New research July 2024

Current research we are reading: July 2024

A June 2024 paper examined the causes and problems of failed back surgery syndrome. The paper points out there are many causes for failed back surgery. Among them: “Incorrect selection of the surgical procedure is a significant risk factor for failed back surgery syndrome. Performing decompression at the wrong level or single-level decompression without recognizing multilevel spinal involvement is unlikely to yield satisfactory outcomes. Inadequate lateral recess (not enough bone was removed)  and neural foraminal decompression are significant causes of failed back surgery syndrome. Errors during spinal surgery can exacerbate preoperative pain and create new sources of pain. Poor surgical techniques can lead to segmental instability and increased pain resulting from direct nerve damage and intraoperative spinal cord ischemia.” Further, if the first surgery fails, the prospects for better success in a second surgery are as follows:

“Revision surgery is often recommended for patients with pain that is refractory (not responding) to other treatments and has an anatomical or pathological source identified by imaging. For example, chronic pain caused by recurrent disc herniation and adjacent segment degeneration usually requires surgical intervention. However, surgical revision is associated with significant morbidity, a higher risk of developing new neurological deficits, and low success rates, with insufficient evidence supporting its efficacy. Given the unsatisfactory outcomes of revision surgery, surgical treatment should be considered a limited therapeutic option. ”

Yeo J. Failed back surgery syndrome-terminology, etiology, prevention, evaluation, and management: a narrative review. Journal of Yeungnam medical science. *

A June 2024 study reviewed the findings of previous research in the use of PRP for low back pain. In this current paper the researchers noted previous outcomes suggesting PRP injections to have shown promising results in managing vertebrogenic and discogenic pain including that of intradiscal injection of autologous PRP . Other data assessed the clinical outcomes of higher-concentration PRP injections in patients with chronic lumbar discogenic pain and found that PRP injections led to significant improvements in pain and function. The authors here noted: “The use of PRP in the management of discogenic pain has also been supported by studies evaluating its long-term effects.” That PRP could be an effective long-term solution for low back pain.

A July 2024 study reviewed the effectiveness of PRP treatments for frozen shoulder. In this review, patient data from six previous studies and 578 patients with 263 patients receiving PRP (45.5%).

• All six studies used PRP as part of non-operative treatment. PRP was compared to another intervention in all six studies. Four of these studies found PRP to be more effective.

The authors concluded: “PRP is a safe treatment option that can be added to the investigative treatment arsenal of adhesive shoulder capsulitis”

El-Swaify ST, Refaat MA, AbdelWahab AA, Seddik ME, Mostafa Abdelrazek AE, Doas Y, Beshay PW. Is platelet-rich plasma a new solution for shoulder adhesive capsulitis? A systematic scoping review of the literature. Shoulder & Elbow. 2023 May 17:17585732231174184.

This research is included in our article Information on Frozen shoulder – Adhesive capsulitis and Platelet Rich Plasma Therapy.

How surgeons and physical therapists see the role of PT in shoulder arthritis

In an August 2024 study, researchers asked  the opinions of expert providers-orthopedic surgeons and physical therapists-regarding the utility of physical therapy in treating glenohumeral arthritis in different stages of radiographic severity.

• 190 surgeons and 39 physical therapists completed the survey.
• Surgeons and therapists demonstrated different opinions.
• They agreed on the benefits of physical therapy for mild arthritis, the benefits of corticosteroid injections, the frequency of strengthening exercises, and that physical therapy failure should not be required for surgical approval in patients with severe arthritis. They disagreed on the whether physical therapy exacerbates symptoms in patients with moderate arthritis, and whether preoperative physical therapy influences postoperative outcomes.

Kane LT, Mahmood H, Singh J, Tate A, Namdari S. Provider Opinions on Effectiveness of Physical Therapy as Treatment for Glenohumeral Arthritis. Journal of Shoulder and Elbow Surgery. 2024 May 10. *r

Ultrasound in diagnosing meniscus tears

A June 2024 study evaluated the current understanding of the role of ultrasound in the diagnosis and treatment of meniscal disorders. As in previous research, this study found “Ultrasound (US) demonstrates similar sensitivity and specificity when compared to magnetic resonance imaging in the evaluation of meniscal injuries when compared to arthroscopy. Meniscal extrusion (how far the meniscus is bulging out of place)  under ultrasound can be a reliable metric to evaluate for meniscal root tears in knees with and without osteoarthritis.” Further, ultrasound “following allograft meniscal transplant may be useful in predicting graft failure. . . diagnostic ultrasound can demonstrate with high accuracy a variety of meniscal pathologies and can be considered a screening tool.”

