Alan Getgood

A cadaveric study of the anterolateral ligament: re-introducing the lateral capsular ligament.

PurposeThe purpose of this study was to verify and characterize the anatomical properties of the anterolateral capsule, with the aim of establishing a more accurate anatomical description of the anterolateral ligament (ALL). Furthermore, microscopic analysis of the tissue was performed to determine whether the ALL can morphologically be classified as ligamentous tissue, as well as reveal any potential functional characteristics.MethodsThree different modalities were used to validate the existence of the ALL: magnetic resonance imagining (MRI), anatomical dissection, and histological analysis. Ten fresh-frozen cadaveric knee specimens underwent MRI, followed by anatomical dissection which allowed comparison of MRI to gross anatomy. Nine additional fresh-frozen cadaveric knees (19 total) were dissected for a further anatomical description. Four specimens underwent H&E staining to look at morphological characteristics, and one specimen was analysed using immunohistochemistry to locate peripheral nervous innervation.ResultsThe ALL was found in all ten knees undergoing MRI and all nineteen knees undergoing anatomical dissection, with MRI being able to predict its corresponding anatomical dissection. The ALL was found to have bone-to-bone attachment points from the lateral femoral epicondyle to the lateral tibia, in addition to a prominent meniscal attachment. Histological sectioning showed ALL morphology to be characteristic of ligamentous tissue, having dense, regularly organized collagenous bundles. Immunohistochemistry revealed a large network of peripheral nervous innervation, indicating a potential proprioceptive role.ConclusionFrom this study, the ALL is an independent structure in the anterolateral compartment of the knee and may serve a proprioceptive role in knee mechanics.

Articular cartilage tissue engineering TODAY’S RESEARCH, TOMORROW’S PRACTICE?

Articular cartilage repair remains a challenge to surgeons and basic scientists. The field of tissue engineering allows the simultaneous use of material scaffolds, cells and signalling molecules to attempt to modulate the regenerative tissue. This review summarises the research that has been undertaken to date using this approach, with a particular emphasis on those techniques that have been introduced into clinical practice, via in vitro and preclinical studies.

Lateral Extra-articular Tenodesis Reduces Rotational Laxity When Combined With Anterior Cruciate Ligament Reconstruction: A Systematic Review of the Literature.

PURPOSE To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction would provide greater control of rotational laxity and improved clinical outcomes compared with ACL reconstruction alone. METHODS Two independent reviewers searched 9 databases for randomized and nonrandomized clinical studies comparing ACL reconstruction plus LET versus ACL reconstruction alone in a human adult population. All years and 5 languages were included. Animal and cadaveric studies, revision or repair surgical techniques, and studies focused on biomechanical outcomes were excluded. Quality assessment of the included studies was performed with the Cochrane Collaboration tool. Outcomes of interest included the pivot-shift test, KT-1000/-2000 measurements (MEDmetric, San Diego, CA), and International Knee Documentation Committee scores. RESULTS The literature search yielded 3,612 articles. After titles and abstracts were reviewed, 106 articles were selected for full-text review, of which 29 studies met the inclusion criteria (8 randomized and 21 nonrandomized studies). Of the 8 randomized studies, 3 concluded that the results were nonsignificant between treatment groups, 4 were in favor of the extra-articular tenodesis, and 1 was in favor of the ACL reconstruction alone. The Cochrane Collaboration tool showed an unclear to high risk of bias for most articles. A meta-analysis showed a statistically significant difference for the pivot-shift test (P = .002, I2 = 34%) in favor of ACL reconstruction with LET. No difference was found between the groups for International Knee Documentation Committee scores (P = .75, I2 = 19%) and KT-1000/-2000 measurements (P = .84, I2 = 34%). CONCLUSIONS Meta-analysis showed a statistically significant reduction in pivot shift in favor of the combined procedure. Studies lacked sufficient internal validity, sample size, methodologic consistency, and standardization of protocols and outcomes. LEVEL OF EVIDENCE Level III, systematic review of Level I, II, and III studies.

