CT-guided vs. fluoroscopically guided transforaminal epidural steroid injections for lumbar radiculopathy: a comparison of efficacy, safety and cost.

INTRODUCTION: There are no formal guidelines for whether CT-guided or fluoroscopy-guided TFESI should be undertaken for patients with symptoms of lumbar nerve root irritation and corresponding nerve impingement. Here, we sought to compare the efficacy, safety and cost of computer tomography (CT)-guided and fluoroscopically guided transforaminal epidural steroid injection (TFESI). MATERIALS AND METHODS: All patients who underwent lumbar TFESI at our institution between June 2016 and June 2018 were identified. Six-week follow-up outcomes were categorised. The radiation doses and associated cost was retrieved from our institution's costing system. RESULTS: One hundred and sixteen patients were included (CT-50; fluoroscopy-56). There were no complications. More patients were discharged 6 weeks after CT-guided lumbar TFESI when compared with fluoroscopically guided TFESI (CT-23, fluoroscopy-14 (P = 0.027)). There was no difference in the number of patients who were referred to surgery (P = 0.18), for further pain management (P = 0.45), or for further TFESI (P = 0.43). The effective radiation dose was significantly higher for CT-guided TFESI (CT-5.73 mSv (3.87 to 7.76); fluoroscopy-0.55 mSv (0.11 to 1.4) (P < 0.01)). The total cost for CT-guided lumbar TFESI was £237.50 (£235 to £337), over £800 less than under fluoroscopic guidance (£1052 (£892.80 to £1298.00), P < 0.01)). Removing cost associated with staff and theatre use (staffing, theatre, medical indemnity and overheads) revealed CT-guided lumbar TFESI to be less expensive than if the procedure was fluoroscopy-guided-CT-guided: £132.6 (130.8 to 197.5); fluoroscopy: £237.4 (£209.2 to £271.9) (P = 0.019). CONCLUSIONS: CT-guided TFESI was associated with a higher discharge rate, a lower cost, but a ten times higher radiation dose when compared with fluoroscopically guided TFESI. Prospective studies are required to compare the efficacy of these procedures and to investigate how the radiation dose of CT-guided TFESI can be reduced without jeopardising efficacy or safety.

Mendelian Randomization Studies of Lifestyle-Related Risk Factors for Osteoarthritis: A PRISMA Review and Meta-Analysis.

Risk factors for osteoarthritis (OA) often exert effects over protracted time-courses. Mendelian randomization (MR) studies therefore have an advantage over conventional observational studies when studying the causal effect of long-term lifestyle-related risk factors on OA. However, given the heterogeneous design of existing MR studies on OA, the reported causal estimates of these effects remain inconsistent, thus obscuring the true extent of the biological effects of OA lifestyle-risk factors. We conducted a PRISMA systematic review and specifically included MR studies that investigated the causal effect between lifestyle-related risk factors and OA, where causal estimates for various lifestyle factors were pooled for meta-analysis. Quality of studies was assessed according to STROBE-MR guidelines. A total of 1576 studies were evaluated and 23 were included. Overall, the studies included were of high quality and had a low risk of bias. Our meta-analysis demonstrates the positive causal effect of BMI (ORIVW-random effects 1.49 [1.23-1.80]) and negative causal effects of serum calcium (ORIVW-random effects 0.69 [0.57-0.83]) and LDL levels (ORIVW-random effects 0.93 [0.90-0.96]) on OA. Despite the heterogeneous designs and estimates of causal effects provided by various MR studies, our meta-analysis suggests that lifestyle-related risk factors in the form of BMI, serum calcium, and LDL have true biological effects on the development of OA.

Surgical treatments for acute unstable acromioclavicular joint dislocations.