Johnson SE, Kruse RC, Boettcher BJ. The Role of Ultrasound in the Diagnosis and Treatment of Meniscal Injuries. Current Reviews in Musculoskeletal Medicine. 2024 Apr 19:1-4.

The meniscus tear that was not there

An upcoming November 2024 paper (1) found that MRI suggestions of a meniscus tear, may not indicate a meniscus tear. The authors of this study looked at patients with a first time lateral patellar dislocation and for evidence of soft tissue injury. The purpose was to help guide surgeons on a proper surgical course. Here are the data highlights:

• Out of 44 cases of lateral patellar dislocation in 42 patients who underwent Medial patellofemoral ligament reconstructive surgery:
  • 27 (61%) cases had grade 2a or higher signal changes in the anterior horn of the lateral meniscus, of which 10 (23%) had grade 3 signal changes. (This is indicating the presence of a meniscus tear).
  • However, during the surgery, “there were zero cases of meniscal tear in these cases upon review of operative reports and arthroscopic images. . . MRI findings of signal alterations in the lateral meniscus post-lateral patellar dislocation may not indicate an actual tear. This could aid in surgical decision-making in primary lateral patellar dislocation management.”

Harris G, Patel N, Lobaton GO, Cabrera C, Quintero D, Baraga M, Jose J. Abnormal Lateral Meniscal Signal in MRI After Patellar Dislocation Does Not Indicate a Meniscal Tear: MR Findings with Surgical Correlation. Journal of Orthopaedics. 2024 Jun 13.

Repair the meniscus or remove meniscus tissue?

An August 2024 study reviewed the management of meniscal injuries in the elite athlete. The authors acknowledge that this “is a difficult problem secondary to the high demands of athletic competition, the need for a timely return to sport, and the desire to maximize performance over time.”

The study goes on: “Historically, partial meniscectomy has been the primary treatment option for meniscus injuries. However, in recent years there has been an increased emphasis on meniscus preservation due to the increased risk of cartilage degeneration over time. Moreover, while partial meniscectomy still provides a quicker return to sport, recent literature has demonstrated similar rates of return to sport and return to pre-injury levels between partial meniscectomy and meniscus repair. In the setting of symptomatic meniscal deficiency, meniscus allograft transplantation has become an increasingly utilized salvage procedure with promising yet variable outcomes on the ability to withstand elite competition. Currently, there is no uniform approach to treating meniscal injuries in elite athletes.”

Marigi EM, Davies MR, Marx RG, Rodeo SA, Williams RJ. Meniscus Tears in Elite Athletes: Treatment Considerations, Clinical Outcomes, and Return to Play. Current Reviews in Musculoskeletal Medicine. 2024 Jun 4:1-8.

Decreased hamstring strength and symptoms of knee osteoarthritis and patellofemoral pain

A July 2024 study looked at the  hamstring strength, flexibility, and morphology in individuals with gradual-onset knee disorders. In a data review of 79 papers with outcomes in patients with knee osteoarthritis, patellofemoral pain, chondromalacia patellae, and patellar tendinopathy, individuals with knee osteoarthritis presented with reduced hamstring strength compared to pain-free controls during isometric and concentric contractions. Individuals with patellofemoral pain presented with reduced hamstring strength compared to pain-free controls during isometric,  concentric, and eccentric contractions. No differences were observed in individuals with patellar tendinopathy. The researchers suggest: “that assessing and targeting impairments in hamstring strength and flexibility during rehabilitation may be recommended for individuals with knee osteoarthritis or patellofemoral pain.”

Lopes HS, Waiteman MC, Priore LB, Glaviano NR, Bazett-Jones DM, Briani RV, Azevedo FM. There is more to the knee joint than just the quadriceps: A systematic review with meta-analysis and evidence gap map of hamstring strength, flexibility, and morphology in individuals with gradual-onset knee disorders. Journal of Sport and Health Science. 2023 Sep 3. *

We cover this research in our extended article: Runner’s Knee – Patellofemoral Pain Syndrome

Do fatty acids protect against knee osteoarthritis? Study says no.