The Structure and Function of the Anterolateral Ligament of the Knee: A Systematic Review

PURPOSE The purpose of this systematic review was to evaluate the anatomic structure and function of the anterolateral ligament (ALL) of the knee. METHODS The Medline, Embase, and Cochrane databases were screened for all studies related to the ALL of the knee. Two reviewers independently reviewed all eligible articles and the references of these articles. Inclusion and exclusion criteria were applied to all searched studies. Quality assessment was completed for the included studies. RESULTS Nineteen studies were identified for final analysis. Pooled analysis identified the ALL in 430 of 449 knees (96%) examined. The ligament was found to originate from the region of the lateral femoral epicondyle and insert on the proximal tibia midway between the Gerdy tubercle and the fibular head. The ALL was found to be 34.1 to 41.5 mm in length, 5.1 to 8.3 mm in width above the lateral meniscus, and 8.9 to 11.2 mm in width below the lateral meniscus. By use of magnetic resonance imaging, the ALL was identified in 93% of knees examined (clinical, 64 of 70; cadaveric, 16 of 16). In one case study the ligament was clearly visualized by ultrasound examination. Histologic analysis across 3 studies showed characteristics consistent with ligamentous tissue. Though not shown in biomechanical studies, it is hypothesized that the ALL provides anterolateral stability to the knee, preventing anterolateral subluxation of the proximal tibia on the femur. One study identified a network of peripheral nerves, suggesting a proprioceptive function of the ALL. CONCLUSIONS This systematic review shows the ALL to be a distinct structure with a consistent origin and insertion sites. The ALL is an extra-articular structure with a clear course from the lateral femoral epicondyle region, running anteroinferiorly, to the proximal tibia at a site midway between the Gerdy tubercle and the head of the fibula. The function of this ligament is theorized to provide anterolateral knee stability. LEVEL OF EVIDENCE Level IV, systematic review of cadaveric and imaging studies.

Evaluation of early-stage osteochondral defect repair using a biphasic scaffold based on a collagen-glycosaminoglycan biopolymer in a caprine model.

The aim of this study was to evaluate a new collagen-GAG-calcium phosphate biphasic scaffold for the repair of surgically created osteochondral defects in goats. Comparison of morphological, histological and mechanical performance of the repair tissue was made with defects repaired using a synthetic polymer scaffold. Defects were created in the medial femoral condyle (MFC) and lateral trochlear sulcus (LTS) of Boer Cross goats and evaluated at 12 and 26 weeks. It was found that the total histology score of the collagen-GAG based biomaterial (23.8; SD 1.7) provided a significant improvement (p<0.05) over the biphasic PLGA material (19;3) and the empty control defect (17.3;1.2) in the LTS. The overall trajectory of histological and morphological improvement between 12 and 26 weeks was found to be higher for the collagen-GAG scaffold compared to the PLGA material. The occurrence of sub-chondral bone cysts was lower for the collagen-GAG scaffold with an incidence of 17% of defects, compared to 67% for the PLGA material at 26 weeks. The cartilage repair tissue for both materials evaluated was superior after 26 weeks implantation than the empty control with 75% of the collagen-GAG-treated defects showing markedly more hyaline-like cartilage and 50% of the PLGA sites exhibiting hyaline-like appearances, compared to 17% for the empty control. These early stage data indicate biphasic scaffolds based on collagen-GAG and PLGA both provide indications of satisfactory development of a structural repair to surgically prepared osteochondral defects. Furthermore, the biomaterial composition of the collagen-GAG may provide a more favourable environment for osteochondral repair.

The role of platelet rich plasma in musculoskeletal science.

The idea of using platelet rich plasma (PRP) in medicine has been around since the 1970s. It is only more recently that its use has been employed in the area of musculoskeletal science. Platelet rich plasma in this area has received much media attention being used by many celebrity sports athletes for musculoskeletal injuries. Therefore it is important for the musculoskeletal practitioner to be aware of the concepts surrounding its use and application. In this article we cover what platelet rich plasma is, how it is prepared and administered, its potential clinical application, and what the current literature discusses in the various areas of musculoskeletal science.

Improvement in outcomes after implantation of a novel polyurethane meniscal scaffold for the treatment of medial meniscus deficiency.