INTRODUCTION: Surgical treatment is usually recommended for acute, high-grade acromioclavicular joint (ACJ) injuries. A wide variety of surgical techniques exist, and the literature does not strongly support one over the other. In this literature review, we describe and compare the results of different surgical treatments for the management of acute unstable ACJ dislocation and aim to guide surgeons on optimal treatment. MATERIALS AND METHODS: A literature review was performed by searching PubMed, Medline, Cochrane, and Embase databases. Seventeen studies met the inclusion criteria and were analyzed. Only studies with comparative data were included. The clinical and radiological outcomes of these studies were reviewed. RESULTS: Seventeen studies were included in this literature review. We found no difference in outcomes between open and arthroscopic procedures. Coracoclavicular ligament (CCL) reconstruction techniques provide better results than the more rigid hook plate fixation. There is no evidence that biologic repair with tendon graft is superior to synthetic grafts. Furthermore, an autograft is not shown to be better than an allograft. Rigid fixation between the clavicle and coracoid and the non-anatomic Weaver-Dunn technique appears less popular in recent literature. The hook plate is associated with subacromial osteolysis, acromial erosion, and the morbidity of a secondary procedure. DISCUSSION: There is a recent increase in publications on the reconstruction of the ACJ after injury, with new techniques focusing on the anatomic reconstruction of the CCLs aiming to restore both vertical and horizontal plane stability of the ACJ using synthetic/biological grafts. Despite the plethora of new techniques introduced, meaningful comparisons are difficult to draw due to the heterogeneity of the treatments used and the outcome measure used to assess the results.

Infrapatellar fat pad adipose-derived stem cells co-cultured with articular chondrocytes from osteoarthritis patients exhibit increased chondrogenic gene expression.

AIM: The variable results in clinical trials of adipose tissue-derived stem cells (ASCs) for chondral defects may be due to the different ex vivo culture conditions of the ASCs which are implanted to treat the lesions. We sought to determine the optimal in vitro chondrocyte co-culture condition that promotes infrapatellar fat pad-derived (IFPD) ASC chondrogenic gene expression in a novel co-culture combination. METHODS: In our study, we utilized an in vitro autologous co-culture of IFPD ASCs and articular chondrocytes derived from Kellgren-Lawrence Grade III/IV osteoarthritic human knee joints at ASC-to-chondrocyte seeding log ratios of 1:1, 10:1, and 100:1. Gene expression following in vitro co-culture was quantified by RT-qPCR with a panel comprising COL1A1, COL2A1, COL10A1, L-SOX5, SOX6, SOX9, ACAN, HSPG2, and COMP for chondrogenic gene expression. RESULTS: The chondrogenic gene expression profiles from co-cultures were greater than would be expected from an expression profile modeled from chondrocyte and ASC-only monocultures. Additionally, chondrogenic gene expression decreased with increasing ASC-to-chondrocyte seeding ratios. CONCLUSIONS: These findings provide insight into the mechanisms underlying clinical ASC therapies and signifies that IFPD ASCs pre-conditioned by chondrocyte co-culture may have improved chondrogenic potential for cartilage repair. This model can help further understand IFPD ASCs in chondral and osteochondral repair and the chondrogenic pathways involved. Video Abstract.

Immunomonitoring of Monocyte and Neutrophil Function in Critically Ill Patients: From Sepsis and/or Trauma to COVID-19.

Immune cells and mediators play a crucial role in the critical care setting but are understudied. This review explores the concept of sepsis and/or injury-induced immunosuppression and immuno-inflammatory response in COVID-19 and reiterates the need for more accurate functional immunomonitoring of monocyte and neutrophil function in these critically ill patients. in addition, the feasibility of circulating and cell-surface immune biomarkers as predictors of infection and/or outcome in critically ill patients is explored. It is clear that, for critically ill, one size does not fit all and that immune phenotyping of critically ill patients may allow the development of a more personalized approach with tailored immunotherapy for the specific patient. In addition, at this point in time, caution is advised regarding the quality of evidence of some COVID-19 studies in the literature.

Virtual Reality Simulator Use Stimulates Medical Students' Interest in Orthopaedic Surgery.

