Publications by authors named "Sathish Muthu"

39 Publications

Autologous bone marrow aspirate concentrate (BMAC) for treatment of keratocystic odontogenic tumour (KCOT)-a case report.

Stem Cell Investig 2021 16;8:16. Epub 2021 Aug 16.

Indian Stem Cell Study Group (ISCSG) Association, Lucknow, Uttar Pradesh, India.

Management of keratocystic odontogenic tumor (KCOT) has always remained a conundrum due to its aggressive behavior, indicating wide resection. Achieving an esthetically and functionally acceptable reconstruction remains a challenge. Herein, we present a novel and less invasive technique for the treatment of KCOT. A 55-year-old female presenting with pain in the lower jaw for the past 3 months was diagnosed with a large KCOT extending from 35 to 47 region. CT images revealed buccal and lingual cortical bone erosion. Management was done in two stages: cyst curettage and chemical cauterization, followed by application of Bone Marrow Aspirate Concentrate (BMAC) with a delay of two months, to increase the thickness of eroded cortical bone. On follow-up at one year, ossification of the defect was observed. BMAC is a cocktail of mesenchymal stromal cells, hematopoietic stem cells, fibroblasts, mononuclear cells, macrophages, endothelial cells, progenitor cells, growth factors and cytokines. BMAC cocktail provide an anti-inflammatory, anti-fibrotic, anti-apoptotic, and immunomodulatory environment. Autologous platelet rich plasma provides various growth factors (TGF-β, PDGF, EGF, HGF, NGF, IGF-1) and cytokines. Addition of PRP in BMAC cocktail enhance the regeneration of tissues, where PRP act as a functional regenerative scaffold for cell integration, proliferation, and differentiation that can expedite macroscale musculoskeletal tissue healing. Autologous BMAC with corticocancellous bone acts as an osteoconductive scaffold capable of regenerating the large bone defect created by the curettage of KCOT.
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http://dx.doi.org/10.21037/sci-2020-059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8413135PMC
August 2021

Accentuating the sources of mesenchymal stem cells as cellular therapy for osteoarthritis knees-a panoramic review.

Stem Cell Investig 2021 9;8:13. Epub 2021 Jul 9.

International Association of Stemcell and Regenerative Medicine (IASRM), New Delhi, India.

The large economic burden on the global health care systems is due to the increasing number of symptomatic osteoarthritis (OA) knee patients whereby accounting for greater morbidity and impaired functional quality of life. The recent developments and impulses in molecular and regenerative medicine have paved the way for inducing the biological active cells such as stem cells, bioactive materials, and growth factors towards the healing and tissue regenerative process. Mesenchymal stem cells (MSCs) act as a minimally invasive procedure that bridges the gap between pharmacological treatment and surgical treatment for OA. MSCs are the ideal cell-based therapy for treating disorders under a minimally invasive environment in conjunction with cartilage regeneration. Due to the worldwide recognized animal model for such cell-based therapies, global researchers have started using the various sources of MSCs towards cartilage regeneration. However, there is a lacuna in literature on the comparative efficacy and safety of various sources of MSCs in OA of the knee. Hence, the identification of a potential source for therapeutic use in this clinical scenario remains unclear. In this article, we compared the therapeutic effects of various sources of MSCs in terms of efficacy, safety, differentiation potential, durability, accessibility, allogenic preparation and culture expandability to decide the optimal source of MSCs for OA knee.
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http://dx.doi.org/10.21037/sci-2020-055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8327191PMC
July 2021

Indian Paradigm of Orthopedic Care in Post-COVID-19 Era.

J Orthop Case Rep 2021 Apr;11(4):110-116

Indian Orthopaedic Research Group (IORG). Thane. Maharashtra. India.

Introduction: COVID-19 pandemic caused by the newly emerged strain of coronavirus (SARS-CoV-2) has had phenomenally casted its impact on the health-care systems globally. The rampant spread of contagiosity has challenged the solidarity of the medical fraternity of the developed and developing world. The rising turmoil enforces to trudge with stoicism and expresses the need for planning because of subjugating the prevailing conditions with judicial channelization of available resources. In many developed and developing countries, the resources such as appropriate equipment as well as personnel have been extended to combat the pandemic substantially. At the same time, the populous country such as India has taken a stand to cancel electively planned orthopedic surgeries. However, under the issued guidelines of apex authorities, trauma and emergency services had have been in continuity with a reorganized manner. Hereby, we discuss the present shift in paradigm in the field of orthopedics with an interplay of regenerative orthopedics and telemedicine and its pivotal role against the odds of the COVID-19 pandemic. Besides, we see over the future perspectives and challenges in the purview of resorting to an effective clinical practice in orthopedics specialty. Albeit these guidelines expound strategies to manage trauma and orthopedic cases amidst pandemics but the subsequent post-COVID-19 phase warrants explicable vision and planning. Indeed, resuming elective orthopedics surgical intervention in post-phase of pandemic shall definitively be a task invoking fundamental planning, especially in a resource-limited background. With the rollout of vaccines in the country, the scenario is in favor of returning to normalcy with evaluation for COVID-19 being added to the list of routine medical and surgical screening profiles.
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http://dx.doi.org/10.13107/jocr.2021.v11.i04.2174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310642PMC
April 2021

Holistic Approach in the Management of Skeletal Deformity in a Case of Homocystinuria.

J Orthop Case Rep 2021 Apr;11(4):1-5

Orthopaedic Research Group, Coimbatore, Tamil Nadu, India.

Introduction: Homocystinuria has a wide range of clinical presentations ranging from near normal intelligence and appearance with just lens dislocation and minimal skeletal deformities to severe mental retardation with gross skeletal deformities. In this background, we describe one such case with skeletal deformity managed comprehensively.

Case Report: A 17-year-old boy presented with complaints of deformity of the left lower limb since childhood more evident for the past 5 years along with a history of blurring of vision. On examination the pubis-heal length > crown-pubis length along with genu valgum of left lower-limb with 16 cm intermalleolar distance. He also had a superolateral subluxation of the lens in both eyes. Valgus angle was 16° on the left leg compared to 6° on the right. The diagnosis of homocystinuria was confirmed by biochemical investigations. The left side genu valgum was addressed with medial closing wedge osteotomy and fixed with distal femur locking compression plating. Lens subluxation was treated with posterior chamber intra-ocular lens surgery. He was also given medical treatment and on regular monitoring of his homocysteine levels. The patient had good functional outcome at 2-year follow-up.

