Use of Platelet-Rich Plasma in Intra-Articular Knee Injections for Osteoarthritis: A Systematic Review.

OBJECTIVE: To systematically analyze the literature on the use of platelet-rich plasma (PRP) for intra-articular injections of the knee and its efficacy in the treatment of knee osteoarthritis (OA). DESIGN: Systematic literature reviews were conducted in PubMed, Embase, and CINAHL (ie, Cumulative Index to Nursing and Allied Health Literature) on October 30, 2013, using the keywords "platelet-rich plasma" and "knee" and "osteoarthritis." Inclusion criteria included (1) studies with human subjects, (2) prospective clinical studies (including either clinical trials or observational studies), and (3) full-text articles published in English. Exclusion criteria were: (1) animal studies; (2) retrospective studies; (3) patients with previous surgical intervention with total knee arthroplasty or reconstruction of the anterior cruciate ligaments; and (4) articles not published in English RESULTS: A total of 319 abstracts and titles were reviewed (60 from PubMed, 250 from Embase, and 9 from CINAHL). A total of 8 relevant journal articles were identified, all of which were published between 2010 and 2013. One-half of the studies were prospective observational studies that included only PRP treatment; the rest were prospective comparative studies including both PRP and controls-2 were randomized controlled trials. Of the 4 comparative studies, 3 compared PRP with hyaluronic acid, which was considered as a commonly used effective treatment for knee OA; the other one used saline injection (ie, placebo) as the control. Although most of the analyses suffered from small sample size and was thus inconclusive, the findings consistently indicated that PRP might have better outcomes in patients with a lesser degree of degeneration and in younger patients. CONCLUSION: PRP intra-articular injections of the knee may be an effective alternative treatment for knee OA. However, current studies are at best inconclusive regarding the efficacy of the PRP treatment. A large, multicenter randomized trial study is needed to further assess the efficacy of PRP treatment for patients with knee OA.

Ventricular peritoneal shunt malfunction after operative correction of scoliosis: report of three cases.

BACKGROUND CONTEXT: Two of the most common disease processes associated with hydrocephalus in children are spina bifida and intraventricular hemorrhage of prematurity, both of which are known to be also associated with spinal deformity in later childhood. The occurrence of shunt malfunction after mechanical injury or stress to the hardware has been well documented. Newer techniques in the treatment of neuromuscular scoliosis, including anterior release with segmental fixation, have resulted in more powerful corrections of these large spinal deformities. A new potential cause of shunt malfunction is the aggressive correction of scoliosis. PURPOSE: To report patients with neuromuscular curves averaging 100° who were subsequently recognized to have perioperative shunt malfunction. STUDY DESIGN: Three case studies from a university hospital setting were included. PATIENT SAMPLE: All three children were young adolescents and had-long term shunts. Two of the children had spina bifida and a third had cerebral palsy. All children underwent anterior release of their scoliosis with posterior segmental instrumentation, with unit rods and sublaminar wires. All had significant correction of their scoliosis. OUTCOME MEASURES: Malfunctioning of the ventriculoperitoneal shunts were recorded. METHODS: Chart reviews of three cases were analyzed. RESULTS: Two children had shunt malfunctions within a month of their surgery, and one child had intraoperative recognition and externalization of the shunt. CONCLUSIONS: Older children undergoing repair of neuromuscular scoliosis are often preadolescents or adolescents who have the same indwelling shunt systems originally implanted in early infancy. The shunt may be brittle and calcified, and the peritoneal catheter may be short. The correction of scoliosis often results in an almost instantaneous growth of a few inches. Because of the potential difficulty in recognizing shunt malfunction in the perioperative period, consideration should be given for elective revision of the peritoneal catheter in children at risk.

Ganglion cyst at the fibular head causing common peroneal neuropathy diagnosed with ultrasound and electrodiagnostic examination: a case report.

The common peroneal nerve is a major source of innervation to the lower limb, but it is sometimes compressed or entrapped at the fibular head. The authors present what they believe is the first reported case where peroneal nerve impingement caused by ganglion cyst compression of the nerve at the fibular head was diagnosed using a combination of ultrasound imaging and electrodiagnostic studies. The authors described the history, physical examination, electrodiagnostic findings, and musculoskeletal ultrasound findings of a patient with a left foot drop caused by a ganglion cyst compressing the common peroneal nerve at the fibular head. The increasing role of ultrasound imaging to evaluate musculoskeletal pathology is discussed.

Concomitant correction of spinal deformity and spasticity management with posterior instrumentation and baclofen pump implantation.

Patients with spastic quadriplegia secondary to cerebral palsy manifest with severe spasticity and often with neuromuscular scoliosis. In order to optimize treatment and minimize morbidity in selected cases, the authors present a surgical option concurrently addressing these problems. This study reviews one case and describes the surgical technique in detail where intrathecal baclofen pump implantation and posterior spinal fusion are concomitantly performed to manage spasticity and scoliosis, respectively.