A June 2024 study suggests that although n-3 (omega-3) fatty acids may reduce inflammation, different n-3 (omega-3) fatty acids have different effects on inflammation and clinical outcomes, with eicosapentaenoic acid (EPA) having the strongest effect, there is a question as to how much impact, good or bad, specific essential fatty acid levels have on the development of osteoarthritis.

A multi-university study lead by Boston University studied 363 cases with incident symptomatic knee osteoarthritis and 295 with incident radiographic knee osteoarthritis. Results for other osteoarthritis outcomes also failed to suggest a protective effect of specific n-3 fatty acids with osteoarthritis outcomes.

Felson DT, Misra D, LaValley M, Clancy M, Rabasa G, Lichtenstein A, Matthan N, Torner J, Lewis CE, Nevitt MC, MOST Study Investigators. Essential Fatty Acids and Osteoarthritis. Arthritis Care & Research. 2024 Jun;76(6):796-801.

Early meniscal surgery did not appear superior to exercise and education in providing better knee function and pain relief after 12 months

A May 2024 paper compared the effect of early meniscal surgery versus exercise and education with the option of later surgery on pain, function, and quality of life in young patients with a meniscal tear.

• 121 patients aged 18-40 years with a meniscal tear were randomized to surgery or 12 weeks of supervised exercise and patient education. Forty-two patients (69%) in the exercise therapy group and 47 (78%) in the surgery group were categorized as having a traumatic tear.
• In patients with traumatic and nontraumatic meniscus tears, early meniscal surgery did not appear superior to exercise and education in improving pain, function, and quality of life after 12 months.

Damsted C, Skou ST, Hölmich P, Lind M, Varnum C, Jensen HP, Hansen MS, Thorlund JB. Early surgery versus exercise therapy and patient education for traumatic and non-traumatic meniscal tears in young adults-an exploratory analysis from the DREAM-trial. Journal of Orthopaedic & Sports Physical Therapy. 2024 May;54(0):1-25. *

A June 2024 study discussed the surgical treatment of meniscus tears in elite athletes. Here are the paper’s highlights:

• Historically, partial meniscectomy has been the primary treatment option for meniscus injuries. However, in recent years there has been an increased emphasis on meniscus preservation due to the increased risk of cartilage degeneration over time. Moreover, while partial meniscectomy still provides a quicker return to sport (RTS), recent literature has demonstrated similar rates of return to sport (RTS) and return to pre-injury levels between partial meniscectomy and meniscus repair.
• When too much meniscus is damaged or removed, meniscus allograft transplantation has become an increasingly utilized salvage procedure with promising yet variable outcomes on the ability to withstand elite competition.
• Currently, there is no uniform approach to treating meniscal injuries in elite athletes.

Marigi EM, Davies MR, Marx RG, Rodeo SA, Williams RJ. Meniscus Tears in Elite Athletes: Treatment Considerations, Clinical Outcomes, and Return to Play. Current Reviews in Musculoskeletal Medicine. 2024 Jun 4:1-8.

A July 2024 paper examined the effects of the combination of various pharmacological treatments and exercise on knee osteoarthritis. In total, 71 studies were included. the various pharmacological agents combined with exercise included: mesenchymal stem cell injection which was ranked the best for short-term pain reduction, followed by botulinum toxin A, dextrose (Prolotherapy), and platelet-rich plasma. For long-term pain relief, dextrose prolotherapy was the optimal, followed by mesenchymal stem cells, platelet rich in growth factor, and platelet-rich plasma.

Cheng HY, Liang CW, Lee YH, Vitoonpong T, Liao CD, Huang SW. Effects of the combination of various pharmacological treatments and exercise on knee osteoarthritis: a systematic review and network meta-analysis. EFORT Open Reviews. 2024 Jul 1;9(7):668-75. *r

A June 2024 study, examining pooled data from previous research “showed the prolotherapy (positive) effect on knee function increases with increasing age and BMI because they are two important risk factors in the occurrence of knee osteoarthritis. (Data also) showed the prolotherapy effect on knee function increased over time after prolotherapy injection in patients. Therefore, the more time passes after prolotherapy injection in patients with knee osteoarthritis, their knee function improves which can be due to the increase in the strength of the ligaments. The results of the present meta‐analysis showed the (average) pain . . . significantly decreased compared with the ones who received other treatments or placebo.”