Conclusion: Homocystinuria is a rare disease that needs early identification and effective management to avoid complications. Skeletal complications are common and include genu valgum, pes cavus, chest wall deformities, and skeletal deformities such as kyphosis and scoliosis. Skeletal deformities can be avoided when identified early and associated osteoporosis which is managed effectively. A holistic approach is needed in the management of such patients with inter-departmental coordination to bring quality to the life of patients with homocystinuria.
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http://dx.doi.org/10.13107/jocr.2021.v11.i04.2126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310640PMC
April 2021

Bracing NK cell based therapy to relegate pulmonary inflammation in COVID-19.

Heliyon 2021 Jul 21;7(7):e07635. Epub 2021 Jul 21.

Department of Biotechnology, School of Engineering &Technology, Sharda University, Greater Noida, Uttar Pradesh, 201310, India.

The contagiosity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has startled mankind and has brought our lives to a standstill. The treatment focused mainly on repurposed immunomodulatory and antiviral agents along with the availability of a few vaccines for prophylaxis to vanquish COVID-19. This seemingly mandates a deeper understanding of the disease pathogenesis. This necessitates a plausible extrapolation of cell-based therapy to COVID-19 and is regarded equivalently significant. Recently, correlative pieces of clinical evidence reported a robust decline in lymphocyte count in severe COVID-19 patients that suggest dysregulated immune responses as a key element contributing to the pathophysiological alterations. The large granular lymphocytes also known as natural killer (NK) cells play a heterogeneous role in biological functioning wherein their frontline action defends the body against a wide array of infections and tumors. They prominently play a critical role in viral clearance and executing immuno-modulatory activities. Accumulated clinical evidence demonstrate a decrease in the number of NK cells in circulation with or without phenotypical exhaustion. These plausibly contribute to the progression of pulmonary inflammation in COVID-19 pneumonia and result in acute lung injury. In this review, we have outlined the present understanding of the immunological response of NK cells in COVID-19 infection. We have also discussed the possible use of these powerful biological cells as a therapeutic agent in view of preventing immunological harms of SARS-CoV-2 and the current challenges in advocating NK cell therapy for the same.
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http://dx.doi.org/10.1016/j.heliyon.2021.e07635DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8294777PMC
July 2021

Platelet lysate for COVID-19 pneumonia-a newer adjunctive therapeutic avenue.

Stem Cell Investig 2021 8;8:11. Epub 2021 Jun 8.

Indian Stem Cell Study Group (ISCSG) Association, Lucknow, Uttar Pradesh, India.

The linchpin for COVID-19 pathogenesis is the severe inflammatory process in the respiratory tract wherein the accumulation of excessive cytokines paves the way for a series of systemic hemodynamic alterations and mortality. The mortality rate is higher in individuals with co-morbidities and advancing age. The absence of a specific therapy is responsible for this uncontrolled spread and the significant mortality. This renders potential insight for considering biologics as a plausible option to repair and regenerate the affected lung tissue and pulverize the causative organism. The plausible role of megakaryocytes against invading microbes was not clearly understood. Platelet lysate is an acellular product consisting of regenerative molecules released from a cluster of platelets. It attenuates the changes caused by immune reactions in allogenic utility with the introduction of growth factors, cytokines, and proteins at supraphysiologic levels and thereby serves as a regenerative immunomodulatory agent to combat COVID-19. This platelet lysate can be used in nebulized form for such acute respiratory distress conditions in COVID-19 elderly patients. Platelet lysate may emerge as a pivotal player provided investigations pace up in this context. Here, we discuss how the platelet lysate can plausibly perquisite to relegate COVID-19. Undertaking prospective randomized controlled trials to prove its efficacy is the need of the hour in this pandemic scenario.
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http://dx.doi.org/10.21037/sci-2020-042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8256133PMC
June 2021

Analysis of Reference Practices among Practicing Orthopaedicians in India.

Indian J Orthop 2021 Aug 17;55(4):869-878. Epub 2021 Jan 17.

Orthopaedic Research Group, Coimbatore, Tamil Nadu India.

Purpose: On-The-Go (OTG) references are those that clinicians make within a tight deadline at the point of patient care to direct critical decisions. We conducted this study to assess the knowledge level of orthopaedicians on clinical usefulness and quality appraisal of different reference methods along with their attitude towards its utility for practice.

Materials And Methods: A web-based survey was administered through Google Forms among the members of the Tamil Nadu Orthopaedic Association (TNOA) by snowball sampling method. The survey was designed by the Quality Appraisal Committee (QAC) of Orthopaedic Research Group (ORG) with 17 items. Association and correlation analysis were done between different responses in the survey to find out ways to improve the reference practices.

Results: 177 participants with a mean age of 43.5 years completed the survey. About 45.8% ( = 81) of participants had prior knowledge on  the Oxford Levels of Evidence. However, they were not familiar with using them for critical appraisal of evidence. About 86.5% ( = 153) of participants were worried about the quality of the content they seek for reference. Among the reference sources, online research articles were used by 54.2% ( = 96), digital applications by 21.4% ( = 38), digital textbooks by 15.2% ( = 27), and other methods like peer discussion by 5.1% ( = 9). A significant association was noted between the participants who chose level I studies for their reference and their familiarity with the concept of fragility ( = 0.006) and heterogenicity ( = 0.021) and types of bias ( = 0.003). A significant association was noted between participants with active journal subscription and their familiarity with the concept of spin ( = 0.016) and their knowledge of the heterogeneity of study results ( = 0.019). We found a significant association between age (< 40 years of age) and knowledge on various types of bias ( = 0.032), heterogenicity ( = 0.01), and fragility ( = 0.021).