Mid-term results and factors affecting outcome of a metal-backed unicompartmental knee design: a case series.

BACKGROUND: Controversies exist regarding the indications for unicompartmental knee arthroplasty. The objective of this study is to report the mid-term results and examine predictors of failure in a metal-backed unicompartmental knee arthroplasty design. METHODS: At a mean follow-up of 60 months, 80 medial unicompartmental knee arthroplasties (68 patients) were evaluated. Implant survivorship was analyzed using Kaplan-Meier method. The Knee Society objective and functional scores and radiographic characteristics were compared before surgery and at final follow-up. A Cox proportional hazard model was used to examine the association of patient's age, gender, obesity (body mass index > 30 kg/m2), diagnosis, Knee Society scores and patella arthrosis with failure. RESULTS: There were 9 failures during the follow up. The mean Knee Society objective and functional scores were respectively 49 and 48 points preoperatively and 95 and 92 points postoperatively. The survival rate was 92% at 5 years and 84% at 10 years. The mean age was younger in the failure group than the non-failure group (p < 0.01). However, none of the factors assessed was independently associated with failure based on the results from the Cox proportional hazard model. CONCLUSION: Gender, pre-operative diagnosis, preoperative objective and functional scores and patellar osteophytes were not independent predictors of failure of unicompartmental knee implants, although high body mass index trended toward significance. The findings suggest that the standard criteria for UKA may be expanded without compromising the outcomes, although caution may be warranted in patients with very high body mass index pending additional data to confirm our results. LEVEL OF EVIDENCE: IV.

Hip resurfacing-keys to success.

In recent years, metal-on-metal hip resurfacing has become an increasingly popular treatment for patients needing hip arthroplasty. Important factors to consider for a successful outcome include proper patient selection and surgical technique, including approach, component positioning, and cementing technique. This review will serve as guide to both those who are learning the technique of hip resurfacing and to more experienced surgeons.

Seasonal birth patterns of cerebral palsy in North Carolina.

This study examined the seasonal birth patterns of patients with cerebral palsy (CP) in North Carolina. Data regarding live births in North Carolina were obtained for years 1980 to 2002 from the National Center for Health Statistics. Data from a pediatric orthopaedic multidisciplinary cerebral palsy clinical database at a regional medical center were weighted against the live births data. The results showed that despite slight fluctuations throughout the year, there was no significant difference between the actual monthly distribution of CP births and the expected monthly distribution (p = .68). There was no significant difference between the actual and expected seasonal distributions for overall CP births (p = .40). In conclusion, the monthly and seasonal distributions of cerebral palsy births are similar to those of live births in North Carolina. This study failed to identify any seasonal birth patterns specific for cerebral palsy.

Instability after total hip arthroplasty: treatment with large femoral heads vs constrained liners.

One of the most common complications after total hip arthroplasty is instability. This study reviewed the recent literature concerning the indications, contraindications, and results of recent studies using both constrained liners and large femoral heads to treat instability after total hip arthroplasty. We also report on the results of a series of 41 patients (52 hips) considered being at high risk for dislocation who were treated with large-diameter metal-on-metal bearings and who were compared with a matched group of hips treated with standard-size metal-on-polyethylene bearings. The large-diameter femoral head group had no dislocations at a minimum follow-up of 24 months, whereas the standard-size group had 2 dislocations. We support the use of large femoral heads to treat instability in a wide variety of patients because of the increased stability, decreased wear of modern metal-on-metal designs, increased range of motion, and variety of revision options.

The impact of intrathecal baclofen on the natural history of scoliosis in cerebral palsy.

BACKGROUND: Intrathecal baclofen (ITB) is an effective treatment of spasticity in patients with cerebral palsy. However, several recent reports have raised concerns that the treatment may be associated with a rapid progression of scoliosis. The objective of this study was to further examine the effect of ITB treatment on the progression of scoliosis in patients with cerebral palsy. METHODS: Spastic cerebral palsy patients who were ITB candidates were followed radiographically. Baseline Cobb angles of the primary curve were measured during the period of ITB pump insertion and at the most recent follow-up visit. Each patient was matched with a control patient by the diagnosis of cerebral palsy, age, sex, topographic involvement, and initial Cobb angle. The mean rate of change in Cobb angle was compared between ITB and control patients using paired t test. A multiple linear regression model was used to examine the difference, controlling for age, sex, topographic involvement, and initial Cobb angle. RESULTS: Fifty ITB patients and 50 controls were included in the analysis. There was no statistically significant difference between the mean change in Cobb angle in ITB patients (6.6 degrees per year) compared with the matched control patients (5.0 degrees per year, P = 0.39). The results from the multiple regression analysis also failed to show a statistically significant difference (0.92 degrees per year difference between ITB patients and controls, P = 0.56). CONCLUSIONS: The progression of scoliosis in cerebral palsy patients with ITB treatment is not significantly different from those without ITB treatment. The findings suggest that patients receiving ITB experience a natural progression of scoliosis similar to the natural history reported in the literature. LEVEL OF EVIDENCE: Level III.