PURPOSE: To investigate whether the use of a VR arthroscopic simulator can influence medical students' attitudes toward a career in orthopaedic surgery. METHODS: Twenty-five medical students completed seven unsupervised sessions on a VR hip-arthroscopic simulator. All participants completed a pre-simulator and post-simulator pseudo-anonymized questionnaire consisting of 10 questions: six 10-point Likert scale questions addressing their interest in orthopaedics, surgery, and arthroscopy; and four 5-point Likert scale questions addressing their attitudes toward simulation. Prepaired and postpaired datasets were analyzed using Wilcoxon signed rank test. RESULTS: Interest in both orthopaedics and surgery was found to increase after simulator use (orthopaedics: 5.3 ± .3 to 8.4 ± .2, P = .0001; surgery: 5.8 ± .3 to 9.0 ± .2; P = .0001). It was also found that simulator use increased participants' interest in arthroscopy (5.4 ± .3 to 8.0 ± .3; P = .0001) and hip-arthroscopy (5.0 ± .3 to 7.6 ± .3; P = .0001). Participants reported they were more likely to attend endoscopic and arthroscopic surgical lists after simulator use (endoscopic: 6.9 ± .3 to 8.4 ± .2; P = .0003; arthroscopic: 5.9 ± .3 to 8.4 ± .2; P = .0001). After using the simulator, participants felt more strongly that VR simulation is a valuable training modality (P = .0025), that simulation should be a mandatory part of orthopaedics and surgical training (P = .0001 and P = .0001), and that access to VR simulators improves the quality of surgical training (P = .0024). CONCLUSIONS: These results demonstrate that exposure to VR arthroscopic simulation increased medical students' interest in orthopaedics, surgery, and arthroscopy, without the need for direct supervision. Following VR simulator use, students reported they were more likely to engage with training opportunities, including arthroscopic and endoscopic surgery. CLINICAL RELEVANCE: Understanding factors that stimulate interest in orthopaedic surgery may help programs attract the broadest pool of potential trainees.

Meta-Analysis of Adipose Tissue Derived Cell-Based Therapy for the Treatment of Knee Osteoarthritis.

Osteoarthritis (OA) is a degenerative disorder associated with cartilage loss and is a leading cause of disability around the world. In old age, the capacity of cartilage to regenerate is diminished. With an aging population, the burden of OA is set to rise. Currently, there is no definitive treatment for OA. However, cell-based therapies derived from adipose tissue are promising. A PRISMA systematic review was conducted employing four databases (MEDLINE, EMBASE, Cochrane, Web of Science) to identify all clinical studies that utilized adipose tissue derived mesenchymal stem cells (AMSCs) or stromal vascular fraction (SVF) for the treatment of knee OA. Eighteen studies were included, which met the inclusion criteria. Meta-analyses were conducted on fourteen of these studies, which all documented WOMAC scores after the administration of AMSCs. Pooled analysis revealed that cell-based treatments definitively improve WOMAC scores, post treatment. These improvements increased with time. The studies in this meta-analysis have established the safety and efficacy of both AMSC therapy and SVF therapy for knee OA in old adults and show that they reduce pain and improve knee function in symptomatic knee OA suggesting that they may be effective therapies to improve mobility in an aging population.

The association between alcohol consumption and osteoarthritis: a meta-analysis and meta-regression of observational studies.

There is conflicting evidence for the association between alcohol consumption and common joint conditions such as Osteoarthritis (OA), which affects millions of people. We sought to determine the true association between alcohol intake and OA. We conducted a PRISMA systematic review and meta-analysis of observational studies that reported associations between alcohol consumption and OA. Pooled estimates of association were represented through odds ratios (ORs). Publication bias was assessed with Funnel and Galbraith plots, and risk of bias was assessed with the Newcastle Ottawa Scale. We included 29 studies and 25,192 subjects with OA and reported an OR between any alcohol consumption and OA of 0.79 (0.68-0.93), suggesting a protective effect. OR of weekly or more frequent use was 0.79 (0.65-0.97). When grouped by covariates, alcohol consumption was negatively associated with radiographic (0.83, 0.70-0.98), hand (0.80, 0.66-0.95) and knee OA (0.85, 0.72-0.99), North American ethnicity and female gender. Subgroup analysis of unadjusted data resulted in an OR of 0.70 (0.55-0.89) but this disappeared upon analysis of studies with data adjusted for any covariate (0.93, 0.78-1.10). Whilst our pooled analysis suggest that weekly or more frequent alcohol consumption was negatively associated with OA, this was not observed when adjusted for confounding factors. Reasons for this include selection bias and lack of longitudinal exposure and adjustment for confounding variables. Therefore, this meta-analysis provides evidence to dispel notions that alcohol use may be protective against OA.