Conclusion: This is the first study on the information-seeking behaviour of the orthopaedicians. OTG references remain a part of the orthopaedic practice and are made mostly by accessing online research articles. Imparting knowledge of their quality appraisal should be an active part of the orthopaedic curriculum. This will, in turn, improve the attitude and reference practices leading to better decision-making towards patient care.
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http://dx.doi.org/10.1007/s43465-021-00350-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192656PMC
August 2021

Secondary Erosive Arthritis in a Young Lady - A Rare Manifestation of Primary Antiphospholipid Antibody Syndrome.

J Orthop Case Rep 2021 Feb;11(2):15-18

Department of Orthopaedics, Apollo Speciality Hospitals, Chennai, Tamil Nadu, India.

Introduction: Arthritis in primary antiphospholipid antibody syndrome (PAPS) is a rare manifestation that is much more common in secondary antiphospholipid antibody syndrome (APS), particularly those associated with systemic lupus erythematosis (SLE), and has been reported to be non-erosive responding to conservative management. In this background, we describe a case of secondary erosive arthritis of knee (SEAK) in a female patient with PAPS.

Case Report: Thirty-seven-year-old working women presented with chronic right knee pain for the past 2 years which was increasing in severity and interfering with her activities of daily living for the past 3 months. The patient was a known case of PAPS with a history of one early and one late abortion. On radiological examination, Grade IV secondary osteoarthritis knee was made out. The patient underwent total knee replacement. At 2 years follow-up, the patient had a good functional outcome. To the best of our knowledge, this is the first report of secondary osteoarthritis in PAPS requiring arthroplasty. Perioperative management is crucial in PAPS to prevent thromboembolic complications. Multimodality approach with strict patient compliance is a key to achieve good functional recovery.

Conclusion: SEAK can be a rare presentation of PAPS. Secondary causes like SLE or rheumatoid arthritis must be ruled out before a diagnosis of PAPS is made. Perioperative management in APS is critical and challenging. Multidisciplinary team approach involving internal medicine, anesthesiology, orthopedics, and rehabilitative departments is essential.
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http://dx.doi.org/10.13107/jocr.2021.v11.i02.2006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8180329PMC
February 2021

Adult Primary Tuberculosis of Lateral End of Clavicle - A Case of Missed Diagnosis.

J Orthop Case Rep 2021 ;11(1):87-90

Orthopaedic Research Group, Coimbatore, Tamil Nadu, India.

Introduction: Of the largest series on osteoarticular tuberculosis (TB) by Tuli et al. involving 1074 cases, only seven involved clavicle. It is also noted that the lateral end of the clavicle has been less frequently involved by tubercular disease than the medial end. We present a case of primary tubercular involvement of the lateral end of the clavicle and discuss its management by an innovative modification of the Weaver-Dunn procedure.

Case Report: Twenty-five-year-old working women came with complaints of swelling in her left shoulder for the past 2 months. On examination, swelling with restricted shoulder movements was noted. Radiological evaluation revealed an osteolytic lesion with a pathological fracture in the lateral end of the clavicle. With a provisional diagnosis of giant cell tumor, we proceeded with fine-needle aspiration cytology which was inconclusive. Blood parameters were within normal limits. We proceeded with the excision biopsy of the lateral end of the clavicle and stabilization with a modified Weaver-Dunn procedure involving the reconstruction of the coracoclavicular ligament and augmentation with an Endobutton loop. Biopsy reported the lesion to be of tuberculous etiology. The patient made a good recovery without any complications.

Conclusion: Primary TB of the clavicle is a rarity that mimics other diseases like a tumor; hence, clinicians should be aware of a wide range of presentations to diagnose such an entity. Although antitubercular treatment remains the mainstay of treatment, surgical resection is justified in cases of uncertain diagnosis or disease not responding to conservative lines of management and in cases that need the removal of the sequestrum.
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http://dx.doi.org/10.13107/jocr.2021.v11.i01.1976DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046478PMC
January 2021

Comparative analysis of leucocyte poor vs leucocyte rich platelet-rich plasma in the management of lateral epicondylitis: Systematic review & meta-analysis of randomised controlled trials.

J Clin Orthop Trauma 2021 Aug 21;19:96-107. Epub 2021 May 21.

Department of Orthopaedics, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India.

Study Design: Systematic Review & Meta-analysis.

Objectives: We aim to comparatively analyse the efficacy and safety of using leucocyte-poor platelet rich plasma (LP-PRP) against leucocyte-rich platelet rich plasma (LR-PRP) in the management of lateral epicondylitis.

Materials And Methods: We conducted independent and duplicate electronic database searches including PubMed, Embase, Web of Science and Cochrane Library till September 2020 for randomised controlled trials analyzing the efficacy and safety of LP-PRP and LR-PRP in the management of lateral epicondylitis. Visual Analog Score(VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) Score, Patient Reported Tennis-Elbow Evaluation (PRETEE) Score, Mayo Elbow Performance Score(MEPS) and adverse events were the outcomes analyzed. Analysis was performed in R-platform using OpenMeta[Analyst] software.

Results: We performed a single arm meta-analysis of 26 studies involving 2034 patients. On analysis it was noted that significant improvement was noted in the VAS for pain (p < 0.001), DASH score (p < 0.001), PRETEE score (p < 0.001) and MEPS (p < 0.027) compared to their pre-operative state. No significant increase in adverse events were noted compared to the control group (p = 0.170). While stratifying the results based on the type of PRP used, no significant difference was noted between the use of LP-PRP or LR-PRP in any of the above-mentioned outcome measures.

Conclusion: PRP is a safe and effective treatment option for lateral epicondylitis with clinical improvements in pain and functional scores and both types of PRP (LR-PRP & LP-PRP) offer similar results.
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http://dx.doi.org/10.1016/j.jcot.2021.05.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8144683PMC
August 2021

"Only 50% of randomized trials have high level of confidence in arthroscopy and sports medicine"-a spin-based assessment.

Knee Surg Sports Traumatol Arthrosc 2021 Sep 22;29(9):2789-2798. Epub 2021 May 22.

Orthopaedic Research Group, Coimbatore, Tamil Nadu, India.

Purpose: Pioneering works on the quality appraisal of RCTs have recognized and addressed most of the issues that affect the RCT quality but some issues such as "Writers' bias" or "Spin" are yet to be sorted out. Spin, particularly in the abstracts, is a potential source of deception to the readers. The purpose of this study is to grade the RCTs of arthroscopy and sports medicine based on a spin in their abstracts, analyze the prevalence of spin, and explore methods to remove spin.

