Andrew G. Geeslin

Outcomes of treatment of acute grade-III isolated and combined posterolateral knee injuries: a prospective case series and surgical technique.

BACKGROUND Few studies have reported the outcomes of surgical treatment of an acute grade-III posterolateral knee injury. Our purpose was to report the objective stability and subjective outcomes for a prospective series of patients with an acute grade-III posterolateral knee injury treated with anatomic repair and/or reconstruction of all injured structures. METHODS A prospective study of all patients with a grade-III posterolateral knee injury treated with an anatomic repair and/or reconstruction within six weeks of injury was initiated in May 2005. International Knee Documentation Committee (IKDC) objective scores and bilateral varus stress radiographs were obtained at each visit, including preoperatively and at the final follow-up visit. In addition, all patients completed Cincinnati and IKDC subjective evaluations. All associated cruciate ligament tears were reconstructed concurrently. RESULTS Twenty-nine patients (twenty-four men and five women with a mean age of twenty-seven years) (thirty knees) were enrolled in the study. Eight knees had an isolated posterolateral corner injury, ten also had an anterior cruciate ligament tear, four also had a posterior cruciate ligament tear, and eight also had tears of both cruciate ligaments. Four patients were lost to follow-up prior to two years, resulting in a final study cohort of twenty-five patients (twenty-six knees). All five IKDC objective subscores had improved significantly at the time of the final follow-up evaluation at an average of 2.4 years postoperatively. Varus stress radiographs demonstrated a significant improvement in the side-to-side difference in the lateral compartment gap, from 6.2 mm preoperatively to 0.1 mm at the time of the final follow-up. The mean Cincinnati and IKDC subjective outcomes scores improved from 21.9 to 81.4 points and from 29.1 to 81.5 points, respectively. CONCLUSIONS Treatment of grade-III posterolateral knee injuries with acute repair of avulsed structures, reconstruction of midsubstance tears, and concurrent reconstruction of any cruciate ligament tears resulted in significantly improved objective stability.

Location of bone bruises and other osseous injuries associated with acute grade III isolated and combined posterolateral knee injuries.

Background Bone bruises on magnetic resonance imaging (MRI) are common in patients with acute knee ligament injuries and have been well described for injuries involving the anterior and posterior cruciate ligaments and the medial collateral ligament. These have not yet been described in detail for posterolateral corner injuries. Hypothesis Acute grade III posterolateral corner (PLC) injuries are often accompanied by bone bruises located in the medial compartment. Study Design Case series; Level of evidence, 4. Methods One hundred two patients with acute grade III PLC knee injuries and MRI scans within 6 weeks of injury were prospectively identified. Images were reviewed for the location of bone bruises, which were defined as areas with high signal intensity adjacent to the joint surface on fat-suppressed, T2-weighted sequences. Results Overall, 83 patients had at least 1 bone bruise and 56 patients had a bone bruise of the anteromedial femoral condyle. Tibial plateau fractures were found in 19 knees, with 12 in the anteromedial quadrant. Isolated PLC injuries were found in 28 patients; of this group, 18 had at least 1 bone bruise with 17 located in the anteromedial femoral condyle. Seventy-four patients sustained a combined ligamentous injury; 65 of these had at least 1 bone bruise on MRI and 39 had a bone bruise on the anteromedial femoral condyle. In patients with a combined injury to the PLC and anterior cruciate ligament (38), anteromedial femoral condyle bruises were seen in 19 patients and posteromedial tibial plateau bruises in 11. Conclusion Medial compartment bone bruises, most commonly of the anteromedial femoral condyle, were frequently found in patients with both acute isolated and combined PLC injuries. Thus, the presence of an anteromedial femoral condyle bone bruise should increase the level of suspicion of a concurrent PLC knee injury. In addition, we believe that the presence of a posteromedial tibial plateau bone bruise may be a secondary sign of a potential combined PLC injury in the setting of anterior cruciate ligament tear.

Improving Outcomes for Posterolateral Knee Injuries

Until recently, the posterolateral corner of the knee was noted both for its complex anatomy and diagnostic challenges. To improve the understanding of the posterolateral knee, we completed a comprehensive and stepwise research program with a focus on five primary areas: (1) surgical approach and relevant anatomy; (2) diagnosis; (3) clinically relevant biomechanics; (4) natural history; and (5) surgical treatment. Based on this comprehensive research program, the diagnosis and outcomes following treatment of posterolateral knee injuries have been significantly improved comparing the preoperative state to the state of the knee at a minimum 2 year follow‐up in the cases series presented here.

Biologic Treatments for Sports Injuries II Think Tank—Current Concepts, Future Research, and Barriers to Advancement, Part 1 Biologics Overview, Ligament Injury, Tendinopathy

Biologic therapies, including stem cells, platelet-rich plasma, growth factors, and other biologically active adjuncts, have recently received increased attention in the basic science and clinical literature. At the 2015 AOSSM Biologics II Think Tank held in Colorado Springs, Colorado, a group of orthopaedic surgeons, basic scientists, veterinarians, and other investigators gathered to review the state of the science for biologics and barriers to implementation of biologics for the treatment of sports medicine injuries. This series of current concepts reviews reports the summary of the scientific presentations, roundtable discussions, and recommendations from this think tank.