Does computer-assisted surgery improve accuracy and decrease the learning curve in hip resurfacing? A radiographic analysis.

BACKGROUND: Hip resurfacing is a technically demanding procedure in which accurate positioning of the femoral component is critical to the avoidance of early implant failures. The purpose of this study was to assess the accuracy of computer-assisted placement of the femoral component and to evaluate the impact of computer-assisted surgery on the learning curve associated with this procedure. METHODS: The accuracy of positioning the femoral component was analyzed radiographically in hips undergoing resurfacing procedures performed by surgeons assigned to four different study groups: Group 1, in which the operations were performed with use of computer-assisted surgery by a fellowship-trained surgeon who was experienced in performing resurfacing arthroplasty (surgical experience, more than 250 hip resurfacings); Group 2, in which the operations were performed with use of computer-assisted surgery by senior residents who were inexperienced in performing resurfacing arthroplasty and who were closely supervised by faculty; Group 3, in which the operations were performed with use of conventional instruments by fellowship-trained faculty members; and Group 4, in which the operations were performed with use of computer-assisted surgery by a lesser experienced fellowship-trained faculty member (surgical experience, more than forty but less than seventy-five hip resurfacings) from Group 3. RESULTS: The range of error in varus or valgus angulation that was observed for navigated procedures was 6 degrees in Group 1, 7 degrees in Group 2, and 5 degrees in Group 4. Compared with the preoperative neck-shaft angle value, the mean postoperative stem-shaft angle value increased by a mean of 4.7 degrees in Group 1, 7.2 degrees in Group 2, 6.5 degrees in Group 3, and 11.6 degrees in Group 4. When compared with the use of standard instrumentation, the use of computer-assisted surgery reduced the number of outliers and facilitated valgus insertion. CONCLUSIONS: In the present study, computer-assisted surgery resulted in improved accuracy and precision in positioning the femoral component. In addition, computer-assisted surgery led to a reduction in the length of the learning curve for beginners in hip resurfacing and improved the surgeon's ability to perform this procedure safely.

The outcome of intrathecal baclofen treatment on spastic diplegia: Preliminary results with a minimum of two year follow-up.

The purpose of this study is to report the short-term outcome of intrathecal baclofen therapy on the function of individuals with diplegic cerebral palsy (CP) and the health-related quality of life (HRQL) of their caregivers. Eight pediatric patients with spastic diplegia were treated with ITB following failed oral spasticity management and were followed for a minimum of 2 years. Physical and functional outcomes were assessed using Ashworth Scores (AS), Physician Rating Scale (PRS), and a subset of the Functional Independence Measure for children (WeeFIM). HRQL was assessed using SF-36, CES-D short form, Impact on Family Scale, Life Orientation Test, Rand Social Support Scale, and Social Desirability Scale. At final follow-up, AS was significantly reduced (all p ⩽ 0.03). The PRS scale showed statistically significant improvement in four out of six subscales: median gait pattern (p = 0.05), median hind foot strike (p = 0.03), median knee position (p = 0.03) and median hind foot gait (p = 0.05). The WeeFIM score improved significantly with a mean increase of 32% (p = 0.03). ITB therapy significantly reduced spasticity and improved the function of these eight children with diplegic CP. HRQL of the parents or the caregivers remained stable despite the surgical intervention and follow-up visits required for pump refills.

Use of intrathecal baclofen in a pediatric cerebral palsy patient with refractory hemiplegia to maintain orthopaedic surgery gains.

Spasticity, a common symptom accompanying cerebral palsy (CP), can severely affect patients' function and cause disability in childhood. Intrathecal baclofen (ITB) therapy is a widely used treatment to reduce spasticity in quadriparetic CP patients. Likewise, adults sustaining strokes and subsequent spastic hemiplegic have proven excellent candidates as well from ITB therapy. However, data on ITB treatment in pediatric patients with hemiplegic CP are lacking. This is the first report to present such a case. A nine-year old girl with spastic hemiplegic CP failed chemical denervation and serial casting of lower extremity spasticity and an associated equinovarus contracture. An ITB bolus test revealed an improvement in her Ashworth score from a mean of 2.8 to 1.2 on the involved side, whereas the unaffected side stayed constant from a mean of 1.3 to 1.2. The patient was subsequently treated with continuous ITB with improvement of Ashworth scores from a mean of 2.8 at baseline to 1.1 at 17 months after implantation of the ITB pump. Subsequent surgery was performed to correct the residual ankle deformity resulting in improvements in passive range of motion, gait function and brace tolerance. Hemiplegic CP pediatric patients can be successfully treated with ITB to reduce spasticity, improve function, and retain postoperative surgical correction without affecting the normal side.