Methods: 250 recent RCTs from the top 5 arthroscopy and sports medicine journals were selected. Baseline data of the articles were collected. Consort Adherence Score (CAS) was calculated. The abstracts of the RCTs were graded using the Level Of Confidence (LOC) grading tool developed by the Orthopaedic Research Group. The association of the spin grade with other characteristics of the articles was analyzed.

Results: The median CAS for the included studies was 9 (IQR 8-10). It was found that only 49.6% (n = 124) articles had high LOC with no or one non-critical spin in the abstract. 20.8% (n = 52) had Moderate LOC with more than one non-critical spin. 19.6% (n = 49) had at least one critical spin and 10% (n = 25) had more than one critical flaw making their results have Low and Critically Low LOC, respectively. Of the ten variables analyzed in multivariate regression analysis, it was found that CAS was the only significant factor that determines the level of confidence in the abstract of RCTs CONCLUSION: Spin is prevalent in abstracts of sports medicine and arthroscopy journals with 50.4% having some form of spin. Grading the LOC of the RCTs based on spin is the necessity of the day for the readers. Only 49.6% of the RCTs had high LOC. Objective structuring of the abstracts would help eliminate spin in the future.

Level Of Evidence: Level 1.
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http://dx.doi.org/10.1007/s00167-021-06614-8DOI Listing
September 2021

Exosomal therapy-a new frontier in regenerative medicine.

Stem Cell Investig 2021 2;8. Epub 2021 Apr 2.

Department of Biotechnology, School of Engineering and Technology, Sharda University, Greater Noida, Uttar Pradesh, India.

The recent advances in translational and nanomedicine have paved the way for developing the targeted drug delivery system at a greater pace among global researchers. On par with these technologies, exosomes act as a potential portal for cell-free drug delivery systems as these are bestowed with the native characteristics of the parent cell of origin. Exosomes, called extracellular vesicles (EcVs), are present in almost all cells, tissues, and body fluids. They help in intercellular signaling and maintains tissue homeostasis in the disease pathobiology. Researchers have characterized 9,769 proteins, 2,838 miRNAs, 3,408 mRNAs, and 1,116 lipids being present in exosomal cargo. The separation of exosomes from cells, tissues, and body fluids follow different patterned kinetics. Exosomes interact with the recipient cells through their surface receptor molecules and ligands and internalize within recipient cells through micropinocytosis and phagocytosis. Advancing technologies in regenerative medicine have facilitated the researchers to isolate exosomes from mesenchymal stem cells (MSCs) as these cells are blessed with supreme regenerative potentiality in targeting a disease. Exosomal cargo is a key player in establishing the diagnosis and executing therapeutic role whilst regulating a disease process. Various studies have exhibited the safety, efficacy, and therapeutic potentiality of exosomes in various cancers, neurodegenerative, cardiovascular, and orthopedic diseases. This article throws light on the composition, therapeutic role, and regulatory potentials of exosomes with the widening of the horizon in the field of regenerative medicine.
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http://dx.doi.org/10.21037/sci-2020-037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8100822PMC
April 2021

Does the Intradiscal Injection of Platelet Rich Plasma Have Any Beneficial Role in the Management of Lumbar Disc Disease?

Global Spine J 2021 Apr 12:2192568221998367. Epub 2021 Apr 12.

Indian Orthopaedic Rheumatology Association, Lucknow, Uttar Pradesh, India.

Study Design: Systematic review and meta-analysis.

Objectives: We performed this meta-analysis to evaluate whether intradiscal Platelet Rich Plasma(PRP) injection has any beneficial role in the management of lumbar disc disease.

Methods: We conducted independent and duplicate electronic database searches including PubMed, Embase, and Cochrane Library till September 2020 for studies investigating the role of intradiscal PRP in the management of lumbar disc disease. The analysis was performed in the R platform using OpenMeta[Analyst] software.

Results: 13 studies including 2 RCTs, 5 prospective, and 6 retrospective studies involving 319 patients were included in the meta-analysis. A single-arm meta-analysis of the included studies showed a beneficial effect of the intervention in terms of pain relief outcomes like VAS score (p < 0.001), pain component of SF-36 (p = 0.003) while such improvement was not seen in functional outcome measures like ODI score (p = 0.071), the physical component of SF-36 (p = 0.130) with significant heterogeneity noted among the included studies. No structural improvement in magnetic resonance imaging was observed (p = 0.106). No additional procedure-related adverse events were noted in the included studies (p = 0.662).

Conclusion: There is a paucity of high-quality studies to give conclusive evidence on the benefits of intradiscal PRP for lumbar disc disease. Although intradiscal PRP injection has shown some beneficial effect in controlling pain for lumbar disc disease, we could not find structural or functional improvement from the included studies. Hence, we recommend large double-blind double-arm randomized controlled studies to analyze the benefits of the intervention being analyzed.
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http://dx.doi.org/10.1177/2192568221998367DOI Listing
April 2021

"Platelet-rich plasma holds promise in management of rheumatoid arthritis"-systematic review.

Rheumatol Int 2021 Apr 8. Epub 2021 Apr 8.

Prasad Institute of Medical Sciences, Lucknow, India.

The treatment of rheumatoid arthritis (RA) has been closely evolving with an understanding of disease pathogenesis with disease modifying anti-rheumatoid drugs (DMARDS) and Biologic DMARDS being the main stay. platelet rich plasma (PRP) has been the center of research in many specialties in the past decade. Its ability to stop and reverse inflammation have attracted researchers to try PRP in RA. A systematic review of studies on PRP in RA is lacking. The study protocol was prospectively registered in PROSPERO. Detailed search of Cochrane, Scopus, Medline, Embase, and Web of science databases were made to identify the relevant articles till Sep 2020 following Cochrane and PRISMA guidelines. Number of subjects, Animal model used, cell lines used for the study, method of induction of arthritis, PRP dose, concentration used, frequency of administration and clinical, histologic, and molecular changes from baseline following PRP use were extracted and analysed. Eight studies were included for the review. Four of these were in-vitro studies. Two were exclusive animal studies. One study analysed the effects of PRP in RA in both animal models (mice) and Hela cell lines. One study was a report of a series of patients of resistant RA treated with PRP. In the in vitro studies while platelets increase the migration and invasion of RA-FLS, they suppressed the inflammation on the whole. Available animal studies and the Human study have shown encouraging results. There has been no evidence of exacerbation of inflammation in these studies. The quantity and quality of literature on the effects of PRP in treating joint pathologies in RA is limited. Preclinical studies show decrease in disease activity with good safety profile. Invitro studies show suppression of inflammation. Thus, the available literature is encouraging towards the use of PRP in RA. Larger trials and molecular studies to understand the exact role of platelets in disease pathogenesis and treatment mechanisms are needed to decide the future course of PRP in RA.
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http://dx.doi.org/10.1007/s00296-021-04849-9DOI Listing
April 2021