A Call for Standardization in Platelet-rich Plasma Preparation Protocols and Composition Reporting: A Systematic Review of the Clinical Orthopaedic Literature

Background: Platelet-rich plasma (PRP) is a blood-derived preparation whose use has grown exponentially in orthopaedic practice. However, there remains an unclear understanding of the biological properties and effects of PRP on musculoskeletal healing. Heterogeneous processing methods, unstandardized nomenclature, and ambiguous classifications make comparison among studies challenging. A comprehensive assessment of orthopaedic clinical PRP trials is key to unraveling the biological complexity of PRP, while improving standardized communication. Toward this goal, we performed a systematic review of the PRP preparation protocols and PRP composition utilized in clinical trials for the treatment of musculoskeletal diseases. Methods: A systematic review of the literature was performed from 2006 to 2016. Inclusion criteria were human clinical trials, English-language literature, and manuscripts that reported on the use of PRP in musculoskeletal/orthopaedic conditions. Basic-science articles, editorials, surveys, special topics, letters to the editor, personal correspondence, and nonorthopaedic applications (including cosmetic use or dental application studies) were excluded. Results: A total of 105 studies (in 104 articles) met the inclusion criteria for analysis. Of these studies, only 11 (10%) provided comprehensive reporting that included a clear description of the preparation protocol that could be used by subsequent investigators to repeat the method. Only 17 studies (16%) provided quantitative metrics on the composition of the final PRP product. Conclusions: Reporting of PRP preparation protocols in clinical studies is highly inconsistent, and the majority of studies did not provide sufficient information to allow the protocol to be reproduced. Furthermore, the current reporting of PRP preparation and composition does not enable comparison of the PRP products being delivered to patients. A detailed, precise, and stepwise description of the PRP preparation protocol is required to allow comparison among studies and provide reproducibility.

Biologic Treatments for Sports Injuries II Think Tank—Current Concepts, Future Research, and Barriers to Advancement, Part 3: Articular Cartilage

Focal chondral defects of the articular surface are a common occurrence in the field of orthopaedics. These isolated cartilage injuries, if not repaired surgically with restoration of articular congruency, may have a high rate of progression to posttraumatic osteoarthritis, resulting in significant morbidity and loss of function in the young, active patient. Both isolated and global joint disease are a difficult entity to treat in the clinical setting given the high amount of stress on weightbearing joints and the limited healing potential of native articular cartilage. Recently, clinical interest has focused on the use of biologically active compounds and surgical techniques to regenerate native cartilage to the articular surface, with the goal of restoring normal joint health and overall function. This article presents a review of the current biologic therapies, as discussed at the 2015 American Orthopaedic Society for Sports Medicine (AOSSM) Biologics Think Tank, that are used in the treatment of focal cartilage deficiencies. For each of these emerging therapies, the theories for application, the present clinical evidence, and specific areas for future research are explored, with focus on the barriers currently faced by clinicians in advancing the success of these therapies in the clinical setting.

A Systematic Review of the Outcomes of Posterolateral Corner Knee Injuries, Part 1 Surgical Treatment of Acute Injuries

Background: There is a paucity of outcome data to guide the surgical treatment of acute grade III posterolateral corner (PLC) knee injuries. Purpose: To systematically review the literature to compare clinical outcomes of the treatment for acute grade III PLC injuries. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature including Cochrane, PubMed, Medline, and Embase was performed. The following search terms were used: posterolateral corner knee, posterolateral knee, posterolateral instability, multiligament knee, and knee dislocation. Inclusion criteria were outcome studies of surgically treated acute PLC injuries with a minimum 2-year follow-up, subjective outcomes, objective outcomes including varus stability, and subgroup data on PLC injuries. Two investigators independently reviewed all abstracts. Accepted definitions of varus stability on examination or stress radiographs and the need for revision surgery were used to categorically define success and failure. Results: Eight studies with a total of 134 patients were included. The mean patient age was reported in 7 studies (range, 21-31.5 years). The mean time to surgery was reported in 5 studies (range, 15-24.3 days); surgery was performed within 3 weeks in the other 3 studies. Four studies reported International Knee Documentation Committee scores (range, 78.1-91.3); 5 studies reported Lysholm scores (range, 87.5-90.3). Only 3 studies obtained bilateral varus stress radiographs. Based on an objective evaluation with varus stress examinations or radiographs, there was an overall success rate of 81% and failure rate of 19%. In 2 studies, the fibular collateral ligament and popliteus tendon were repaired and staged cruciate reconstruction performed in most patients; there were 17 failures of 45 patients (38%). In the remainder of the studies, patients were treated with local tissue transfer, hybrid repair for amenable structures or reconstruction for midsubstance tears, or reconstruction of all torn structures; the failure rate was 9%. Conclusion: The repair of acute grade III PLC injuries and staged treatment of combined cruciate injuries were associated with a substantially higher postoperative PLC failure rate. Further research is required to identify the reconstruction technique that provides optimal subjective and objective outcomes.

