoporosis therapy. Fourteen suitable studies were identified.

AREAS OF AGREEMENT

SiRNAs may be useful in studying metabolic processes in osteoporosis and identify possible therapeutic targets for novel drug therapies.

AREAS OF CONTROVERSY

The metabolic processes of osteoporosis are regulated by many genes and cytokines that can be targeted by siRNAs. However, it is not easy to predict whether the in vitro responses of the studied siRNAs and drugs are applicable in vivo.

GROWING POINTS

Metabolic processes can be affected by the effect of gene dysregulation mediated by siRNAs on various growth factors.

AREAS TIMELY FOR DEVELOPING RESEARCH

Despite the predictability of pharmacological response of siRNA in vitro, similar responses cannot be expected in vivo.

Patient outcomes and return to play after arthroscopic rotator cuff repair in overhead athletes: a systematic review

BACKGROUND

Rotator cuff tear injuries in overhead athletes are common and may lead to chronic pain and joint disability, impairing sport participation and leading to premature retirement. The improvement of the patient reported outcome measures (PROMs) was evaluated, as were the time and level of return to sport and the rate of complication in overhead athletes who had undergone arthroscopic rotator cuff repair.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. In September 2022, the following databases were accessed: Pubmed, Web of Science, Google Scholar and Embase. No time constraints were used for the search. All the clinical trials investigating arthroscopic rotator cuff repair in overhead athletes were accessed.

RESULTS

Data from 20 studies were collected. The mean length of the follow-up was 40 months. All PROMs improved at last follow-up: Kerlan-Jobe Orthopaedic Clinic score (P = 0.02), visual analogue scale (P = 0.003), Constant score (P < 0.0001), University of California Los Angeles Shoulder score (P = 0.006) and American Shoulder and Elbow Surgeons' score (P < 0.0001). Elevation also improved (P = 0.004). No difference was found in external and internal rotation (P = 0.2 and P = 0.3, respectively). In total, 75.4% (522 of 692 of patients) were able to return to play within a mean of 6.4  ±  6.0 months. Of 692 patients, 433 (62.5%) were able to return to sport at pre-injury level. Fourteen out of 138 patients (10.1%) underwent a further reoperation. The overall rate of complications was 7.1% (20 of 280).

CONCLUSION

Arthroscopic reconstruction of the rotator cuff is effective in improving function of the shoulder in overhead athletes, with a rate of return to sport in 75.4% of patients within an average of 6.4 months.

LEVEL OF EVIDENCE

III, systematic review.

TRIAL REGISTRATION

Not applicable.

Reduced knee laxity and failure rate following anterior cruciate ligament reconstruction compared with repair for acute tears: a meta-analysis

BACKGROUND

Following anterior cruciate ligament (ACL) tears, both repair and reconstruction may be performed to restore joint biomechanics and proprioception. The present study compared joint laxity, patient-reported outcome measures (PROMs), and rate of failure following primary repair versus reconstruction for ACL ruptures.

METHODS

This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pubmed, Google scholar, Embase, and Web of Science were accessed in September 2022. All the clinical investigations comparing repair versus reconstruction for primary ACL tears were accessed. Studies reporting data on multiple ligament injuries settings were not eligible.

RESULTS

Data from eight articles (708 procedures) were collected. The mean length of the follow-up was 67.3 ± 119.4 months. The mean age of the patients was 27.1 ± 5.7 years. Thirty-six percent (255 of 708 patients) were women. The mean body mass index (BMI) was 24.3 ± 1.1 kg/m². The mean time span from injury to surgery was 36.2 ± 32.3 months. There was comparability at baseline with regards to instrumental laxity, Lachman test, International Knee Document Committee (IKDC), and Tegner Scale (P > 0.1). Similarity between ACL reconstruction and repair was found in IKDC (P = 0.2) and visual analog scale (VAS) satisfaction (P = 0.7). The repair group demonstrated greater mean laxity (P = 0.0005) and greater rate of failure (P = 0.004).

CONCLUSION

ACL reconstruction may yield greater joint stability and lower rate of failure compared with surgical repair. Similarity was found in PROMs.

LEVEL OF EVIDENCE

III.

Meniscectomy is associated with a higher rate of osteoarthritis compared to meniscal repair following acute tears: a meta-analysis

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.

