Antongiulio Marmotti

Medial Opening Wedge High Tibial Osteotomy for Medial Compartment Overload/Arthritis in the Varus Knee Prognostic Factors

Background: Medial opening wedge high tibial osteotomy (OWHTO) is a widely accepted procedure for the treatment of medial compartment arthritis of the knee. Compared with closing wedge HTO, however, the outcomes of OWHTO reported in the literature are incomplete. Purpose: To identify the positive and negative prognostic factors related to the outcomes of OWHTO through an evaluation of midterm study results and survivorship analysis. Study Design: Case series; Level of evidence, 4. Methods: From January 2001 to December 2009, a total of 141 consecutive OWHTOs were performed in 123 patients. Only patients with symptomatic medial knee overload/arthritis were included. The patients were evaluated preoperatively and at every follow-up visit with (1) the Knee Society score, (2) the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, (3) another self-evaluation scale, (4) long-leg radiographs, and (5) plain radiographs. Preoperative, intraoperative, and postoperative variables were investigated to find an association with the outcomes. Results: Of the 123 patients, 15 were lost to follow-up, and 24 were excluded from the study, leaving 84 patients (99 OWHTOs) for the present study. The mean age of the patients at the time of surgery was 54.5 ± 9.2 years. The mean follow-up was 51.5 ± 23.8 months. The Knee Society and WOMAC scores significantly improved after surgery (P < .001). The variables significantly related to a poor outcome were (1) age >56 years (P = .008) and (2) postoperative knee flexion <120° (P < .001); the variables significantly related to a good outcome were (1) Ahlbäck grade 0 arthritis of the medial compartment (P < .001) and (2) excellent preoperative Knee Society score (P < .001). The Kaplan-Meier analysis showed a survival rate of 98.7% at 5 years and 75.9% at 7.5 years. Conclusion: With correct indications, OWHTO is a reliable procedure for medial knee arthritis/overload. The outcomes reported are similar to those from other studies, although the variables related to outcomes are slightly different.

Cocultures of Adult and Juvenile Chondrocytes Compared With Adult and Juvenile Chondral Fragments In Vitro Matrix Production

Background: The use of allogenic juvenile chondrocytes or autologous chondral fragments has shown promising laboratory results for the repair of chondral lesions. Hypothesis: Juvenile chondrocytes would not affect matrix production when mixed with adult chondrocytes or cartilage fragments. Study Design: Controlled laboratory study. Methods: Cartilage sources consisted of 3 adult and 3 juvenile (human) donors. In part 1, per each donor, juvenile chondrocytes were mixed with adult chondrocytes in 5 different proportions: 100%, 50%, 25%, 12.5%, and 0%. Three-dimensional cultures in low-melt agarose were performed. At 6 weeks, biochemical and histologic analyses were performed. In part 2, isolated adult, isolated juvenile, and mixed 3-dimensional cultures (1:1) were performed with chondral fragments (<1 mm), both with low-melt agarose and a hyaluronic acid scaffold. At 2 and 6 weeks, cultures were evaluated with biochemical and histologic analyses. Results: Part 1: Biochemical and histologic analyses showed that isolated juvenile cultures performed significantly better than mixed and isolated adult cultures. No significant differences were noted between mixed cultures (1:1) and isolated adult cultures. Part 2: Biochemical and histologic results at 6 weeks showed that mixed cartilage fragment cultures performed better than isolated adult cultures in terms of proteoglycans/DNA ratio (P = .014), percentage of safranin O–positive cells (P = .012), Bern score (P = .001), and collagen type II. No statistically significant difference was noted between juvenile and mixed cultures. Conclusion: Extracellular matrix production of juvenile chondrocytes is inhibited by adult chondrocytes. The addition of juvenile cartilage fragments to adult fragments improves matrix production, with a positive interaction between the 2 sources. Clinical Relevance: Even if the underlying mechanisms are still unknown, this study describes the behavior of juvenile/adult cocultures using both chondrocytes and cartilage fragments, with potential for new research and clinical applications.