Pain 47 ± 14.5 75 ± 17.7 p < 0.0001 82 ± 17.4 p < 0.0001 83 ± 18.6 p < 0.0001 Symptom 60 ± 16.2 67 ± 18.5 p = 0.0091 85 ± 9.7 p < 0.0001 81 ± 13.4 p = 0.0003 ADL 53 ± 16.0 85 ± 14.5 p < 0.0001 88 ± 13.0 p < 0.0001 91 ± 14.7 p < 0.0001 Sport/Rec 26 ± 20.5 60 ± 25.3 p = 0.0001 68 ± 24.0 p < 0.0001 66 ± 28.5 p < 0.0001 QOL 28 ± 16.6 55 ± 26.9 p = 0.0007 67 ± 20.4 p < 0.0001 63 ± 18.9 p < 0.0001 KSS Function score 61 ± 22.2 87 ± 10.2 p = 0.0001 89 ± 15.7 p = 0.0001 96 ± 7.9 p < 0.0001 Knee score 65 ± 9.4 89 ± 13.1 p < 0.0001 87 ± 14.1 p < 0.0001 88 ± 12.4 p < 0.0001 UCLA 5.4 ± 1.8 6.1 ± 1.8 n.s. 6.5 ± 2.1 n.s. 7.3 ± 1.8 p = 0.0035 VAS 5.1 ± 2.0 2.1 ± 2.4 p = 0.0004 1.8 ± 2.3 p < 0.0001 1.5 ± 2.1 p < 0.0001

Effect of a solution of hyaluronic acid- chondroitin sulfate-N-acetyl glucosamine on the repair response of cartilage to single-impact load damage

OBJECTIVE To investigate effects of 1% hyaluronic acid-chondroitin sulfate-N-acetyl glucosamine (HCNAG) on the damage repair response in equine articular cartilage. SAMPLE Articular cartilage from 9 clinically normal adult horses. PROCEDURES Full-thickness cartilage disks were harvested from the third metacarpal bone. Cartilage was single-impact loaded (SIL) with 0.175 J at 0.7 m/s and cultured in DMEM plus 1 % (vol/vol) HCNAG or fibroblastic growth factor (FGF)-2 (50 ng/mL). Histologic and immunohistochemical techniques were used to identify tissue architecture and apoptotic cells and to immunolocalize type I and II collagen and proliferating nuclear cell antigen (PCNA). RESULTS Type II collagen immunoreactivity increased in SIL cartilage, compared with control samples. At days 14 and 28 (day 0 = initiation of culture), control samples had significantly fewer repair cells than did other treatment groups. In control samples and SIL + HCNAG, there was a significant decrease in apoptotic cell number, compared with results for SIL and SIL + FGF-2 samples. At days 14 and 28, there was a significant increase in chondrocytes stained positive for PCNA in the control samples. CONCLUSIONS AND CLINICAL RELEVANCE 1% HCNAG significantly affected apoptotic and repair cell numbers in an SIL damage-repair technique in adult equine articular cartilage. However, HCNAG had no effect on the number of PCNA-positive chondrocytes or on type II collagen immunohistochemical results. The inclusion of 1% HCNAG in lavage solutions administered after arthroscopy may be beneficial to cartilage health by increasing the number of repair cells and decreasing the number of apoptotic cells.

Distal Femoral Varus Osteotomy for Lateral Compartment Osteoarthritis in the Valgus Knee. A Systematic Review of the Literature

The primary objectives of this systematic review were to define the indications, functional outcomes, survivorship and complications associated with distal femoral varus osteotomy (DFVO). Cumulative survival with arthroplasty as the endpoint ranged from 64 to 82% at 10 years, and 45% at 15 years. The mean pre-operative HSS score ranged from 46 to 65 and this improved at latest follow up to means of between 72 and 88. Pooled results show an overall complication rate of 5.8% (5/86) for unanticipated re-operation due to a complication. Poor reporting of included studies and considerable heterogeneity between them precluded any statistical analysis. Further study is required to determine the precise indications for DFVO, optimum surgical technique, implant of choice and post-operative rehabilitation regimen as all of these factors may significantly affect the complication profile and outcomes of this procedure. DFVO is technically demanding and requires a significant period of rehabilitation for the patient. However, long-term survivorship and good function have been demonstrated and it remains a potential option for valgus osteoarthritis in carefully selected patients.

The evolution of anatomic anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction has evolved significantly since the early 1900’s, back when an emphasis was placed on repair and not reconstruction. Over the past century, the technique has evolved from intra-articular non anatomic reconstruction, to extra articular reconstruction, back to intra articular (performed arthroscopically), to now, the advent of anatomic insertion site restoration. This review will aim to illustrate the changes that have occurred, describing the rational for this process, based upon anatomical, radiological, biomechanical and clinical studies, all of which have aimed to improve patient function following ACL injury.