Head, acetabular liner composition, and rate of revision and wear in total hip arthroplasty: a Bayesian network meta-analysis

Total hip arthroplasty (THA) is a common procedure for patients suffering from hip pain e.g. from osteoarthritis, osteonecrosis, or hip fractures. The satisfaction of patients undergoing THA is influenced by the choice of implant type and material, with one key factor being the selection of the appropriate material combination for the bearing surface. In this Bayesian network meta-analysis, we investigated the impact of material combinations for the bearing surface on the longevity of hip implants. The wear penetration rate per year and the total wear penetration in the liner resulting from different material combinations, as well as the survival rate at last follow-up, were examined. We analyzed a total of 663,038 THAs, with 55% of patients being women. Mean patient age was 59.0 ± 8.1 years and mean BMI 27.6 ± 2.6 kg/m2. The combination of an aluminium oxide (Al2O3) head and an Al2O3 liner demonstrated the lowest wear penetration at last follow-up and the lowest rate of wear penetration per year. Additionally, the combination of a crosslinked polyethylene (XLPE) liner and a zircon oxide (ZrO2) head demonstrated the lowest rate of revision at last follow-up. These findings underscore the importance of careful material selection for hip implant bearing surfaces to optimize their longevity and patient satisfaction after THA.

Efficacy of ibuprofen and indomethacin as prophylaxis of heterotopic ossification: a comparative study

The prophylactic action of non-steroidal anti-inflammatory drugs (NSAIDs) in heterotopic ossification (HO) was first described following analgesic therapy with indomethacin. Following that evidence, several compounds have been successfully used for prophylaxes of HO. Ibuprofen has been also proposed for the prevention of HO following THA. The present study compared the administration of ibuprofen for three weeks versus indomethacin as prophylaxis for HO following primary THA. In all THA procedures, pre- and post-operative protocols were conducted in a highly standardized fashion. The type of HO prophylaxis (indomethacin 100 mg/daily or ibuprofen 100 mg/daily) was chosen according to a chronological criterion: from 2017 to 2019 indomethacin was used, whereas from 2019 to 2022 ibuprofen was administered. In case of allergy or intolerance to NSAIDs, no prophylaxis was performed, and patients were included as a control group. All patients who underwent an anteroposterior radiography of the pelvis at a minimum of 12 months following THA were considered for inclusion. On admission, the age and sex of the patients were recorded. Moreover, the causes of osteoarthritis and the date of surgery were recorded. The grade of HO was assigned by a blinded assessor who was not involved in the clinical management of the patients. The modified Brooker Staging System was used to rate the efficacy of the interventions. Data from 1248 patients were collected. 62% (767 of 1248 patients) were women. The mean age was 67.0 ± 2.9 years. The mean follow-up was 21.1 ± 10.8 months. In the ibuprofen group, 73% of patients evidenced Brooker 0, 17% Brooker I, and 10% Brooker II. In the indomethacin group, 77% of patients evidenced Brooker 0, 16% Brooker I, 6% Brooker II. No patient in the ibuprofen and indomethacin group developed Brooker III or IV. In the control group, 64% of patients evidenced Brooker 0, 21% Brooker I, 3% Brooker II, and 12% Brooker III. No patient in the control group developed Brooker IV HO. Concluding, three weeks of administration of ibuprofen demonstrated similar efficacy to indomethacin in preventing HO following primary THA. The prophylaxis with ibuprofen or indomethacin was more effective in preventing HO compared to a control group who did not receive any pharmacological prophylaxis.

Management of partial-thickness rotator cuff tears with autologous adipose-derived regenerative cells is safe and more effective than injection of corticosteroid

Symptomatic, partial-thickness rotator cuff tears (sPTRCT) are problematic. This study tested the hypothesis that management of sPTRCT with injection of fresh, uncultured, unmodified, autologous, adipose-derived regenerative cells (UA-ADRCs) is safe and more effective than injection of corticosteroid even in the long run. To this end, subjects who had completed a former randomized controlled trial were enrolled in the present study. At baseline these subjects had not responded to physical therapy treatments for at least 6 weeks, and were randomly assigned to receive respectively a single injection of UA-ADRCs (n = 11) or a single injection of methylprednisolone (n = 5). Efficacy was assessed using the ASES Total score, pain visual analogue scale (VAS), RAND Short Form-36 Health Survey and range of motion at 33.2 ± 1.0 (mean ± SD) and 40.6 ± 1.9 months post-treatment. Proton density, fat-saturated, T2-weighted MRI of the index shoulder was performed at both study visits. There were no greater risks connected with injection of UA-ADRCs than those connected with injection of corticosteroid. The subjects in the UA-ADRCs group showed statistically significantly higher mean ASES Total scores than the subjects in the corticosteroid group. The MRI scans at 6 months post-treatment allowed to "watch the UA-ADRCs at work".