The Effectiveness of Anti-Nerve Growth Factor Monoclonal Antibodies in the Management of Pain in Osteoarthritis of the Hip and Knee: A PRISMA Systematic Review and Meta-Analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis of the efficacy of anti-nerve growth factor (NGF) monoclonal antibodies in osteoarthritis pain (hip and knee). DESIGN: Grade the evidence for anti-NGF use. METHODS: An interdisciplinary work group conducted a literature search for anti-NGF use in osteoarthritis. The systematic review was performed in accordance with methods described by the Cochrane collaboration. General inclusion criteria included all osteoarthritis trials studying any monoclonal anti-NGF antibody at any dose/phase. Excluded studies were those where participants received NSAIDs or analgesics other than anti-NGF antibodies. The Jadad Scale score was used to assess the quality of the included studies. RESULTS: Thirteen studies were included in the analysis, involving 8145 participants with a diagnosis of hip and/or knee osteoarthritis. Anti-NGF antibody treatment was associated with a significant improvement in all Western Ontario and McMaster Universities Arthritis Index (WOMAC) indices when compared to placebo. These agents were not associated with a significantly increased incidence of serious adverse events but were associated with significant increases in therapy discontinuation due to adverse events or side effects (e.g., peripheral neuropathy). CONCLUSIONS: Future randomized clinical trials are needed to characterize the overall risk-to-benefit ratio of anti-NGF antibodies in managing pain associated with OA, particularly with long-term use, in order to verify their efficacy and safety in clinical practice.

Mesenchymal stem cell therapy in hypertrophic and keloid scars.

Scars are the normal outcome of wound repair and involve a co-ordinated inflammatory and fibrotic process. When a scar does not resolve, uncontrolled chronic inflammation can persist and elicits excessive scarring that leads to a range of abnormal phenotypes such as hypertrophic and keloid scars. These pathologies result in significant impairment of quality of life over a long period of time. Existing treatment options are generally unsatisfactory, and there is mounting interest in innovative cell-based therapies. Despite the interest in mesenchymal stem cells (MSCs), there is yet to be a human clinical trial that investigates the potential of MSCs in treating abnormal scarring. A synthesis of existing evidence of animal studies may therefore provide insight into the barriers to human application. The aim of this PRISMA systematic review was to evaluate the effectiveness of MSC transplantation in the treatment of hypertrophic and keloid scars in in vivo models. A total of 11 case-control studies were identified that treated a total of 156 subjects with MSCs or MSC-conditioned media. Ten studies assessed hypertrophic scars, and one looked at keloid scars. All studies evaluated scars in terms of macroscopic and histological appearances and most incorporated immunohistochemistry. The included studies all found improvements in the above outcomes with MSC or MSC-conditioned media without complications. The studies reviewed support a role for MSC therapy in treating scars that needs further exploration. The transferability of these findings to humans is limited by factors such as the reliability and validity of the disease model, the need to identify the optimal MSC cell source, and the outcome measures employed.

A meta-analysis of clinical and radiological outcomes in simultaneous bilateral unicompartmental knee arthroplasty.