Khateri S, Nejad FB, Kazemi F, Alaei B, Azami M, Moradkhani A, Majidi L, Moradi Y. The effect of dextrose prolotherapy on patients diagnosed with knee osteoarthritis: A comprehensive systematic review and meta‐analysis of interventional studies. Health Science Reports. 2024 Jun;7(6):e2145.

A July 2024 consensus study issued by the European Society of Sports Traumatology, Knee Surgery, and Arthroscopy (ESSKA), and the International Cartilage Regeneration and Joint Preservation Society (ICRS) established recommendations on the appropriateness or inappropriateness of PRP injections for the treatment of knee osteoarthritis, providing a useful reference for clinical practice. PRP injections are considered appropriate in patients aged less than 80 years old with knee Osteoarthritis grade 0 – III after failed conservative non-injective or injective treatments. The doctors did not consider PRP an appropriate as first treatment in patients with Grade IV knee osteoarthritis.

Kon E, de Girolamo L, Laver L, Andriolo L, Andia I, Bastos R, Beaufils P, Biant L, Bøe B, Boffa A, Cugat R. Platelet‐rich plasma injections for the management of knee osteoarthritis: The ESSKA‐ICRS consensus. Recommendations using the RAND/UCLA appropriateness method for different clinical scenarios. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. *r

A May 2024 study assessed the effectiveness of Bone marrow aspirate concentrate injections. In this prospective, single-center study, 63 patients with grade II-III knee OA (Kellgren-Lawrence (K-L) scale) unresponsive to conservative management underwent Bone marrow aspirate concentrate (BMAC) injection. The procedure involved bone marrow aspiration from the anterior iliac crest, processing to obtain a concentrate, followed by intra-articular injection. Patients were followed for 24 months, assessing pain and functional outcomes.

Bone marrow aspirate concentrate (BMAC) injection provides significant improvement in both pain and functional outcomes at mid-term follow-up in patients with mild-to-moderate osteoarthritis of the knee. Further high-quality, adequately powered, multi-center, prospective, double-blinded, randomized controlled trials with longer follow-up are necessary to justify the routine clinical use of BMAC for treatment of patients suffering with knee osteoarthritis.

Jeyaraman M, Jeyaraman N, Ramasubramanian, S, Ranjan R., Jha S.K. and Gupta, A., 2024. Bone Marrow Aspirate Concentrate for Treatment of Primary Knee Osteoarthritis: A Prospective, Single-Center, Non-randomized Study with 2-Year Follow-Up. Indian Journal of Orthopaedics, pp.1-11.

A July 2024 study aimed to evaluate whether a combination of platelet-rich plasma (PRP) and hyaluronic acid is more effective and safer than either injection alone for treating knee osteoarthritis. Ten studies involving 943 patients were included in the analysis.

• The statistical findings did not differ between the treatment of PRP + hyaluronic acid and PRP alone.
• However PRP + hyaluronic acid treatment efficacy was observed when compared to hyaluronic acid alone in self-reported pain and function patient scores.

Gao J, Ma Y, Tang J, Zhang J, Zuo J. Efficacy and safety of platelet-rich plasma and hyaluronic acid combination therapy for knee osteoarthritis: a systematic review and meta-analysis. Archives of Orthopaedic and Trauma Surgery. 2024 Jul 7:1-21.

Sarcopenic obesity increases the odds of knee osteoarthritis

A May 2024 study revealed that low muscle mass index and sarcopenic obesity were associated with an increased risk of developing knee osteoarthritis especially in women. The researchers wrote: “The findings with moderate-quality evidence indicated that sarcopenic obesity increases the odds of knee osteoarthritis by approximately 90% in females. . . ”

Wu Q, Xu Z, Ma X, Li J, Du J, Ji J, Ling X, Kan J, Zhao M. Association of low muscle mass index and sarcopenic obesity with knee osteoarthritis: a systematic review and meta-analysis. Journal of the International Society of Sports Nutrition. 2024 Dec 31;21(1):2352393. *

A June 2024 network meta-analysis study compared radiofrequency ablation versus intra-articular mesenchymal stem cell injection for knee osteoarthritis. Included were 34 randomized controlled trial (2371 patients). The findings revealed that radiofrequency ablation and intra-articular mesenchymal stem cell injection were significantly more effective than conventional treatments in managing pain at both three and six months with moderate certainty. The researchers do suggest that evidence could be mixed, however, “these treatments consistently outperformed conventional treatments, particularly in the short to mid-term, although with varying levels of certainty in their efficacy.”