TENDINopathy Severity Assessment - Achilles (TENDINS-A): Development and Content Validity Assessment of a New Patient-Reported Outcome Measure for Achilles Tendinopathy

OBJECTIVE: To develop a new patient-reported outcome measure (PROM) assessing TENDINopathy Severity of the Achilles (TENDINS-Achilles) and evaluate its content validity. DESIGN: Mixed-methods, modified Delphi. METHODS: We performed 1 round of semistructured one-on-one interview responses with professionals and patients, for initial item generation. This was followed by 1 round of survey responses for professionals and a final round of semistructured one-on-one interviews with patients. The work culminated in a PROM to quantify Achilles tendinopathy severity under the core health domain of disability. Participants identified 3 subdomains contributing to the severity of disability of Achilles tendinopathy: pain, symptoms, and functional capacity. RESULTS: All 8 patient participants invited to participate were enrolled. Forty professional participants (50% women, six different continents) were invited to participate and 30 were enrolled (75% response rate). Therefore, a total of 30 professionals and 8 patients were included within this study. Following 3 rounds of qualitative or quantitative feedback, this study has established the content validity of TENDINS-A (good relevance, comprehensibility, and comprehensiveness) as a new PROM to assess the severity of Achilles tendinopathy, which assesses aspects of pain, symptoms, and functional capacity. CONCLUSION: TENDINS-A has established content validity and is appropriate for use with clinical and research populations. We recommend users interpret TENDINS-A results cautiously, until further testing evaluates the most appropriate scoring scale, reliability, construct validity, criterion validity, and responsiveness of TENDINS-A. Until these psychometric properties are established, we suggest using TENDINS-A alongside existing tools. J Orthop Sports Phys Ther 2023;53(11):1-16. Epub: 24 August 2023. doi:10.2519/jospt.2023.11964.

Allogenic umbilical cord tissue for temporomandibular joint injuries

The temporomandibular joint (TMJ) is crucial for functions of daily living such as mastication and articulation. Common TMJ issues include osteoarthritis, internal derangement, and myofascial pain dysfunction. Conservative methods such as physical therapy and medications are used, with surgical options such as arthroscopy and replacement for severe cases. Emerging regenerative medicine explores non-surgical treatments using human stem cells from umbilical cord derivatives, showing potential for tissue regeneration in TMJ disorders. A systematic search was conducted across PubMed, Embase, Scopus, and Web of Science databases, adhering to PRISMA guidelines, aiming to identify relevant articles published in English until August 2023. The search used specific terms to target in vitro, preclinical, and clinical studies on umbilical cord (UC)-derived tissue and mesenchymal stem cells (MSCs) for treating TMJ disorders. The search was extended to three clinical trial registries for on-going investigations related to UC tissue and MSCs for TMJ disorder management. The studies included in this article report the safety and efficacy profiles of allogenically acquired, umbilical cord-derived tissues and associated mesenchymal stem cells for temporomandibular joint ailments, future adequately powered, randomized controlled trials are warranted to conclusively justify the clinical use of this biologic therapy.

CT-based navigation for total hip arthroplasty: a meta-analysis

INTRODUCTION

Computer tomography (CT) based navigation is considered by some authors as an advance in total hip arthroplasty (THA). A meta-analysis was conducted to compare CT based versus conventional THA in terms of surgical duration of the procedure, leg length difference, acetabular cup position, and rate of dislocation.

MATERIAL AND METHODS

The present study was conducted according to the PRISMA 2020. In December 2022, the following databases were accessed: PubMed, Web of Science, Google Scholar, Embase with no time constrain. All the clinical studies comparing CT based navigation versus the conventional THA were accessed.

RESULTS

Data from 1801 procedures were collected. The mean age of the patients was 61.6 ± 5.3 years, and the mean BMI was 26.9 ± 2.3 kg/m2. There was between studies comparability at baseline in terms of age, BMI, pain score, Harris hip score, leg length discrepancy (P > 0.1). The navigated group demonstrated lower leg length discrepancy (P = 0.02), and lower degrees of cup anteversion (P = 0.002). Similarity was found in cup inclination (P = 0.98), surgical duration (P = 0.3), and the rate of dislocation (P = 0.6).