BACKGROUND: The most common pattern seen in bilateral knee osteoarthritis involves only the medial compartment in both knees. In such cases, bilateral Unicompartmental Knee Arthroplasty (UKA) would be a suitable surgery, this can be done simultaneously in one surgery or in stages with a period of time between each UKA. Simultaneous bilateral UKA in appropriately selected patients have the potential advantages of a lower cost, a shorter hospital stay, and a shorter overall recovery process. Despite this, there are concerns that operating on both knees in one surgery may increase the risk of complications, revisions and mortality. METHODS: A PRISMA systematic review and meta-analysis was conducted using three databases (MEDLINE, EMBASE, and Scopus) to identify all studies which investigated either clinical or radiological outcomes in simultaneous bilateral UKA. RESULTS: All sixteen studies included found that simultaneous bilateral UKA improved clinical and radiological outcomes. Eight studies compared clinical or radiological outcomes between simultaneous and staged bilateral UKA. Simultaneous bilateral UKA was found to have a significantly shorter length of operation, length of hospital stay, and a lower treatment cost (P < 0.001). Our meta-analysis found no statistically significant difference in the all-cause complication rate between simultaneous and staged bilateral UKA (P = 0.36). Only one study compared radiological outcomes between simultaneous and staged bilateral UKA which found no significant difference. CONCLUSION: Our review suggests that simultaneous bilateral UKA is comparable to staged bilateral UKA in terms of clinical and radiological outcomes and has the potential to be increasingly adopted in clinical practice due to its superior cost-effectiveness.

Obesity does not adversely impact the outcome of unicompartmental knee arthroplasty for osteoarthritis: a meta-analysis of 80,798 subjects.

BACKGROUND: Patients with end-stage single compartment osteoarthritis benefit from the less invasive unicompartmental knee arthroplasty (UKA). With increasing financial restraints, some healthcare services have set specific BMI cut-offs when determining patient eligibility for knee arthroplasty due to perceived obesity-related complications. The aim of this systematic review is to determine the effect obesity has on outcomes following UKA, and thus elucidate whether obesity should be a contraindication for UKA. METHODS: A PRISMA systematic review was conducted using five databases (MEDLINE, EMBASE, Cochrane, PubMed and Web of Science) to identify all clinical studies that examined the effect of obesity on outcomes following UKA. Quantitative meta-analysis was carried out using RevMan 5.3 software. Quality assessment was carried out using the Critical Appraisal Skills Programme (CASP) checklist. RESULTS: Thirty studies, including a total of 80 798 patients were analysed. The mean follow- up duration was 5.42 years. Subgroup meta-analyses showed no statistically significant difference following UKA between patients cohorts with and without obesity in overall complication rates (95% CI, P = 0.52), infection rates (95% CI, P = 0.81), and revision surgeries (95% CI, P = 0.06). When further analysing complications, no differences were identified in minor (95% CI, P = 0.23) and major complications (95% CI, P = 0.68), or venous thromboembolism rates (95% CI, P = 0.06). When further analysing revision surgeries, no differences were identified for revisions specifically for infection (95% CI, P = 0.71) or aseptic loosening (95% CI, P = 0.75). CONCLUSIONS: This meta-analysis shows that obesity does not result in poorer post-operative outcomes following UKA and should not be considered a contraindication for UKA. Future studies, including long-term follow-up RCTs and registry-level analyses, should examine factors associated with obesity and consider stratifying obesity to better delineate any potential differences in outcomes.

Cost effectiveness analyses of total hip arthroplasty for hip osteoarthritis: A PRISMA systematic review.