Autologous bone marrow derived mesenchymal stem cell therapy for osteonecrosis of femoral head: A systematic overview of overlapping meta-analyses.

J Clin Orthop Trauma 2021 Feb 26;13:134-142. Epub 2020 Nov 26.

Indian Stem Cell Study Group, Lucknow, Uttar Pradesh, India.

Study Design: Systematic Review.

Objectives: We performed this systematic overview on the overlapping meta-analyses that analyzed autologous bone marrow-derived mesenchymal stem cell(BM-MSC) therapy along with core decompression(CD) for the management of osteonecrosis of the femoral head(ONFH) and identify which study provides the current best evidence on the topic and generate recommendations for the same.

Materials And Methods: We conducted independent and duplicate electronic database searches in PubMed, Web of Science, Embase, Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects till September 2020 for meta-analyses that analyzed the efficacy of BM-MSC therapy along with CD for ONFH. Methodological quality assessment was made using Oxford Levels of Evidence, AMSTAR scoring, and AMSTAR 2 grades. We then utilized the Jadad decision algorithm to identify the study with the highest quality to represent the current best evidence to generate the recommendation.

Results: 6 meta-analyses fulfilling the eligibility criteria were included. The AMSTAR scores of the included studies varied from 4 to 9 (mean:7) and all the included studies had critically low reliability in their summary of results due to their methodological flaws according to AMSTAR 2 grades. The current best evidence showed that utilization of BM-MSC therapy along with CD for ONFH resulted in significant improvement in Harris hip scores at 12 and 24 months along with a significant reduction in the necrotic area of the femoral head and the rate of conversion to total hip arthroplasty(THA) without a significant rise in adverse events due to the procedure.

Conclusion: Based on this systematic overview, we give a Level II recommendation that BM-MSC therapy is more efficacious along with CD in the management of ONFH compared to CD alone. BM-MSC therapy provides better pain relief with significant functional improvement and delaying the collapse of the femoral head thereby preventing further treatment such as THA.
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http://dx.doi.org/10.1016/j.jcot.2020.11.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920111PMC
February 2021

Placenta-derived mesenchymal stem cells (P-MSCs) for COVID-19 pneumonia-a regenerative dogma.

Stem Cell Investig 2021 3;8. Epub 2021 Feb 3.

Indian Stem Cell Study Group ISCSG, Lucknow, Uttar Pradesh, India.

With a robust rise in the number of COVID-19 cases, the World Health Organization (WHO) has declared COVID-19 as a pandemic on 11 March 2020. COVID-19 pandemic has invited global researchers from various biomedical and biotechnological researchers to plan various treatment modalities for combating this pandemic crisis. At present, there is the unavailability of specific treatment modality; however, researchers have thrown light into the exploration of mesenchymal stem cells (MSCs) to therapeutically perquisite in ameliorating immune-mediated progressive worsening in COVID-19 infected patients. Cellular therapy (CT) has revolutionized the treatment of untreatable diseases with a better clinical and functional outcome. Placenta, being considered as medical waste, contains a variety of stem cells, and hence placenta-derived MSCs (P-MSCs) owe potentiality for extrapolation to combat COVID-19 pandemic. The usage of P-MSCs in combating the COVID-19 pandemic has plausible challenges in terms of isolation, harvesting, expansion, characterization, and involvement of ethical concerns. This article provides an insight into dealing COVID-19 pandemic with P-MSCs as cell-based therapy embracing immunomodulatory and immune-privileged potentials and future prospects. Advocating prospective randomized controlled clinical trials ethically will concretely supplement for its efficacy and safety concerns.
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http://dx.doi.org/10.21037/sci-2020-034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7937692PMC
February 2021

Hemi-Fibular Grafting for Metacarpal Giant Cell Tumor - Surgical Technique.

J Orthop Case Rep 2020 Oct;10(7):80-84

Department of Orthopaedics, Institute of Orthopaedics and Traumatology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India.

Introduction: Giant cell tumor (GCT) of small bones of hand is no so uncommon, especially in the metacarpals. Considering the aggressive behavior in the metacarpals, en bloc resection is often required. Following resection, reconstruction techniques available include tricortical iliac grafting, vascularized or non-vascularized fibular grafting, or metatarsal grafting. We present an innovative surgical technique for the management of such bone defects.

Case Report: A 14-year-old girl presented with pain and swelling over the dorsum of the right hand for 2 months which was progressively increasing in size. The range of movements of the metacarpophalangeal (MCP) joint was normal. Radiological evaluation showed a lytic lesion with a well-defined margin over the metaphyseal region of the second metacarpal without articular involvement. The lesion was diagnosed as GCT on biopsy. Reconstruction of bone loss was managed by hemi-fibular grafting technique which involves selective osteotomy of the anterior half of the middle third of the fibula for the reconstruction of bone loss. This new technique ensures a renewable source of autograft with good incorporation at the recipient site with good hand function despite maintaining the esthetic appearance of the hand. Lesion being very aggressive had two episodes of recurrence at 2-3 years of post-operative period which was excised.

Conclusion: This case illustrates the management of aggressive GCT of metacarpal bone by excision and reconstruction with hemi-fibular grafting technique. Hence, hemi-fibular grafting can be considered as an innovative technical substitute to the traditional methods of autograft harvesting with good regenerative potential at the donor site and better incorporation rates at the recipient site providing good functional results.
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http://dx.doi.org/10.13107/jocr.2020.v10.i07.1928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857663PMC
October 2020

Is Platelet-Rich Plasma Effective in Enhancing Spinal Fusion? Systematic Overview of Overlapping Meta-Analyses.