CONCLUSION

CT guided THA may have the potential to increase the accuracy of acetabular positioning and reduce the leg length discrepancy. Current evidence is very limited and heterogeneous, and no recommendations can be inferred. Further investigations are required to definitely clarify the role of CT based THA in current practice.

Endotenon-Derived Type II Tendon Stem Cells Have Enhanced Proliferative and Tenogenic Potential

Tendon injuries caused by overuse or age-related deterioration are frequent. Incomplete knowledge of somatic tendon cell biology and their progenitors has hindered interventions for the effective repair of injured tendons. Here, we sought to compare and contrast distinct tendon-derived cell populations: type I and II tendon stem cells (TSCs) and tenocytes (TNCs). Porcine type I and II TSCs were isolated via the enzymatic digestion of distinct membranes (paratenon and endotenon, respectively), while tenocytes were isolated through an explant method. Resultant cell populations were characterized by morphology, differentiation, molecular, flow cytometry, and immunofluorescence analysis. Cells were isolated, cultured, and evaluated in two alternate oxygen concentrations (physiological (2%) and air (21%)) to determine the role of oxygen in cell biology determination within this relatively avascular tissue. The different cell populations demonstrated distinct proliferative potential, morphology, and transcript levels (both for tenogenic and stem cell markers). In contrast, all tendon-derived cell populations displayed multipotent differentiation potential and immunophenotypes (positive for CD90 and CD44). Type II TSCs emerged as the most promising tendon-derived cell population for expansion, given their enhanced proliferative potential, multipotency, and maintenance of a tenogenic profile at early and late passage. Moreover, in all cases, physoxia promoted the enhanced proliferation and maintenance of a tenogenic profile. These observations help shed light on the biological mechanisms of tendon cells, with the potential to aid in the development of novel therapeutic approaches for tendon disorders.

Epidemiology of injuries in young volleyball athletes: a systematic review

BACKGROUND

Volleyball is among the five most popular sports in the world. Regardless of level and age, volleyball athletes perform fast high-impact movements such as jumps, landings, and changes in direction, demanding motor and sensory skills to avoid injuries. The available scientific literature provides information regarding the incidence of injuries in volleyball, but the evidence of injuries in young volleyball athletes (12-18 years old) is not well defined. Therefore, a systematic review was conducted to investigate the incidence and prevalence of injuries in young volleyball players.

METHODS

This systematic review was conducted according to the PRISMA recommendations and prospectively registered in PROSPERO (ID: CRD42022344623). An electronic search was conducted in the following databases: Web of Science, PubMed, and SportDiscuss via EBSCO in August 2022 and March 2023. Inclusion criteria followed the PICOS acronym: (P) youth volleyball players; (I) volleyball; (C) none; (O) incidence and/or prevalence of injury; and (S) cohort studies. The risk of bias was analysed using the adapted STROBE instrument.

RESULTS

Five studies were included in the qualitative analysis. They had a mean methodological quality of 6 (range 4-8) on the modified STROBE scale. Injury incidence was presented in varying ways, ranging from 1.51 injuries/1000 player hours to 12.4 injuries/10,000 athlete exposures (AEs). The prevalence was 1.6 ± 1.7 per 100 AEs. A total sample of 3698 youth volleyball athletes predominantly females was found. The body sites with the highest rate of injuries were the ankle, the distal portion of the upper limbs (wrist/hand/fingers) and the knee, respectively.

CONCLUSION

There was remarkable variability in the rate of injuries and the form of presentation between the studies. In addition, junior volleyball athletes had lower injury rates compared to other sports practised in high school, and older athletes had higher injury rates.

Amniotic membrane and/or umbilical cord tissue for treatment of facet joint syndrome: a narrative review

Musculoskeletal spine disorders, especially low back pain, induce enormous amounts of stress and financial burden on individuals and healthcare systems throughout the world. Disorders of the facet joints in the lumbar spine are the most predominant cause of back pain, resulting in facet joint syndrome (FJS). Conventional treatments for FJS are short-lived and have limitations and side effects. Thus, safer and more effective alternatives that can reduce pain and improve patient-reported outcomes are needed. Recently, the utilization of biologics, including the ones derived from perinatal tissue such as amniotic membrane (AM) and umbilical cord (UC), has significantly increased for regenerative medicine applications. This manuscript summarizes the outcomes of preclinical and clinical studies utilizing AM and/or UC for FJS. We identified no preclinical studies and 3 retrospective studies utilizing the search terms "amniotic membrane" and/or "umbilical cord" and "facet joint syndrome". The administration of AM + UC is safe and potentially efficacious for patients with FJS. However, more preclinical studies and appropriately powered, multi-center, prospective non-randomized and randomized controlled studies with longer follow-up are warranted to further evaluate the efficacy of AM + UC to justify its clinical use.