BACKGROUND: Healthcare services are facing economic constraints globally with an increasingly elderly population, and greater burdens of osteoarthritis. Because of the chronic nature of osteoarthritis and the costs associated with surgery, arthroplasty is seen as potentially cost saving. There have been no systematic reviews conducted on cost effectiveness analysis (CEA) studies of total hip arthroplasty (THA) in the management of osteoarthritis. The aim of this systematic review was to evaluate CEAs conducted on THA for osteoarthritis to determine if THA is a cost-effective intervention. MATERIALS AND METHODS: A systematic review was conducted using five databases to identify all clinical CEAs of THA for osteoarthritis conducted after 1 January 1997. Twenty-eight studies were identified that met the inclusion criteria. The Quality of Health Economic Analysis (QHES) checklist was employed to assess the quality of the studies. RESULTS: The average QHES score was 86 indicating high quality studies. All studies reviewed concluded that THA was a cost-effective intervention. In younger patients, cementless THA and ceramic on polyethylene implants were found to be most cost effective. Hybrid THA and metal on polyethylene implants had the greatest cost utility in older patients. In patients with acetabular defects, cemented cup with impaction bone grafting was most cost effective, while dual mobility THA was most cost effective in patients with high risk of dislocation. CONCLUSION: We have shown that THA is a cost-effective treatment for hip osteoarthritis. These findings should be implemented into clinical practice to improve cost utility in health services across the world.

Modelling the cost-effectiveness of total knee arthroplasty: A systematic review.

Objective: Osteoarthritis causes a significant healthcare burden and the number of total knee arthroplasty (TKA) procedures is predicted to increase significantly in the coming years. We conducted a systematic review to assess the scope and quality of all current TKA cost-effectiveness analysis (CEA) studies, identify trends, and identify areas for improvement. Methods: An electronic database search of MEDLINE, Embase, the CEA registry and Scopus was used to identify all CEA studies where TKA was used with a comparator. Studies were included from January 1, 1997 to February 2, 2020. The Quality of Health Economic Analysis Studies (QHES) instrument was used to assess their quality. Thirty-three studies were included that offered both a QALY and cost calculation. The main findings, incremental-cost effectiveness ratios and other important study characteristics were then ascertained, and trends identified. Results: Certain surgical interventions were suggested to be more cost-effective than TKA. This included unicompartmental knee arthroplasty for unicompartmental osteoarthritis, computer-assisted TKA compared to conventional TKA, and resurfacing the patella compared to no resurfacing. TKA was more cost-effective compared to non-operative management regardless of specific patient variables. Conclusions: The analyses of the CEAs included in the study have to be interpreted with caution. Overall, certain surgical methods within TKA and alternative methods to TKA appear to be favoured for treating particular knee osteoarthritic conditions due to their suggested greater cost-effectiveness but this should be interpreted within local contexts. Our results should help guide future policy-making as healthcare associated costs continue to rise.

The Treatment of Cartilage Damage Using Human Mesenchymal Stem Cell-Derived Extracellular Vesicles: A Systematic Review of in vivo Studies.

Damage to joints through injury or disease can result in cartilage loss, which if left untreated can lead to inflammation and ultimately osteoarthritis. There is currently no cure for osteoarthritis and management focusses on symptom control. End-stage osteoarthritis can be debilitating and ultimately requires joint replacement in order to maintain function. Therefore, there is growing interest in innovative therapies for cartilage repair. In this systematic literature review, we sought to explore the in vivo evidence for the use of human Mesenchymal Stem Cell-derived Extracellular Vesicles (MSC-EVs) for treating cartilage damage. We conducted a systematic literature review in accordance with the PRISMA protocol on the evidence for the treatment of cartilage damage using human MSC-EVs. Studies examining in vivo models of cartilage damage were included. A risk of bias analysis of the studies was conducted using the SYRCLE tool. Ten case-control studies were identified in our review, including a total of 159 murine subjects. MSC-EVs were harvested from a variety of human tissues. Five studies induced osteoarthritis, including cartilage loss through surgical joint destabilization, two studies directly created osteochondral lesions and three studies used collagenase to cause cartilage loss. All studies in this review reported reduced cartilage loss following treatment with MSC-EVs, and without significant complications. We conclude that transplantation of MSC-derived EVs into damaged cartilage can effectively reduce cartilage loss in murine models of cartilage injury. Additional randomized studies in animal models that recapitulates human osteoarthritis will be necessary in order to establish findings that inform clinical safety in humans.

Human umbilical cord derived mesenchymal stem cells in peripheral nerve regeneration.

