Published Literature on Platelet Rich Plasma Is Extensive but Flawed in Methodology.

Recent research shows that most orthopaedic published investigations on platelet rich plasma (PRP) lack reporting of preparation methods or PRP composition. The studies are thus unreproducible, and the outcomes cannot be verified. Unfortunately, this is not surprising. PubMed search reveals over 500 orthopaedic PRP publications from 2023 alone, almost 42 musculoskeletal PRP papers per month, and unfortunately, despite peer review, "Nature" reports that 44% of published research is flawed, and 26% of studies cannot be trusted. PubMed citation does not ensure quality. Guidelines and checklists such as the CONSORT statement (Consolidated Standards of Reporting Trails) can result in quality.

Artificial Intelligence and Machine Learning May Resolve Health Care Information Overload.

Biomedical information doubles almost every 2 months, and this very rate is expected to double by 2025. The result is information overload for clinicians and researchers. Today, artificial intelligence (AI) and machine learning (ML) research contribute to the deluge of information. In addition, AI large language models, although capable of automating scientific writing, are flawed. They hallucinate (make things up), are trained primarily on non-peer-reviewed content, raise ethical and legal issues, and lack human empathy. Still, when it comes to AI including ML, we are optimistic. The technology is improving rapidly. In the future, AI will help us manage unwieldy information by processing data, determining diagnoses, recommending treatments, and predicting outcomes. In research, AI and ML similarly promise efficient data analysis and literature review and will create new content in response to our instructions. Human touch will be required, and we will disclose use of AI proactively, including rationale for its use, our data input, our level of confidence in the output, and the patients or populations to whom the output may be applied. In addition, we will ensure data quality is high and bias is minimized. Most of all, we will provide essential reasoning, clinical and research guidance, and diligent oversight. Humans will remain accountable.

Editorial Commentary: Women Do Not Return to Sport at the Same Level After Anterior Cruciate Ligament Reconstruction as Often as Men: This May Be Associated With Lower Risk Tolerance-and Not Necessarily a Bad Thing!

It has been established that women do not return to preinjury sports (RTS) at the same level after anterior cruciate ligament reconstruction at the same rate as men. Normalization of strength parameters does influence the return to sports in men, but not women. Lower RTS rates may be associated with lower risk tolerance, and this is not necessarily a bad thing. Neither lower RTS rates nor lower risk tolerance is maladaptive or in need of correction. Awareness of the psychological diversity between the sexes does help in understanding this difference. Appreciation of this perspective will improve the relationship with the female athlete during her recovery.

Editorial Commentary: When Performing Proximal Tibial Slope Decreasing Osteotomies in Patients Undergoing Primary or Revision Anterior Cruciate Ligament Reconstruction, Surgeons Must Be Cautious to Avoid Overcorrection of the Posterior Tibial Slope: Teeter-Totter Tibial Translation.

An excessive or large proximal tibial posterior slope is directly correlated with the risk of knee joint injury. This includes anterior cruciate ligament (ACL) graft reconstruction failure and meniscal tear. Correction of the excessive posterior slope seems prudent in patients whose prior surgical procedures have not succeeded in restoring normal knee stability including anterior tibial translation. Such an approach has been presented through techniques involving tibial osteotomy. By decreasing the tibial slope, there will be a decrease in the rate of ACL graft failure. When one is performing a corrective osteotomy, the correction should be neither too little nor too much. Too little a correction will not sufficiently alter the mechanics, resulting in a limited effect. Too great a change will produce negative static anterior tibial translation. Moreover, recent research has shown that after slope-correcting osteotomy, achieving the target slope occurs in fewer than 50% of cases. Surgeons must be cautious to avoid overcorrection of the posterior tibial slope.

Evidence-Based Practice Should Supersede Evidence-Based Medicine Through Consideration of Clinical Experience and Patient Characteristics in Addition to the Published Literature.

On the surface, the benefits of evidence-based medicine (EBM) seem self-evident. However, reliance on the scientific literature alone has limitations. Studies may be biased, statistically fragile, and/or not reproducible. Reliance solely on EBM may ignore physician clinical experience and individual patient characteristics and input. Reliance solely on EBM may overvalue quantitative, statistical significance, resulting in a false sense of certainty. Reliance solely on EBM may fail to consider lack of generalizability of published studies to individually unique patients. The concept of evidence-based practice goes beyond EBM and incorporates (1) EBM, (2) clinical expertise, and (3) individual patient characteristics, values, and preferences. Even if branded as evidence-based, a suggested treatment may not be the best treatment. Evidence-based practice must be considered before determining what is best for our patients.

Editorial Commentary: If Individual Treatments Are Potentiated, Multimodal Therapy Including Cells and Platelet-Rich Plasma May Beneficially Treat Cartilage Degeneration and Arthritis.

Multimodal therapies may optimize treatments if individual treatments are potentiated. In an attempt to obtain the elusive cure for cartilage degeneration, combined biologic injectable therapy might improve results. Due to the multipotent mesenchymal stem cells in adipose tissue, microfat containing adipose-derived stem cells may assist in cartilage repair. Platelet-rich plasma (PRP) has been similarly shown to be an effective biologic therapy through the release of growth factors affecting chondrocyte metabolism and decreasing inflammation. These 2 different products might be synergistic. Recent study, however, shows no significant differences when evaluating microfat with or without PRP, and importantly also shows that PRP with microfat does provide improvement in knee arthritic pain. This improvement may not correlate with the development of new cartilage, but it does improve function. Each biologic has beneficial effects on knee joint function through different mechanisms.

Articular Cartilage Restoration Requires Cells, Scaffolds, Growth Factors, and Mechanical Stimulation.