Global Spine J 2021 Jan 21:2192568220988278. Epub 2021 Jan 21.

Indian Stem Cell Study Group, Lucknow, India.

Study Design: Systematic review.

Objectives: We performed this systematic overview on overlapping meta-analyses that analyzed the role of platelet-rich plasma(PRP) in enhancing spinal fusion and identify which study provides the current best evidence on the topic and generate recommendations for the same.

Materials And Methods: We conducted independent and duplicate electronic database searches in PubMed, Web of Science, Embase, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects till October-2020 for meta-analyses that analyzed the role of PRP in spinal fusion procedures. Methodological quality assessment was made using Oxford Levels of Evidence, AMSTAR scoring, and AMSTAR 2 grades. We then utilized the Jadad decision algorithm to identify the study with highest quality to represent the current best evidence to generate recommendations.

Results: 3 meta-analyses fulfilling the eligibility criteria were included. The AMSTAR scores of included studies varied from 5-8(mean:6.3) and all included studies had critically low reliability in their summary of results due to their methodological flaws according to AMSTAR 2 grades. The current best evidence showed that utilization of PRP was not associated with significant improvement in patient-reported outcomes such as Visual Analog Score for pain compared to the standard fusion procedure. Moreover, PRP was found to be associated with lower fusion rates.

Conclusion: Based on this systematic overview, the effectiveness of PRP as a biological agent in augmenting spinal fusion is limited. Current evidence does not support the use of PRP as an adjuvant to enhance spinal fusion.
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http://dx.doi.org/10.1177/2192568220988278DOI Listing
January 2021

Evidence of Coronavirus (CoV) Pathogenesis and Emerging Pathogen SARS-CoV-2 in the Nervous System: A Review on Neurological Impairments and Manifestations.

J Mol Neurosci 2021 Jan 19. Epub 2021 Jan 19.

Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute (HMRI), University of Newcastle, New Lambton Heights, Newcastle, NSW, 2305, Australia.

The coronavirus disease 2019 (COVID-19) pandemic is an issue of global significance that has taken the lives of many across the world. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus responsible for its pathogenesis. The pulmonary manifestations of COVID-19 have been well described in the literature. Initially, it was thought to be limited to the respiratory system; however, we now recognize that COVID-19 also affects several other organs, including the nervous system. Two similar human coronaviruses (CoV) that cause severe acute respiratory syndrome (SARS-CoV-1) and Middle East respiratory syndrome (MERS-CoV) are also known to cause disease in the nervous system. The neurological manifestations of SARS-CoV-2 infection are growing rapidly, as evidenced by several reports. There are several mechanisms responsible for such manifestations in the nervous system. For instance, post-infectious immune-mediated processes, direct virus infection of the central nervous system (CNS), and virus-induced hyperinflammatory and hypercoagulable states are commonly involved. Guillain-Barré syndrome (GBS) and its variants, dysfunction of taste and smell, and muscle injury are numerous examples of COVID-19 PNS (peripheral nervous system) disease. Likewise, hemorrhagic and ischemic stroke, encephalitis, meningitis, encephalopathy acute disseminated encephalomyelitis, endothelialitis, and venous sinus thrombosis are some instances of COVID-19 CNS disease. Due to multifactorial and complicated pathogenic mechanisms, COVID-19 poses a large-scale threat to the whole nervous system. A complete understanding of SARS-CoV-2 neurological impairments is still lacking, but our knowledge base is rapidly expanding. Therefore, we anticipate that this comprehensive review will provide valuable insights and facilitate the work of neuroscientists in unfolding different neurological dimensions of COVID-19 and other CoV associated abnormalities.
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http://dx.doi.org/10.1007/s12031-020-01767-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7814864PMC
January 2021

Sudden painless loss of vision following spine surgery: lessons learnt in darkness.

BMJ Case Rep 2021 Jan 18;14(1). Epub 2021 Jan 18.

Institute of Orthopaedics & Traumatology, Madras Medical College, Chennai, Tamil Nadu, India.

A 26-year-old male driver presented with a history of pain in the neck for the past 1 week following trauma due to a road traffic accident. The patient had no neurological deficit. He had type 1 diabetes and was on regular oral hypoglycemics. After radiological investigations, the patient was diagnosed to have traumatic AO Spine Classification type C translational injury involving anterolisthesis of C6 over C7. After a detailed preoperative assessment, the patient was taken up for surgery. The patient underwent posterior stabilisation with instrumentation from C5 to T2. On extubation from anaesthesia, he immediately complained of complete painless loss of this vision in his left eye. Ophthalmological investigations attributed the cause to be due to central retinal artery occlusion. The patient was discharged with reassurance on the 20th postoperative day with minimal improvement in his vision and at 6-month follow-up, his vision improved to 1/60 and was advised for close follow-up.
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http://dx.doi.org/10.1136/bcr-2020-235888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7813331PMC
January 2021

Regarding "Analyzing Spin in Abstracts of Orthopaedic Randomized Controlled Trials With Statistically Insignificant Primary Endpoints".

Arthroscopy 2021 Jan;37(1):13-14

Government Hospital, Velayuthampalayam, Karur, Tamil Nadu, India; Orthopaedic Research Group, Coimbatore, Tamil Nadu, India.

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http://dx.doi.org/10.1016/j.arthro.2020.11.006DOI Listing
January 2021

'Bone within bone appearance' in a pathological fracture.

BMJ Case Rep 2020 Dec 21;13(12). Epub 2020 Dec 21.

Orthopaedic Research Group, Coimbatore, Tamil Nadu, India.