Incidence and Detection of Meniscal Ramp Lesions on Magnetic Resonance Imaging in Patients With Anterior Cruciate Ligament Reconstruction

Background: Meniscal ramp lesions have been reported to be present in 9% to 17% of patients undergoing anterior cruciate ligament (ACL) reconstruction. Detection at the time of arthroscopy can be accomplished based on clinical suspicion and careful evaluation. Preoperative assessment via magnetic resonance imaging (MRI) has been reported to have a low sensitivity in identifying meniscal ramp lesions. Purpose: To investigate the incidence of meniscal ramp lesions in patients with ACL tears and the sensitivity of preoperative MRI for the detection of ramp lesions. Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent ACL reconstruction by a single surgeon between 2010 and 2016 were included in this study, and patients with medial meniscal ramp lesions found at the time of arthroscopy were identified. The sensitivity of MRI compared with the gold standard of arthroscopic evaluation was determined by review of the preoperative MRI musculoskeletal radiologist report, mimicking the clinical scenario. The incidence was calculated based on arthroscopic findings, and the potential secondary signs of meniscal ramp tears were evaluated on MRI. Results: In a consecutive series of 301 ACL reconstructions, 50 patients (33 male, 17 female) with a mean age of 29.6 years (range, 14-61 years) were diagnosed with a medial meniscal ramp lesion at arthroscopic evaluation (16.6% incidence). The sensitivity of MRI for ramp lesions was 48% based on the preoperative MRI report. A secondary finding of a posteromedial tibial bone bruise was identified on preoperative MRI in 36 of the 50 patients with ramp lesions in a retrospective MRI review by 2 orthopaedic surgeons. Conclusion: Medial meniscal ramp lesions were present in approximately 17% of 301 patients undergoing ACL reconstruction, and less than one-half were diagnosed on the preoperative MRI. A posteromedial tibial bone bruise was found to be a secondary sign of a ramp lesion in 72% of patients. Increased awareness of this potentially combined injury pattern is necessary, and careful intraoperative evaluation is required to identify all meniscal ramp tears.

Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO): Platelet-Rich Plasma and Mesenchymal Stem Cells.

Background: A comprehensive approach to the evaluation of biologic therapies for musculoskeletal conditions is required to guide appropriate future use. Clinical studies evaluating platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs) are limited by inadequate reporting of scientific details critical to outcome. We developed minimum reporting requirements for clinical studies evaluating PRP and MSCs using Delphi consensus methods. Methods: The need for consensus on the minimum reporting requirements for studies evaluating biologics was identified at the American Academy of Orthopaedic Surgeons/Orthopaedic Research Society (AAOS/ORS) Biologic Treatments for Orthopaedic Injuries Symposium in 2015 and the American Orthopaedic Society for Sports Medicine (AOSSM) Biologic Treatments for Sports Injuries II Think Tank in 2015. A working group facilitated the development of 2 expert consensus statements for PRP and MSCs using Delphi techniques. Exhaustive lists of items that could be reported on by clinical studies evaluating PRP or MSCs were generated by searching the published literature and protocols. PRP and MSC expert groups, each made up of 24 invited speakers at the AAOS and AOSSM symposia, were surveyed on 3 occasions to establish consensus on the inclusion of each item within minimum reporting guidelines. In addition to rating their agreement, the experts were encouraged to propose further items or modifications. Predefined criteria were used to refine item lists after each survey. Final lists were compiled into checklist statements by the working group. Results: For PRP, the working group identified 93 experimental information items from the literature. Twenty-three experts (96%) completed 3 rounds of surveys. After 3 rounds, 58 items generated consensus with >75% agreement and <5% disagreement. These items were compiled into a 23-statement checklist. For MSCs, 103 items were identified from the published literature. Twenty-three experts (96%) completed 3 rounds of surveys. After 3 rounds, the 61 items for which consensus was reached were compiled into a 25-statement checklist. Conclusions: This study has established expert consensus on the minimum reporting requirements for clinical studies evaluating PRP and MSCs. Clinical Relevance: These checklists provide specifications for the minimum information that should be reported by clinical studies evaluating PRP or MSCs.

AAOS Research Symposium Updates and Consensus: Biologic Treatment of Orthopaedic Injuries.

Strategies that seek to enhance musculoskeletal tissue regeneration and repair by modulating the biologic microenvironment at the site of injury have considerable therapeutic potential. Current and emerging biologic approaches include the use of growth factors, platelet-rich plasma, stem cell therapy, and scaffolds. The American Academy of Orthopaedic Surgeons hosted a research symposium in November 2015 to review the current state-of-the-art biologic treatments of articular cartilage, muscle, tendon, and bone injuries and identify knowledge gaps related to these emerging treatments. This review outlines the findings of the symposium and summarizes the consensus reached on how best to advance research on biologic treatment of orthopaedic injuries.