BACKGROUND: Peripheral nerve injury can occur as a result of trauma or disease and carries significant morbidity including sensory and motor loss. The body has limited ability for nerve regeneration and functional recovery. Left untreated, nerve lesions can cause lifelong disability. Traditional treatment options such as neurorrhaphy and neurolysis have high failure rates. Surgical reconstruction with autograft carries donor site morbidity and often provide suboptimal results. Mesenchymal stem cells (MSCs) are known to have promising regenerative potential and have gained attention as a treatment option for nerve lesions. It is however, unclear whether it can be effectively used for nerve regeneration. AIM: To evaluate the evidence for the use of human umbilical cord derived MSCs (UCMSCs) in peripheral nerve regeneration. METHODS: We carried out a systematic literature review in accordance with the PRISMA protocol. A literature search was performed from conception to September 2019 using PubMed, EMBASE and Web of Science. The results of eligible studies were appraised. A risk of bias analysis was carried out using Cochrane's RoB 2.0 tool. RESULTS: Fourteen studies were included in this review. A total of 279 subjects, including both human and animal were treated with UCMSCs. Four studies obtained UCMSCs from a third-party source and the remainder were harvested by the investigators. Out of the 14 studies, thirteen conducted xenogenic transplantation into nerve injury models. All studies reported significant improvement in nerve regeneration in the UCMSC treated groups compared with the various different controls and untreated groups. CONCLUSION: The evidence summarised in this PRISMA systematic review of in vivo studies supports the notion that human UCMSC transplantation is an effective treatment option for peripheral nerve injury.

Clinical and Radiological Outcomes in Robotic-Assisted Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: The aim of this systematic review is to determine if robotic-assisted total knee arthroplasty (RATKA) results in improved clinical and radiological outcomes, and to elucidate the breadth and depth of studies conducted on this topic. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review was conducted using 4 databases (MEDLINE, EMBASE, Cochrane, and Web of Science) to identify all clinical studies that investigate clinical or radiological outcomes using RATKA. The Critical Appraisal Skills Program checklist for cohort studies was employed for critical appraisal and evaluation of all 22 studies that met the inclusion criteria. RESULTS: All studies reviewed determined that knee arthroplasty improved clinical outcomes. Twelve studies found statistically better clinical outcomes with RATKA compared with conventional TKA, whereas 9 studies found no difference. One study did not assess clinical outcomes. When assessing radiological outcomes, 14 studies reported that RATKA resulted in more consistent and accurate postoperative mechanical alignment, whereas 2 studies reported no difference. Six studies did not assess radiological outcomes. CONCLUSION: Although knee arthroplasty is one of the most commonly performed orthopedic operations, the level of patient satisfaction varies. The meta-analyses conducted in our systematic review shows that RATKA results in greater improvements in postoperative Hospital for Special Surgery score and Western Ontario and McMaster Universities scores compared to conventional TKA. Furthermore, it shows that RATKA results in more accurate postoperative alignment of prostheses. These together can explain the improved postoperative outcomes. More randomized controlled trials must be conducted before this technique is integrated into routine clinical practice.

Synovium-Derived Mesenchymal Stem Cell Transplantation in Cartilage Regeneration: A PRISMA Review of in vivo Studies.

Articular cartilage damaged through trauma or disease has a limited ability to repair. Untreated, focal lesions progress to generalized changes including osteoarthritis. Musculoskeletal disorders including osteoarthritis are the most significant contributor to disability globally. There is increasing interest in the use of mesenchymal stem cells (MSCs) for the treatment of focal chondral lesions. There is some evidence to suggest that the tissue type from which MSCs are harvested play a role in determining their ability to regenerate cartilage in vitro and in vivo. In humans, MSCs derived from synovial tissue may have superior chondrogenic potential. We carried out a systematic literature review on the effectiveness of synovium-derived MSCs (sMSCs) in cartilage regeneration in in vivo studies in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Twenty studies were included in our review; four examined the use of human sMSCs and 16 were conducted using sMSCs harvested from animals. Most studies reported successful cartilage repair with sMSC transplantation despite the variability of animals, cell harvesting techniques, methods of delivery, and outcome measures. We conclude that sMSC transplantation holds promise as a treatment option for focal cartilage defects. We believe that defining the cell population being used, establishing standardized methods for MSC delivery, and the use of objective outcome measures should enable future high quality studies such as randomized controlled clinical trials to provide the evidence needed to manage chondral lesions optimally.