Use of chondral fragments for one stage cartilage repair: A systematic review

AIM To investigate the state of the art regarding Cartilage Autograft Implantation System (CAIS) or Particulated Juvenile Allograft Cartilage (PJAC). METHODS The authors searched the English literature regarding CAIS and PJAC. The search strategy was: (particulated cartilage) OR autologous cartilage fragments. All basic science articles were included. Clinical articles with less than 10 patients treated and less than 6 mo of follow-up were excluded. With these criteria, a total of 17 articles were available for the present review. RESULTS PJAC and CAIS are relatively novel techniques for cartilage repair. Good basic science evidence was described to support the concept. Although the preliminary clinical reports show encouraging results, clinical data are still limited, especially for CAIS. The indications for both techniques need to be precisely defined (age of the patients, size of the lesion, and involvement of the subchondral bone), together with other debated issues. CONCLUSION In conclusion, the authors can state that encouraging preliminary results are available for both techniques. However, further studies are necessary to precisely determine the indications, surgical techniques, and long term outcomes for PJAC and CAIS.

Intra- and inter-observer reliability of ten major histological scoring systems used for the evaluation of in vivo cartilage repair

AbstractPurpose In the last two decades, many surgical techniques have been described for articular cartilage repair. Reliable histological scoring systems are fundamental tools to evaluate new procedures. Several histological scoring systems have been described, and these can be divided in elementary and comprehensive scores, according to the number of sub-items. The aim of this study was to test the inter- and intra-observer reliability of ten main scores used for the histological evaluation of in vivo cartilage repair. The authors tested the starting hypothesis that elementary scores would show superior intra- and inter-observer reliability compared with comprehensive scores.MethodsFifty histological sections obtained from the trochlea of New Zealand Rabbit and stained with Safranin-O fast green were used. The histological sections were analysed by 4 observers: 2 experienced in cartilage histology and 2 inexperienced. Histological evaluations were performed at time 1 and time 2, separated by a 30-day interval. The following scores were used: Mankin, O’Driscoll, Pineda, Wakitani, Fortier, Selleres, ICRS, ICRSII, Oswestry (OsScore) and modified O’Driscoll. Intra- and inter-observer reliability were evaluated for each score. In addition, the pavement–ceiling effect and the Bland–Altman Coefficient of Repeatability were then evaluated for each sub-item of every score.ResultsIntra-observer reliability was high for all observers in every score, even though the reliability was significantly lower for non-expert observers compared with expert counterparts. In terms of Coefficient of Repeatability, some scores performed better (O’Driscoll, Modified O’Driscoll and ICRSII) than others (Fortier, Seller). Inter-observer reliability was high for all observers in every score, but significantly lower for non-expert compared with expert observers.ConclusionsIn expert hands, all the scores showed high intra- and inter-observer reliability, independently of the complexity. Although every score has advantages and disadvantages, ICRSII, O’Driscoll and Modified O’Driscoll scores should be preferred for the evaluation of in vivo cartilage repair in animal models.