Free tendon grafts for surgical management of chronic tears of the main body of the Achilles tendon: a systematic review

PURPOSE

After four weeks from injury, tears of the Achilles tendon are considered chronic. Their management is challenging, and the use of a graft is suggested when the gap between proximal and distal stumps is greater than 6 cm. The present study systematically reviews the outcome of free tendon grafts in chronic ruptures of the Achilles tendon, evaluating clinical outcomes, complications and return to sport.

METHODS

The present study was conducted according to the PRISMA 2020 guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in February 2023. All the published clinical studies reporting clinical outcome, return to sport and complications of free tendon grafts used the treatment of chronic rupture of the midportion of the Achilles Tendon were accessed. The mean CMS (Coleman Methodology Score) of 65.7 suggested an overall good quality of the available published articles, attesting to the low risk of bias.

RESULTS

Data from 22 articles (368 patients with a mean age of 47 years) were retrieved. The average time from rupture to surgery was 25.1 week. At last follow-up, the AOFAS (American Orthopaedic Foot and Ankle Surgery) and ATRS (Achilles Tendon Total Rupture Score) scores improved of 33.8 (P = 0.0004), and 45.1 points (P = 0.0001) respectively. Return to activity was reported in 105 patients, and 82 (78.1%) had no activity limitations, while 19 (18.1%) had limited recreational but not daily activity limitations, and 4 (3.8%) reported limitations in daily activities. Return to sport data was reported in six studies, and 45 of 93 (48.4%) patients returned to sport at an average of 22.6 weeks.

CONCLUSION

In chronic tears of the Achilles tendon, with a gap of at least 6 cm, free tendon grafts allow predictable return to sport and acceptable recovery function.

LEVEL OF EVIDENCE

Level IV.

Outside-in repair technique is effective in traumatic tears of the meniscus in active adults: a systematic review

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.

Greater rate of return to play and re-injury following all-inside meniscal repair compared to the inside-out technique: a systematic review

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.

Risk factors for liner wear and head migration in total hip arthroplasty: a systematic review

Total hip arthroplasty (THA) is a successful orthopaedic surgical procedure, and its longevity depends on bearing components and implant fixation. Optimizing polyethylene and ceramics has led to improved wear parameters and contributed to improved long-term outcomes. The present systematic review investigated whether time span from implantation, patient characteristics and performance status exert an influence on liner wear and head migration in THA. This study was conducted in conformity to the 2020 PRISMA guidelines. All the clinical investigations which reported quantitative data on the amount of liner wear and head migration in THA were considered. Only studies which reported quantitative data at least on one of the following patient characteristics were suitable: mean age, mean BMI (kg/m2), sex, side, time span between the index THA and the last follow-up (months) were eligible. A multiple linear model regression analysis was employed to verify the association between patient characteristics and the amount of liner wear and/or head migration. The Pearson Product-Moment Correlation Coefficient was used to assess the association between variables. Data from 12,629 patients were considered. The mean length of the follow-up was 90.5 ± 50.9 months. The mean age of patients at surgery was 58.4 ± 9.4 years, and the mean BMI was 27.2 ± 2.5 kg/m2. 57% (7199 of 12,629 patients) were women, and in 44% (5557 of 12,629 patients) THAs were performed on the left. The mean pre-operative Harris hip score was 46.5 ± 6.0 points. There was evidence of a moderate positive association between the amount of liner wear and the time elapsed between the index surgery to the follow-up (P = 0.02). There was evidence of a moderate positive association between the amount of head migration and the time elapsed between the index surgery to the follow-up (P = 0.01). No further statistically significant association was found. The time elapsed between the index surgery to the follow-up was the most important factor which influence the head migration and liner wear in THA. Patients' characteristics and preoperative physical activity did not influence the amount of head migration and liner wear.