Patients dissatisfied with their results of their knee replacement

Osteoporosis and hip replacement

A July 2024 paper provides an updated analysis for patients with osteoporosis following total hip replacement.

• Osteoarthritis patients who suffer from alcohol abuse, chronic kidney disease, cerebrovascular disease, obesity, and rheumatoid arthritis continue to be significant risk factors for periprosthetic femur fracture  and aseptic loosening. Further, the patient population with severe osteoporosis may have higher risks for aseptic loosening and periprosthetic femur fracture  than previously recognized.

Layson JT, Hameed D, Dubin JA, Moore MC, Mont M, Scuderi GR. Patients with Osteoporosis Are at Higher Risk for Periprosthetic Femoral Fractures and Aseptic Loosening Following Total Hip Arthroplasty. Orthopedic Clinics. 2024 Mar 23.

A June 2024 study explored the long-term changes in pain and hand function over a 2-year period in patients with thumb osteoarthritis. The researchers looked at those who received occupational therapy or brief information on how to manage their thumb pain while waiting for a surgical consultation.

When comparing groups receiving occupational therapy only, occupational therapy and surgery, brief information only, and brief information and surgery, patients receiving brief information and surgery had significantly more pain and poorer function at four months compared to the other groups, whereas no difference was found between the four groups at 24 months. (Eventually the occupational; therapy and surgery performed equally).

In patients who received surgery after having received occupational therapy, pain and function did not change between 4 and 24 months, suggesting that surgery did not provide additional improvement in this group.

Tveter AT, Østerås N, Nossum R, Eide REM, Klokkeide Å, Matre KH, Olsen M, Kjeken I. Long-term changes in pain and function in patients with thumb base osteoarthritis receiving brief information, occupational therapy and/or surgery. Musculoskeletal Care. 2024 Jun;22(2):e1883. doi: 10.1002/msc.1883. PMID: 38629865. *

A July 2024 study  evaluated the effects of low doses of botulinum toxin type A to control pain in patients with sleep bruxism, awake bruxism, and temporomandibular disorder (TMD) during a 180 day treatment period.

• thirty-five patients with chronic pain related to TMD, sleep bruxism, and awake bruxism received a single dose of 20 U of botulinum toxin type A in masseter and temporalis muscles. The pain was assessed with a visual analog scale (VAS recording pain scores from 0 – 10) before and after 15, 30, 60, 90, and 180 days of the application.

The three clinical conditions sleep bruxism, awake bruxism, and temporomandibular disorder (TMD) experienced decrease in pain after 15 days of treatment, the maximum pain relief persisted for up to 90 days after botulinum toxin type A application in patients with sleep bruxism and awake bruxism and 15 days for patients with TMD. Conclusion: A low dose of BoNT-A may be effective for controlling chronic pain related to sleep bruxism and awake bruxism, but TMD pain reduction was short-lived.

de Lima MC, Rizzatti Barbosa CM, Duarte Gaviao MB, Ferreira Caria PH. Is low dose of botulinum toxin effective in controlling chronic pain in sleep bruxism, awake bruxism, and temporomandibular disorder?. CRANIO®. 2021 Sep 16:1-8. *

This research is included in our article Research on different types of TMJ injections.

A July 2024 study, (x) citing that  high-quality evidence supporting the use of PRP with lateral epicondylitis and knee osteoarthritis to accelerate the healing process and decrease pain, sought to determine if the injection of PRP relieved pain faster and improved function compared with no injection or placebo in patients with a lateral ankle sprain. In examining the data of three previously published studies, the researchers found: “PRP injection reduces pain and increases function after lateral ankle sprain 5 to 8 weeks after intervention. . . The use of PRP after lateral ankle sprain to decrease pain and increase function is supported with moderate evidence.”

Frey E, Brown CD, Tripp B. Effectiveness of Platelet-Rich Plasma in Reducing Pain and Increasing Function After Acute Lateral Ankle Sprain: A Critically Appraised Topic. Journal of Sport Rehabilitation. 2024 Jul 12;1(aop):1-4. No