Tibial Tuberosity Anteromedialization for Patellofemoral Chondral Disease

Background: Tibial tuberosity anteromedialization (TTA) is a well-established treatment option for patellofemoral chondral disease that is resistant to nonoperative treatment. However, the prognostic factors of this procedure are unknown. Purpose: To analyze the prognostic factors correlated with the midterm outcomes of TTA for patellofemoral chondral disease and determine the survivorship. Study Design: Case series; Level of evidence, 4. Methods: Indications of TTA for chondral disease included skeletal maturity, age <65 years, <grade 3 Kellgren-Lawrence degeneration, and isolated patellofemoral pain for ≥6 months despite nonoperative treatment. Inclusion criteria were (1) patellofemoral chondral disease, (2) TTA with or without lateral release, and (3) minimum 2-year follow-up. Exclusion criteria were (1) previous knee surgeries, (2) previous patellar dislocations, (3) inflammatory/rheumatic conditions, (4) major combined procedures other than lateral release, (5) focal chondral lesions amenable to cartilage repair, and (6) severe trochlear dysplasia. The patients were prospectively evaluated radiographically and clinically using the Western Ontario and McMaster Universities Osteoarthritis Index–Short-Form (WOMAC-SF) and Kujala scores. Different clinical and radiological data were collected (preoperative, intraoperative, and postoperative) and correlated with the outcomes using multiple logistic regression. The Kaplan-Meier survivorship was also evaluated. Results: From January 2003 to December 2013, among 76 eligible patients, 69 patients (78 knees, 74.4% female) were included, with a mean follow-up of 67.9 ± 34.5 months (range, 24-163 months) and a mean age at the time of surgery of 43.5 ± 16.1 years. The mean preoperative WOMAC-SF (17.8 ± 5.3) and Kujala (49.3 ± 15.6) scores significantly (P < .001) improved after surgery (WOMAC-SF: 6.6 ± 6.9; Kujala: 74.2 ± 20.5). The patients graded their operated knee as 7.2 ± 2.1 of 10 points, on average, and stated that they would undergo the surgery again in 58 (74.4%) cases. A WOMAC-SF score of >7 points (34.6% of knees) in the multiple regression model was associated with age >45 years (odds ratio [OR], 10.4; 95% CI, 2.0-55.0) and increased femoral anteversion (OR, 7.9; 95% CI, 1.4-44.1). A Kujala score of <80 points (61.5% of knees) was associated with age >45 years (OR, 12.0; 95% CI, 2.6-56.2) and foot pronation (OR, 5.1; 95% CI, 1.3-20.4). Patient satisfaction of <7 of 10 points (32.1% of knees) was associated with positive postoperative patellofemoral crepitus (OR, 3.6; 95% CI, 1.1-11.7). The Kaplan-Meier survivorship of TTA with dissatisfaction (<5/10 points) as an end point was 94% at 43 months, 88% at 77 months, and 77% at 108 months. Conclusion: Overall, good outcomes and survivorship (77% at 108 months) were obtained in this case series. However, 25.6% of the patients would not undergo the surgery again. Increased age, increased femoral anteversion, foot pronation, and postoperative patellofemoral crepitus were identified as negative prognostic factors.

The use of spacers (static and mobile) in infection knee arthroplasty

Revision total knee arthroplasty (TKA) is the treatment of choice in patients with periprosthetic joint infection. It may be performed in either a single stage or two stages. In the latter option, between stages, an antibiotic-loaded spacer may be used to maintain a certain amount of joint stability and mobility after the infected implant is removed, adding an intra-articular concentration of antibiotics. There are two types of antibiotic-loaded cement spacers: static and dynamic. Static spacers basically create a temporary arthrodesis with antibiotic-loaded cement and usually are handmade within the surgical field. Dynamic spacers can be created intraoperatively by using different tools or may be prepackaged by the manufacturer; they allow range of motion between stages. In this article, the authors review the indications, surgical techniques, and results for static and dynamic spacers in two-stage revision TKA.

Risk Factors for Shoulder Stiffness: Current Concepts

Shoulder stiffness is a condition of painful restriction of the glenohumeral range of motion. Numerous risk factors for primary and postoperative shoulder stiffness have been described. This article summarizes the known aspects of the pathophysiology of shoulder stiffness, with special attention to elements of molecular biology and genetics, which could influence the risk of developing shoulder stiffness. Furthermore, the role of hormonal and metabolic factors, medical disorders, drugs, and of other published risk factors for primary and postoperative shoulder stiffness is reviewed and discussed. Finally, aspects related to shoulder surgery and postoperative rehabilitation protocols, which could influence the development of postoperative stiffness are presented.

Recent advances in cartilage repair (ICL 3)

Articular cartilage possesses low intrinsic healing property due to its lack of vascularity and progenitor cells. Thus, damage to the hyaline cartilage may lead to a progressive degeneration of the joint and eventually to osteoarthritis (OA). In the last years, different surgical techniques have been introduced in the clinical practice to overcome this issue. Bone marrow stimulation, for example, is a widely known method to allow cell invasion from the bloodstream to the site of damage. However, the reparative tissue has different morphological and biomechanical properties when compared to the native cartilage. In particular, the newly formed fibrocartilage has a low amount of proteoglycans and a higher concentration of type I collagen. This different matrix composition leads to a decrease in the mechanical strength and to a poor integration of the reparative tissue with the native cartilage.