A 60-year-old man presented to our hospital with complaints of pain and deformity on his right thigh for the past 2 days following a history of accidental slip and fall. Radiological investigations suggested a pathological type 2 Seinsheimer subtrochanteric fracture of the right femur with a 'bone within bone' appearance, which posed a diagnostic dilemma as this radiological appearance is seen in a spectrum of conditions. Radiographic skeletal survey failed to identify a similar appearance elsewhere in the body. Laboratory investigations pointed in favour of bone mineral disease, and histopathological examination of the bone narrowed it down to Paget's disease. The fracture was fixed with a contralateral distal femur locking compression plate. The fracture site failed to show signs of union until 6 months postsurgery and hence the patient was advised for grafting procedure. The patient deferred surgery and remains without major complications until 18 months of follow-up.
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http://dx.doi.org/10.1136/bcr-2020-238567DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754666PMC
December 2020

TO THE EDITOR.

Authors:
Sathish Muthu

Spine (Phila Pa 1976) 2020 12;45(24):E1707-E1708

Government Hospital, Velayuthampalayam, Karur, Tamil Nadu, India.

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http://dx.doi.org/10.1097/BRS.0000000000003730DOI Listing
December 2020

Current evidence on mesenchymal stem cell therapy for traumatic spinal cord injury: systematic review and meta-analysis.

Cytotherapy 2021 03 9;23(3):186-197. Epub 2020 Nov 9.

Department of Orthopaedics, School of Medical Sciences and Research, Sharda University, Greater Noida, India.

Background Aims: The authors aim to analyze the evidence in the literature regarding the efficacy and safety of mesenchymal stem cell (MSC) therapy in human subjects with traumatic spinal cord injury (SCI) and identify its potential role in the management of SCI.

Methods: The authors conducted independent and duplicate searches of electronic databases, including PubMed, Embase and the Cochrane Library, until May 2020 for studies analyzing the efficacy and safety of stem cell therapy for SCI. American Spine Injury Association (ASIA) impairment scale (AIS) grade improvement, ASIA sensorimotor score, activities of daily living score, residual urine volume, bladder function improvement, somatosensory evoked potential (SSEP) improvement and adverse reactions were the outcomes analyzed. Analysis was performed in R platform using OpenMeta[Analyst] software.

Results: Nineteen studies involving 670 patients were included for analysis. On analysis, the intervention group showed statistically significant improvement in AIS grade (P < 0.001), ASIA sensory score (P < 0.017), light touch (P < 0.001), pinprick (P = 0.046), bladder function (P = 0.012), residual urine volume (P = 0.023) and SSEP (P = 0.002). However, no significant difference was noted in motor score (P = 0.193) or activities of daily living score (P = 0.161). Although the intervention group had a significant increase in complications (P < 0.001), no serious or permanent adverse events were reported. On subgroup analysis, low concentration of MSCs (<5 × 10 cells) and initial AIS grade A presentation showed significantly better outcomes than their counterparts.

Conclusions: The authors' analysis establishes the efficacy and safety of MSC transplantation in terms of improvement in AIS grade, ASIA sensory score, bladder function and electrophysiological parameters like SSEP compared with controls, without major adverse events. However, further research is needed to standardize dose, timing, route and source of MSCs used for transplantation.
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http://dx.doi.org/10.1016/j.jcyt.2020.09.007DOI Listing
March 2021

Surgical strategies in management of ankylosed bilateral hips and knees in crouched posture.

BMJ Case Rep 2020 Oct 30;13(10). Epub 2020 Oct 30.

Orthopaedic Research Group, Coimbatore, Tamil Nadu, India.

A 26-year-old wheelchair-bound man was brought to our institute with progressive painful deformity of both lower limbs involving bilateral hip and knee for the past 5 years. The patient was wheelchair-bound for the past 18 months. He was only able to crawl to meet his locomotor demands. On examination, the patient was in a crouched posture with mild kyphosis at the thoracolumbar region and ankylosis of bilateral hip and knee in an unfavourable position. Radiological and serological evaluation diagnosed him to be a case of neglected ankylosing spondylosis. We planned for arthroplasty of the bilateral hip and knee for correcting his posture and to regain his locomotor ability. The severity of the deformity mandated extensive releases and the handling of neurovascular structures. Hence, a holistic treatment plan with various surgical strategies was devised to manage his deformities. The patient made a good recovery and regained his locomotor ability without any major complications at a 2-year follow-up.
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http://dx.doi.org/10.1136/bcr-2020-236043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604799PMC
October 2020

Recurrence-free management of type 2 variant of giant cell tumour of extensor tendon sheath of thumb.

BMJ Case Rep 2020 Oct 29;13(10). Epub 2020 Oct 29.

Institute of Orthoapaedics & Traumatology, Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India.

A 30-year-old woman presented with swelling in her right thumb of 3-month duration which was slow-growing in nature without a history of trauma. On examination, firm non-tender swelling with ill-defined border over the dorsomedial aspect of the first metacarpal was noted. The swelling was mobile only in the vertical plane with restricted adduction and abduction. Plain X-ray revealed mild erosion of the first metacarpal head. Diagnostic ultrasound confirmed the lesion to arise from the extensor tendon sheath of diffuse type without any bony involvement. A wide local excision biopsy of the swelling was planned. Intraoperatively, a 3×2 cm greyish-white mass, bony hard in consistency with lobulated surface was found arising from the tendon sheath of the extensor tendon of the thumb; it was completely excised with a wide margin. Histopathological examination revealed polyhedral cells admixed with osteoclastic type giant cells. Biopsy from the first metatarsal was normal. The patient is on follow-up for the last 5 years with no evidence of recurrence.
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http://dx.doi.org/10.1136/bcr-2020-235762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7597518PMC
October 2020

Trending Literature in Spinal Tuberculosis: Bibliographic Analysis of Top 250 Cited Articles.

Int J Spine Surg 2020 Oct 23;14(5):838-846. Epub 2020 Oct 23.

Institute of Orthopaedics and Traumatology, Madras Medical College & Rajiv Gandhi Government General Hospital, Chennai, India.

Background: This bibliographic analysis aims to identify the top 250 cited articles on spinal tuberculosis (TB) and report on their impact on the spinal field.

Methods: All databases included in the Thomson Reuters Web of Science were searched for publications on spinal TB. The most cited articles published between 1950 and 2019, with the main focus on orthopaedic surgery, were identified using a multistep approach, and a total of 250 articles were included and analyzed for title, year of publication, total citations, citations in 2019, citation density, article age, journal, first author, senior author, geographic origin, and level of evidence.

