Given the continuing evolution of the anatomical understanding of the ligament, the current treatment protocol for deltoid injuries requires further standardization, with an emphasis on proper diagnosis.

Background: Blood flow restriction (BFR) is a novel technique involving the use of a cuff/tourniquet system positioned around the proximal end of an extremity to maintain arterial flow while restricting venous return. Purpose: To analyze the available literature regarding the use of BFR to supplement traditional resistance training in healthy athletes. Study Design: Systematic review. Methods: A systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. From November to December 2018, studies that examined the effects of BFR training in athletes were identified using PubMed and OVID Medline. Reference lists from selected articles were analyzed for additional studies. The inclusion criteria for full article review were randomized studies with control groups that implemented BFR training into athletes’ resistance training workouts. Case reports and review studies were excluded. The following data were extracted: patient demographics, study design, training protocol, occlusive cuff location/pressure, maximum strength improvements, muscle size measurements, markers of sports performance (eg, sprint time, agility tests, and jump measurements), and other study-specific markers (eg, electromyography, muscular torque, and muscular endurance). Results: The initial search identified 237 articles. After removal of duplicates and screening of titles, abstracts, and full articles, 10 studies were identified that met the inclusion criteria. Seven of 9 (78%) studies found a significant increase in strength associated with use of BFR training as compared with control; 4 of 8 (50%) noted significant increases in muscle size associated with BFR training; and 3 of 4 (75%) reported significant improvements in sport-specific measurements in the groups that used BFR training. Occlusive cuff pressure varied across studies, from 110 to 240 mm HG. Conclusion: The literature appears to support that BFR can lead to improvements in strength, muscle size, and markers of sports performance in healthy athletes. Combining traditional resistance training with BFR may allow athletes to maximize athletic performance and remain in good health. Additional studies should be conducted to find an optimal occlusive pressure to maximize training improvements. Registration: CRD42019118025 (PROSPERO).

Osteochondral lesions (OCLs) occur in up to 70% of sprains and fractures involving the ankle. Atraumatic aetiologies have also been described. Techniques such as microfracture, and replacement strategies such as autologous osteochondral transplantation, or autologous chondrocyte implantation are the major forms of surgical treatment. Current literature suggests that microfracture is indicated for lesions up to 15 mm in diameter, with replacement strategies indicated for larger or cystic lesions. Short- and medium-term results have been reported, where concerns over potential deterioration of fibrocartilage leads to a need for long-term evaluation. Biological augmentation may also be used in the treatment of OCLs, as they potentially enhance the biological environment for a natural healing response. Further research is required to establish the critical size of defect, beyond which replacement strategies should be used, as well as the most appropriate use of biological augmentation. This paper reviews the current evidence for surgical management and use of biological adjuncts for treatment of osteochondral lesions of the talus.

Osteochondral lesions of the talus are common injuries in the athletic patient. They present a challenging clinical problem as cartilage has a poor potential for healing. Current surgical treatments consist of reparative (microfracture) or replacement (autologous osteochondral graft) strategies and demonstrate good clinical outcomes at the short and medium term follow-up. Radiological findings and second-look arthroscopy however, indicate possible poor cartilage repair with evidence of fibrous infill and fissuring of the regenerative tissue following microfracture. Longer-term follow-up echoes these findings as it demonstrates a decline in clinical outcome. The nature of the cartilage repair that occurs for an osteochondral graft to become integrated with the native surround tissue is also of concern. Studies have shown evidence of poor cartilage integration, with chondrocyte death at the periphery of the graft, possibly causing cyst formation due to synovial fluid ingress. Biological adjuncts, in the form of platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC), have been investigated with regard to their potential in improving cartilage repair in both in vitro and in vitro settings. The in vitro literature indicates that these biological adjuncts may increase chondrocyte proliferation as well as synthetic capability, while limiting the catabolic effects of an inflammatory joint environment. These findings have been extrapolated to in vitro animal models, with results showing that both PRP and BMAC improve cartilage repair. The basic science literature therefore establishes the proof of concept that biological adjuncts may improve cartilage repair when used in conjunction with reparative and replacement treatment strategies for osteochondral lesions of the talus.

Level IV, retrospective case series.

Platelet-rich plasma (PRP) has been suggested as an adjunct to aid in long-bone healing. The purpose of this study was to systematically review the basic science in vivo evidence for the use of PRP in the treatment of bone pathology. The PubMed/MEDLINE and EMBASE databases were screened using the following search criteria: "(Platelet-rich plasma OR PRP OR autologous conditioned plasma OR ACP) AND (bone OR osteocytes OR osteogenesis OR nonunion OR delayed union)." Studies were included if they fulfilled the following criteria: (1) studied the effect of PRP or a similar concentrated platelet product, defined as a blood product with platelet concentration elevated to higher than baseline; (2) established a control with which to compare PRP; (3) were published in a peer-reviewed journal; and (4) looked specifically at animal long-bone models. All review articles and clinical studies, including randomized controlled trials and case series, were excluded from the review. Studies examining the effects of PRP on bones of animals with confounding pathology were excluded. In studies that contained additional treatment variables, only the portion of the experiment that compared PRP directly with the control were evaluated. Data were then extracted with a standardized table. The search yielded 29 articles for inclusion. Seventy-two percent of the studies reported platelet concentrations. Eighty-nine percent of studies reported significant improvement in earlier bone healing on histologic/histomorphometric assessment. One hundred percent showed significant increase in bone formation on radiographs in the PRP group. Eighty percent of studies reported a significant increase in bone area on microcomputed tomography. One hundred percent of studies showed a higher torsional stiffness for the PRP-treated defects. In the in vivo studies evaluated, PRP confers several beneficial effects on animal long-bone models. Proof of concept for PRP as a biologic adjunct in long-bone models has been determined.

Therapeutic, Level V, Expert Opinion.

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