Autologous adipose tissue grafting for the management of the painful scar.

BACKGROUND AIMS: There is currently no definitive treatment for the painful scar. Autologous adipose tissue grafting (AATG) as a treatment option for scars has become increasingly popular and there is now an abundance of evidence in the literature that supports its application. Some studies suggest that human adipose tissue is a rich source of multipotent mesenchymal stromal cells. To our knowledge, there is currently no systematic literature review to date that examines the effectiveness of AATG for reducing pain in scars. Our novel systematic review aims to examine clinical studies on the use of AATG in the treatment of the painful scar. METHODS: A literature search was performed using the following databases: PubMed, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Medline, Cochrane library and Embase. The following key words and search terms were used: adipose stem cells, scar, pain, autologous fat grafting, scar management and neuropathic pain. Human interventional studies using autologous adipose tissue grafting for the treatment of painful scars including case series, case-control, cohort studies and randomized controlled trials were reviewed. RESULTS: A total of 387 studies were found and 18 studies from January 1990 to January 2019 were identified as relevant for the purpose of this systematic review. Two studies were evidence level V, seven were evidence level IV, six were evidence level III, two were evidence level II and one was level I. A total of 337 scars were assessed in 288 patients for improvement in pain after scar treatment using adipose tissue grafting. An improvement in the analgesic effect was recorded in 12 of the 18 studies with adipose tissue grafting. A total of 233 of the 288 treated subjects responded with reduction in pain, whereas the rest did not. We carried out a pooled analysis of the studies and observed an odds ratio of 3.94 (P = 0.00001) when comparing pain reduction to no change in pain. CONCLUSIONS: We conclude that AATG is a promising and safe modality for the treatment of the painful scar. There is an abundance of low-level evidence to support its use as an alternative treatment but there is a lack of high-level evidence at present to support its standard use. Future long-term randomized controlled trials with analgesic scores as the primary outcome measures are required to assess long-term efficacy.

The effects of knee meniscectomy on the development of osteoarthritis in the patellofemoral joint 40 years following meniscectomy.

Most knee osteoarthritis and meniscectomy studies focus on osteoarthritis in the tibiofemoral joint and ignore the patellofemoral joint. This study aims to assess the long-term effects of total meniscectomy on the patellofemoral joint. To our knowledge, this is the only study of osteoarthritis in the patellofemoral joint following meniscectomy that extends to a 40-year follow-up period. Twenty-two patients with osteoarthritis were evaluated at a mean of 40 years post-meniscectomy using standardised weight-bearing radiographs of the operated and non-operated knees. Patellofemoral joint osteoarthritis was diagnosed by the presence of osteophytes and joint space narrowing to less than 5 mm. Kellgren and Lawrence scores were calculated from the radiographs. Patellofemoral joint osteoarthritis and tibiofemoral joint osteoarthritis were correlated with International Knee Documentation Committee scores and range of movement measurements. A significant difference was observed between the operated and non-operated knees in terms of patellofemoral joint osteophyte formation. There was a significant difference in tibiofemoral joint Kellgren and Lawrence scores, International Knee Documentation Committee scores and range of movement measurements between knees with lateral facet patellofemoral joint space of < 5 mm and > 5 mm. This study shows an association between open total meniscectomy and patellofemoral joint osteoarthritis at 40 years following surgery. There was also an association between patellofemoral joint space narrowing in the lateral facet and tibiofemoral joint osteoarthritis. Possible causes include altered biomechanical loading patterns following meniscectomy as well as global processes within the knee.