Results: The number of citations ranged from 31 to 257, with an average of 65.38. Studies were published from 31 different countries and published in 83 different journals. The top 3 countries, India, United States, and China published a total of 57.8% (n = 145) of all articles. Indian and Chinese researchers seem to be the most resourceful, as 17 of the 31 (54.8%) prospective studies were conducted by them. African centers produced only 3.2% (n = 8) of all included articles. Only 3.2% (n = 8) were of Level 1 evidence on the subject. A total of 37.8% (n = 95) were on diagnosis, while 46.6% (n = 117) dealt with surgery, and only 15.1% (n = 38) were about conservative management. Anil K Jain followed by S Rajasekaran were the most published authors on the subject.

Conclusions: Indian and Chinese researchers dominate evidence in spinal TB. Regions with high disease burden, such as Africa, do not contribute their data to the literature. Though these are the top cited articles in the subject, their level of evidence needs improvement for better impact of their results.
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http://dx.doi.org/10.14444/7119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671453PMC
October 2020

Mesenchymal Stem Cell-Derived Exosomes: A Potential Therapeutic Avenue in Knee Osteoarthritis.

Cartilage 2020 Oct 5:1947603520962567. Epub 2020 Oct 5.

School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India.

Knee osteoarthritis is the leading cause of functional disability in adults. The goals of knee osteoarthritis management are directed toward symptomatic pain relief along with the attainment of the functional quality of life. The treatment strategy ranges from conservative to surgical management with reparative and restorative techniques. The emergence of cell-based therapies has paved the way for the usage of mesenchymal stem cells (MSCs) in cartilage disorders. Currently, global researchers are keen on their research on nanomedicine and targeted drug delivery. MSC-derived exosomes act as a directed therapy to halt the disease progression and to provide a pain-free range of movements with increased quality of cartilage on regeneration. International Society for Extracellular Vesicles and the European Network on Microvesicles and Exosomes in Health and Disease have formed guidelines to foster the use of the growing therapeutic potential of exosomal therapy in osteoarthritis. Although regenerative therapies with MSC are being seen to hold a future in the management of osteoarthritis, extracellular vesicle-based technology holds the key to unlock the potential toward knee preservation and regeneration. The intricate composition and uncertain functioning of exosomes are inquisitive facets warranting further exploration.
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http://dx.doi.org/10.1177/1947603520962567DOI Listing
October 2020

Is Endoscopic Discectomy the Next Gold Standard in the Management of Lumbar Disc Disease? Systematic Review and Superiority Analysis.

Global Spine J 2021 Sep 16;11(7):1104-1120. Epub 2020 Sep 16.

Orthopaedic Research Group, Coimbatore, Tamil Nadu, India.

Study Design: Systematic review and meta-analysis.

Objectives: We performed this meta-analysis to evaluate whether endoscopic discectomy (ED) shows superiority compared with the current gold standard of microdiscectomy (MD) in management of lumbar disc disease.

Materials And Methods: We conducted independent and duplicate electronic database search including PubMed, Embase, and Cochrane Library from 1990 till April 2020 for studies comparing ED and MD in the management of lumbar disc disease. Analysis was performed in R platform using OpenMeta[Analyst] software.

Results: We included 27 studies, including 11 randomized controlled trials (RCTs), 7 nonrandomized prospective, and 9 retrospective studies involving 4018 patients in the meta-analysis. We stratified the results based on the study design. Considering the heterogeneity in some results between study designs, we weighed our conclusion essentially based on results of RCTs. On analyzing the RCTs, superiority was established at 95% confidence interval for ED compared with MD in terms of functional outcomes like Oswestry Disability Index (ODI) score ( = .008), duration of surgery ( = .023), and length of hospital stay ( < .001) although significant heterogeneity was noted. Similarly, noninferiority to MD was established by ED in other outcomes like visual analogue scale score for back pain ( = .860) and leg pain ( = .495), MacNab classification ( = .097), recurrences ( = .993), reoperations ( = .740), and return-to-work period ( = .748).

Conclusion: Our meta-analysis established the superiority of endoscopic discectomy in outcome measures like ODI score, duration of surgery, overall complications, length of hospital stay and noninferiority in other measures analyzed. With recent advances in the field of ED, the procedure has the potential to take over the place of MD as the gold standard of care in management of lumbar disc disease.
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http://dx.doi.org/10.1177/2192568220948814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8351066PMC
September 2021

Systematic Reviews and Meta-Analysis in Spine Surgery-How Good Are They in Methodological Quality? A Systematic Review.

Global Spine J 2021 Apr 26;11(3):378-399. Epub 2020 Feb 26.

Institute of Orthopaedics and Traumatology, Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India.

Study Design: Systematic review.

Objectives: To assess the methodological quality of systematic reviews and meta-analyses in spine surgery over the past 2 decades.

Materials And Methods: We conducted independent and in duplicate systematic review of the published systematic reviews and meta-analyses between 2000 and 2019 from PubMed Central and Cochrane Database pertaining to spine surgery involving surgical intervention. We searched bibliographies to identify additional relevant studies. Methodological quality was evaluated with AMSTAR score and graded with AMSTAR 2 criteria.

Results: A total of 96 reviews met the eligibility criteria, with mean AMSTAR score of 7.51 (SD = 1.98). Based on AMSTAR 2 criteria, 13.5% (n = 13) and 18.7% (n = 18) of the studies had high and moderate level of confidence of results, respectively, without any critical flaws. A total of 29.1% (n = 28) of the studies had at least 1 critical flaw and 38.5% (n = 37) of the studies had more than 1 critical flaw, so that their results have low and critically low confidence, respectively. Failure to analyze the conflict of interest of authors of primary studies included in review and lack of list of excluded studies with justification were the most common critical flaw. Regression analysis demonstrated that studies with funding and studies published in recent years were significantly associated with higher methodological quality.

Conclusion: Despite improvement in methodological quality of systematic reviews and meta-analyses in spine surgery in current decade, a substantial proportion continue to show critical flaws. With increasing number of review articles in spine surgery, stringent measures must be taken to adhere to methodological quality by following PRISMA and AMSTAR guidelines to attain higher standards of evidence in published literature.
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http://dx.doi.org/10.1177/2192568220906810DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013933PMC
April 2021
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