Percutaneous cruciate repair of ruptured Achilles tendon

Percutaneous repair is a safe and reliable method to restore continuity after acute Achilles tendon ruptures, with a lower incidence of wound complications compared to open techniques. We describe a novel percutaneous cruciate suture performed through 5 stab skin incisions, four of which are longitudinal and parallel to the course of the sural nerve to minimize the risk of injury and one transverse incision at the site of rupture, with a total of 16 suture threads and the knot outside the tendon body, increasing the tensile strength of the suture and minimizing the risk of re-rupture. Clinical studies are necessary to ascertain whether the theoretical advantages of the cruciate suture technique translate into better clinical outcomes compared to established percutaneous techniques.

Efficacy of hydrodilatation in frozen shoulder: a systematic review and meta-analysis

INTRODUCTION

It is unclear whether hydrodilatation is beneficial in the management of frozen shoulder compared with other common conservative management modalities. This systematic review evaluates the efficacy of hydrodilatation for the management of frozen shoulder.

SOURCES OF DATA

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An extensive search of PubMed, Embase, Scopus, Cochrane Central, Web of Science and CINAHL databases using multiple keyword combinations of 'shoulder', 'rotator', 'adhesive capsulitis', 'hydrodilatat*', 'distension' since inception of the databases to June 2023 was implemented.

AREAS OF AGREEMENT

Hydrodilatation leads to at least transient more marked improvements in shoulder disability and passive external rotation compared with intra-articular corticosteroid injections.

AREAS OF CONTROVERSY

Hydrodilatation improves passive external rotation in the longer term. Moreover, hydrodilatation may be a preferable option over manipulation under anaesthesia, given its lower cost and better patient convenience.

GROWING POINTS

Intensive mobilization after hydrodilatation is a promising adjuvant treatment option for patients suffering from a frozen shoulder.

AREAS TIMELY FOR DEVELOPING RESEARCH

Although current evidence suggests that hydrodilatation provides a transient improvement in disability in patients with frozen shoulder, its clinical relevance remains unclear. Further research is necessary to establish its role in the management of the condition.

Management of transient bone osteoporosis: a systematic review

INTRODUCTION

Transient bone osteoporosis (TBO) is characterized by persistent pain, loss of function, no history of trauma and magnetic resonance image (MRI) findings of bone marrow edema.

SOURCE OF DATA

PubMed, Google scholar, EMABSE and Web of Science were accessed in February 2023. No time constrains were used for the search.

AREAS OF AGREEMENT

TBO is rare and misunderstood, typically affecting women during the third trimester of pregnancy or middle-aged men, leading to functional disability for 4-8 weeks followed by self-resolution of the symptoms.

AREAS OF CONTROVERSY

Given the limited evidence in the current literature, consensus on optimal management is lacking.

GROWING POINTS

This systematic review investigates current management of TBO.

AREAS TIMELY FOR DEVELOPING RESEARCH

A conservative approach leads to the resolution of symptoms and MRI findings at midterm follow-up. Administration of bisphosphonates might alleviate pain and accelerate both clinical and imaging recovery.

Conservative Management of Partial Thickness Rotator Cuff Tears: A Systematic Review

BACKGROUND

Conservative management has emerged as an attractive option for partial thickness rotator cuff tears (PT-RCTs). A single algorithmic treatment strategy for patients with symptomatic PT-RCT has not yet been developed. This systematic review aims to ascertain whether a conservative approach to PT-RCTs yields positive results in terms of clinical outcomes and functional recovery.

METHODS

This is a systematic review of the literature on patients with PT-RCTs receiving conservative treatment with physiotherapy, platelet-rich plasma (PRP) injections, collagen injections, hyaluronic acid (HA) injections, or corticosteroids injections coupled with polydeoxyribonucleotide (PDRN). Outcomes such as the Visual Analog Scale (VAS) for pain, American Shoulder and Elbow Surgeons and Constant-Murley Score evaluations, as well as the Shoulder Pain and Disability Index and Euro Quality of Life-5D questionnaires were reported following a conservative approach.

RESULTS

Eleven studies were included. Six articles explored the outcomes of patients with PT-RCT treated with PRP injections. Significant improvements in VAS for pain were observed. Two studies examined collagen injections and reported variations in VAS for pain and Constant-Murley Score. Sodium hyaluronate and HA injections were studied in two other articles, showing notable improvements in American Shoulder and Elbow Surgeons scores. Corticosteroid and PDRN injections also displayed favorable outcomes. In addition, physical therapy protocols demonstrated improvements in VAS for pain and strength, particularly with eccentric rehabilitation.

