Alberto Gobbi

New Frontiers for Cartilage Repair and Protection

Objective: Articular cartilage injury is common after athletic injury and remains a difficult treatment conundrum both for the surgeon and athlete. Although recent treatments for damage to articular cartilage have been successful in alleviating symptoms, more durable and complete, long-term articular surface restoration remains the unattained goal. In this article, we look at both new ways to prevent damage to articular surfaces as well as new techniques to recreate biomechanically sound and biochemically true articular surfaces once an athlete injures this surface. This goal should include reproducing hyaline cartilage with a well-integrated and flexible subchondral base and the normal zonal variability in the articular matrix. Results: A number of nonoperative interventions have shown early promise in mitigating cartilage symptoms and in preclinical studies have shown evidence of chondroprotection. These include the use of glucosamine, chondroitin, and other neutraceuticals, viscosupplementation with hyaluronic acid, platelet-rich plasma, and pulsed electromagnetic fields. Newer surgical techniques, some already in clinical study, and others on the horizon offer opportunities to improve the surgical restoration of the hyaline matrix often disrupted in athletic injury. These include new scaffolds, single-stage cell techniques, the use of mesenchymal stem cells, and gene therapy. Conclusion: Although many of these treatments are in the preclinical and early clinical study phase, they offer the promise of better options to mitigate the sequelae of athletically induced cartilage.

Next Generation Cartilage Solutions

First generation autologous chondrocyte implantation (ACI) introduced by Peterson has been proven capable of restoring hyaline cartilage tissue. Recent studies suggested the durability of this treatment, primarily due to its ability to produce hyaline-like cartilage that is mechanically and functionally stable.

Clinical Outcomes and Rehabilitation Program After ACL Primary Repair and Bone Marrow Stimulation

Objective The purpose of this study is to evaluate the outcome of anterior cruciate ligament (ACL) primary repair combined with bone marrow stimulation and followed by a specific rehabilitation program in the treatment of acute ACL lesions in athletes.

Emerging Orthobiologic Approaches to Ligament Injury

Ligament injuries about the knee occur frequently during recreational and competitive sporting activities, and there is a wide array of treatment options to restore function and enable return-to-play. Interventions that utilize biologic therapy, or surgical augmentation with these biologic factors, may provide valuable additional therapeutic options to current methods typically used for treatment of these conditions. Cellular therapies have the potential to address deficiencies in the healing of injured ligaments by treating damaged tissue at a molecular level and by providing an environment that enhances reparative processes.

Elmslie-Trillat Procedure: A Distal-Based Procedure for Patellar Stabilization

Patellofemoral problems are a frequent common complaint in patients with knee pain. This is present in both adolescents and adults, and many terms have been used to describe this condition. Anterior knee pain and chondromalacia patella are two terms used to describe the knee pain which is noted to be present in the anterior aspect of the knee in the retropatellar area. In addition, many adolescents present with patellofemoral instability which can be with either frank dislocation or subluxation. Insall described this as patellofemoral malalignment in an attempt to explain patellofemoral tracking problems which lead to abnormal tracking, acute and chronic dislocation, and anterior knee pain.

How to Handle a Poorly Placed Femoral Tunnel

Majority of primary anterior cruciate ligament reconstruction (ACLR) failures are caused by non-anatomically positioned femoral tunnels. They are predominantly anteriorly-proximally located by trans-tibial tunnel techniques for fear of posterior cortical blowout. For revision ACLR, it is important to avoid overlapping tunnels.

The Role of Orthobiologics in Return to Play

Bioactive proteins and growth factors are an integral component of healing processes and have the potential to affect metabolic cascades that impact tissue regeneration at all stages. These factors can be used in athletes for a wide variety of musculoskeletal injuries in the form of such biologics as platelet-rich plasma, or in conjunction with cellular therapies, to facilitate return to play. Cellular therapies, most often used in the form of mesenchymal stem cell isolates, are increasingly being used to treat athletic injury. In addition to tendinous or ligamentous injury, mesenchymal stem cell therapies are used to treat articular cartilage lesions. In combination with biologic scaffolding, mesenchymal stem cell isolates can be used to treat cartilage lesions of wide ranging sizes and severity. Orthobiologic therapies are advancing rapidly and are used to treat a large spectrum of injuries, helping to facilitate return to play at all levels of football competition.

Acute ACL Rupture: A Biological Approach Through Primary ACL Repair and Augmentation with Bone Marrow Stimulation and Growth Factor Injection

Techniques of arthroscopically assisted anterior cruciate ligament (ACL) reconstruction have been used successfully to treat all types of ACL injury. In the event of partial ACL rupture, surgical management may include standard ACL reconstruction techniques typically used in complete rupture, or a more selective approach may be employed. Surgical repair of the disrupted ligament, or selective reconstruction of the injured ACL bundle, may be considered in the case of partial ACL rupture. Advances in the understanding of cellular repair mechanisms and the availability of various biologics may factor prominently in future treatment algorithms for certain types of ACL injury. ACL repair with bone marrow stimulation and growth factor application has the potential to restore ligamentous integrity and function, without altering the anatomic footprint of the ACL while partially maintaining proprioceptive function. Following a strict treatment protocol in our most recent cohort of patients suffering from acute partial ACL injury, high rates of functional recovery and return to sport were achieved after surgical repair of the ACL, with concurrent bone marrow stimulation and the application of growth factors.

Osteochondritis Dissecans of the Knee in Football Players

Osteochondritis dissecans (OCD) of the knee is a frequent cause of pain and functional limitation among skeletally immature and young athletes. Chronic overuse of the lower extremity in young soccer players can cause OCD at the knee and ankle joints; furthermore, with increased competitiveness of amateur sports, more injuries may cause OCD. Increased joint stress, such as an increased pressure at the medial femoral condyle in young patients with genu varum, might cause decreased blood flow and trigger the development of OCD. Symptoms are usually preceded by trauma in 40–60% of the cases. Juveniles and adolescents will complain of vague, nonspecific poorly localized anterior knee pain with variable intermittent amount of swelling, locking of the knee grinding, or catching; pain is aggravated by activity and relieved by rest. If not recognized and appropriately treated, it can create further limitation and lead to early osteoarthritis. OCD is a disorder of one or more ossification centers, characterized by sequential degeneration or aseptic necrosis and recalcification. OCD lesions involve both bone and cartilage but appear to affect the subchondral bone primarily and secondarily affect the articular cartilage.

Osteochondritis Dissecans: Pathoanatomy, Classification, and Advances in Biologic Surgical Treatment

Osteochondritis dissecans (OCD) is an articular disorder that results from a pathologic process involving subchondral bone that frequently leads to injury of the overlying articular cartilage. This condition may lead to significant pain and functional impairment, particularly among young athletes. In cases where surgical treatment is considered, a variety of therapeutic options may be used for repair of the injured tissue, including grafting of the osteochondral unit with allograft or autograft, or cell-based cartilage repair. Recent developments that make use of biomaterials and cell-based cartilage repair have demonstrated encouraging results and are an important treatment advancement in this rapidly evolving field of tissue repair.