Tissue engineering requires cells, scaffolds, growth factors, and mechanical stimulation. In terms of cartilage restoration or repair, various innovative approaches are evolving, using host or allograft cells, biomimetic scaffolds, matrices, or membranes including hyaluronic acid, as well as diverse biological and growth factors. A current approach for the treatment of chondral or osteochondral defects enhances a microfracture procedure (introducing autologous, mesenchymal stem cells) with dehydrated micronized allograft extracellular matrix (scaffold), platelet-rich plasma (containing anabolic, anticatabolic, and anti-inflammatory growth factors), a fibrin glue sealant, and careful rehabilitation providing mechanical stimulation. Early results are encouraging; long-term outcomes including a larger number of study subjects remain to be reported.

Editorial Commentary: Revision Anterior Cruciate Ligament Surgery, Unlike Cheese, Is Not Improved With Age but Nationality and Culture May Matter.

Recurrent instability and future joint damage occur if there is a repeated anterior cruciate ligament injury after reconstruction. This prognostic declaration is said to those who have sustained a rupture to the repaired anterior cruciate ligament. Both younger and older patients seek stable knees to allow a return to stability and twisting activity without the risk of added joint damage. To achieve this goal, revision ligament surgery is needed.

Editorial Commentary: The Forgotten Joint Score-Don't Compare Apples to Oranges.

Patient outcomes have become focused on satisfaction with the end result. It is now appreciated that objective measurements are not the sole criterion for a successful surgical procedure. With the transition to evaluating patient-reported outcome measures, additional scoring techniques are being used to determine the best method for defining surgical success. The Forgotten Joint Score asks the simple question, "Are you aware of the joint that had surgery?" Essentially, does the patient have any sense that there has been surgery on the limb or joint? Although it has been validated as a reliable testing technique in specific surgical procedures, it has not been validated as a method of comparing 2 dissimilar surgical procedures. One must be selective and careful when using scoring methods. There are no data or validation to support the use of patient perception of the joint on surgical procedures that are divergent in their approach. Patient-reported outcomes such as the Forgotten Joint Score should not be used to compare procedures that are dissimilar in technique.

Editorial Commentary: Variations of National Health Systems: Time From Injury to Surgery Can Affect Anterior Cruciate Ligament-Medial Collateral Ligament Treatment Outcomes.

A recent investigation using the Swedish National Knee Registry large database showed that "The risk of ACL revision did not differ between HT and PT autografts in patients undergoing ACL reconstruction with a non-surgically treated MCL injury. However, the use of ST-G was associated with poorer two-year patient-reported knee function compared with the ST." However, the Swedish Health care system is so unique that the results may not be universally applicable. Sweden provides universal health care, which is laudable, but there was an average delay of 314 days between injury and surgical intervention. This suggests that the medial collateral ligament (MCL) injury had already become chronic and the anterior cruciate ligament surgery was not effective for or directed toward acute MCL pathology. The timing and MCL treatment algorithm is different from published recommendations. Delay may have negative consequences.

Editorial Commentary: Meniscal Allograft Success-How Do We Get There?

Patients undergoing meniscal allograft transplantation show improvement at 10 years and even 15 years of follow-up. However, it is unclear what factors influence the results, including but not limited to bone plug versus all-suture repair, fresh versus cryopreserved grafts, proper sizing, and rehabilitation.

The risk of noise-induced hearing loss performing knee replacement surgery.

OBJECTIVE: Powered surgical instruments use to cut bones and fashion them for joint implant produce noise. Prior studies have not analyzed direct in vivo measurements of multiple procedures and exposure time. This study evaluates actual surgical noise levels exposure to the surgeon and this cumulative exposure that can result in noise-induced hearing loss (NIHL). WHAT IS KNOWN: Prior studies evaluated short duration noise exposure to surgical equipment in vitro, or in an operating room environment. WHAT THIS ADDS: This study evaluated in vivo cumulative measurements over an entire operating day and the associated risks. METHODS: Noise exposure to operating room personnel was measured during multiple knee replacement surgeries over three days. Measurements were compared to occupational exposure limits set by the National Institute for Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OSHA). RESULTS: Surgeons' noise exposures exceed noise occupational exposure limits. Recorded levels of 104 dBA did occur with levels of 85dBA found from 10-18% of the time. CONCLUSIONS: Surgeons performing multiple total knee replacements per day are at risk of NIHL due to noise exposures that exceed National Institute for Occupational Safety and Health recommendations. Surgeons should be included in a hearing loss prevention program. LEVEL OF EVIDENCE: Therapeutic Level 1.

"Publish or Perish" Promotes Medical Literature Quantity Over Quality.

When it comes to medical research, incentives align to promote "publish or perish." This results in quantity over quality. A solution is to change the goal of medical scientist and clinician training from bolstering a curriculum vitae to mastering scientific research methods. In addition, the metric for scholarly authorship should be quality, for which validated measurement tools exist, rather than number of publications.

Editorial Commentary: "Defer No Time, Delays Have Dangerous Ends" (Henry VI, Shakespeare): Delayed Anterior Cruciate Ligament Reconstruction Has Consequences.

There continues to be controversy over the timing of anterior cruciate ligament (ACL) surgery. Early or delayed intervention after ACL injury is a topic that has not been settled. The issue is whether ACL tears should have surgery performed in an expedient manner. Or is delay an option with no repercussions to the health of the knee? My associates in nonsurgical specialties wave the New England Journal of Medicine to support their view that surgery is not needed. I routinely espouse the literature confirming that delay of surgery may cause future damage. It is now established that a failure to intervene in a timely manner does cause additional damage. I stand vindicated and can affirm to my colleagues that I have found the answer. There is no longer any doubt or equivocation. Delay in reconstructing an unstable knee does cause damage.