CONCLUSIONS

Conservative management of PT-RCTs, involving physical therapy, PRP injections, collagen injections, corticosteroid injections, HA injections, and PDRN in jections, demonstrates favorable clinical outcomes. In addition, favorable results are observed in terms of decreased tear width and improved strength recovery, at least during a short-term follow-up. Unfortunately, long-term insight into the structural integrity of conservatively treated rotator cuff tendons following a partial injury has not been thoroughly evaluated yet.

STUDY DESIGN LEVELS OF EVIDENCE

Level IV-systematic review.

The management of the long head of the biceps in rotator cuff repair: A comparative study of high vs. subpectoral tenodesis

BACKGROUND

Tenodesis of the long head of the biceps (LHB) is commonly undertaken during arthroscopic rotator cuff repair. We assessed the clinical and structural outcomes after high arthroscopic tenodesis (HAT) or mini-open subpectoral tenodesis (ST). We hypothesized that the clinical and structural results after HAT and ST are similar.

METHODS

We included 40 patients with rotator cuff tear and LHB tendinopathy. Twenty patients (7 women and 13 men; mean age: 57.9 years; range: 56-63 years) were treated using HAT, and 20 patients (8 women and 12 men; mean age: 58.5 years; range: 55-64 years) were treated using ST. Functional evaluation was performed preoperatively and at 6 weeks, 6 months, and 1 year after surgery, using the Constant Murley Score and Simple Shoulder Test scores; the LHB was evaluated using the LHB score. A Visual Analogue Scale was administered to all patients preoperatively and 2 days after surgery.

RESULTS

The postoperative total and pain subscale's Constant scores were significantly higher in the ST group. Moreover, 2 LHB score values were significantly different between the groups. The postoperative LHB total score in the ST and HAT groups averaged 86.9 ± 4.1 (mean ± SD) points and 73.3 ± 6.4 points, respectively. The Pain/Cramps subscale in the ST and HAT groups averaged 47.1 ± 5.9 and 33.2 ± 4.6 points, respectively. The 2 groups showed no difference in Visual Analogue Scale values (5.5 in the HAT group; 5.8 in the ST group) postoperatively. One patient in the HAT group reported a secondary onset of Popeye deformity.

CONCLUSION

Both high arthroscopic and mini-open ST of the LHB tendon produced reliably good functional results, but the ST group was associated with better postoperative clinical outcomes.

Artificial Intelligence and Machine Learning in Rotator Cuff Tears

Rotator cuff tears (RCTs) negatively impacts patient well-being. Artificial intelligence (AI) is emerging as a promising tool in medical decision-making. Within AI, deep learning allows to autonomously solve complex tasks. This review assesses the current and potential applications of AI in the management of RCT, focusing on diagnostic utility, challenges, and future perspectives. AI demonstrates promise in RCT diagnosis, aiding clinicians in interpreting complex imaging data. Deep learning frameworks, particularly convoluted neural networks architectures, exhibit remarkable diagnostic accuracy in detecting RCTs on magnetic resonance imaging. Advanced segmentation algorithms improve anatomic visualization and surgical planning. AI-assisted radiograph interpretation proves effective in ruling out full-thickness tears. Machine learning models predict RCT diagnosis and postoperative outcomes, enhancing personalized patient care. Challenges include small data sets and classification complexities, especially for partial thickness tears. Current applications of AI in RCT management are promising yet experimental. The potential of AI to revolutionize personalized, efficient, and accurate care for RCT patients is evident. The integration of AI with clinical expertise holds potential to redefine treatment strategies and optimize patient outcomes. Further research, larger data sets, and collaborative efforts are essential to unlock the transformative impact of AI in orthopedic surgery and RCT management.

Graphical Abstract in Scientific Research

A graphical abstract (GA) summarizes the key and important findings of an article graphically, potentially stimulating researchers to view the published manuscript. A GA should enhance dissemination, augment engagement, and impact clinical practice. Infographics play a key role in a quicker understanding of the significant findings of a manuscript. Few level 1 studies reported that GAs enhanced the engagement of readers on social media when compared to plain text abstracts. With the evolution of Industry 4.0, 5.0, and 6.0, GA plays a major role in understanding the technical aspects of various technologies. This article outlines tips to prepare an effective GA and reports the impact of GAs on research and clinical translation.