Francesco Uboldi

Treatment of Large Knee Osteochondral Lesions With a Biomimetic Scaffold: Results of a Multicenter Study of 49 Patients at 2-Year Follow-up.

Background: Osteochondral knee lesions represent a challenging condition encountered by orthopaedic surgeons. A variety of methods have been developed to repair articular cartilage defects. However, these techniques are limited by donor site morbidity or by the requirement for a staged procedure. Purpose: To assess the effectiveness of a biomimetic osteochondral scaffold for the treatment of large osteochondral knee lesions. Study Design: Case series; Level of evidence, 4. Methods: From 2009 to 2011, a total of 49 patients affected by isolated large osteochondral knee lesions (mean [± SD] size, 4.35 ± 1.26 cm2) were treated with the biomimetic scaffold. Patients were evaluated using the International Knee Documentation Committee (IKDC), Tegner, and visual analog scale (VAS) pain scores, as well as magnetic resonance imaging (MRI) up to 3-year follow-up. The MOCART (magnetic resonance observation of cartilage repair tissue) score was performed to analyze different variables. Biopsies were carried out in 5 patients. Four of the 5 second-look arthroscopies and biopsies were performed on patients with failed results because of ethical issues. Results: The mean IKDC subjective score increased significantly from 45.45 ± 19.29 preoperatively to 70.86 ± 18.08 at 1-year follow-up and to 75.42 ± 19.31 at 2-year follow-up (P < .001). The IKDC objective score changed from 50% normal and nearly normal knees before treatment to 89.79% at the 2-year follow-up. There was a statistically significant improvement (P < .005) in VAS score from the preoperative level (6.69 ± 1.88) to the 2-year follow-up (1.96 ± 2.47). Tegner scores increased (P < .001) from the preoperative value (2.20 ± 0.67) to the 2-year follow-up (4.9 ± 1.73) without achieving preinjury level. A correlation was found between the IKDC subjective score and age (P < .001, r = −0.497, ρ = −0.502). Patients affected by osteochondritis dissecans (OCD) achieved a statistically significantly better outcome (P < .05). A subgroup of 19 competitive athletes showed a statistically significantly improvement (P < .001) in the subjective IKDC (86.5 ± 13.2) compared with the nonathletic subpopulation (69.03 ± 19.41) at the 2-year follow-up. The MRI findings of 30 patients were available at 2-year follow-up: 70% showed complete filling of the lesion, 63.3% had an intact articular surface, and 86% had mild or no effusion. In all cases, in dual T2-weighted fast spin echo sequence, the repair tissue showed a hyperintensive signal with respect to the surrounding subchondral bone; however, no edema was observed. Conclusion: The study findings indicate that the biomimetic scaffold that was investigated is an off-the-shelf, cell-free, and cost-effective implant that can regenerate either cartilage or subchondral bone. The scaffold allows a 1-step surgical procedure that can be used for osteochondral lesions, OCD, and in some cases osteonecrosis.

Use of an Elastomeric Knee Brace in Patellofemoral Pain Syndrome: Short-Term Results

Purpose  This article verifies the effectiveness of a new brace on patellofemoral pain syndrome (PFPS) in adjunct to a specifically developed rehabilitation program. Methods  Two groups of 30 patients with PFPS were prospectively and randomly allocated to a rehabilitation protocol, with (group A) or without (group B) the use of a specific brace. All the patients were assessed at 3, 6, and 12 months using the disease-specific Kujala scale and a visual analog scale (VAS) for pain; time to return to sport and patient satisfaction with the brace were also recorded. Results  Kujala scales values showed constant and progressive improvement. The mean score at 6 months was 79.8 ± 6.8 points in group A and 76.8 ± 8.6 in group B, rising at 12 months to 80.9 ± 7.5 in group A and 78.4 ± 8.3 in group B. VAS scores significantly differed ( p  < 0.05) between the two groups at both 6 and 12 months; the score recorded at 12 months was 0.9 ± 1.3 in the brace-treated group and 1.8 ± 1.6 in the controls. The patients who used a brace showed a quicker return to sports and 75% of the patients in this group were satisfied. Conclusion  All the scores improved progressively in both groups. The most significant improvement concerned pain, showing that the brace used in this study may allow a better subjective outcome and a quicker return to sport. Level of Evidence  Level II, prospective randomized controlled trial.

Suture Anchors Fixation in MPFL Reconstruction using a Bioactive Synthetic Ligament

Medial patellofemoral ligament (MPFL) reconstruction has a key role in patellofemoral instability surgery. Many surgical techniques have been described so far using different types of grafts (autologous, heterologous, or synthetic) and fixation techniques. The hereby described technique for MPFL reconstruction relies on the use of a biosynthetic graft (LARS Arc Sur Tille, France). Fixation is obtained by means of suture anchors on the patellar side and a resorbable interference screw on the femoral side locating the insertion point according to Schottle et al. An early passive range of motion (ROM) recovery is fundamental to reduce the risk of postoperative stiffness; a partial weight bearing with crutches is allowed until 6 weeks after the surgery. In our experience, the use of a biosynthetic graft and suture anchors provides stable fixation, minimizing donor site morbidity and reducing the risk of patellar fracture associated with transosseous tunnels. This technique represents a reliable and reproducible alternative for MPFL reconstruction, thereby minimizing the risk of possible complications.

Revision Surgery in Permanent Patellar Dislocation in DiGeorge Syndrome

A 29-year-old patient, suffering from DiGeorge syndrome, came to our attention with a history of persistent pain and patellar instability in the left knee after failure of arthroscopic lateral release and Elmslie-Trillat procedure. The patient was unable to walk without crutches and severely limited in daily living activities. Because of arthritic changes of the patellofemoral joint and the failure of previous surgeries it was decided to perform only an open lateral release and medial patellofemoral ligament (MPFL) reconstruction using a biosynthetic ligament in order to obtain patellofemoral stability. At one year post-op range of motion (ROM) was 0–120 with a firm end point at medial patellar mobilization; patella was stable throughout the entire ROM. All the scores improved and she could be able to perform daily activity without sensation of instability. Bilateral patellar subluxation and systemic hyperlaxity are characteristics of syndromic patients and according to literature can be also present in DiGeorge syndrome. MPFL reconstruction with lateral release was demonstrated to be the correct solution in the treatment of patellar instability in this complex case. The choice of an artificial ligament to reconstruct the MPFL was useful in this specific patient with important tissue laxity due to her congenital syndrome.

Surgical Treatment of Objective Patellar Instability: Long-Term Results

Purpose  To evaluate the long-term results of classical “à la carte” surgical treatment of objective patellar instability as proposed by Dejour in 1987. Methods  A multicentric retrospective study was conducted evaluating patients that underwent surgical procedure with a 10-year minimum follow-up (mean 12.7; range, 10–15). Surgical procedures were medial transfer of the tibial tubercle transfer according to Elmslie and Trillat et al in 38 cases, plasty of the vastus medialis obliquus according to Insall in 15 cases, open lateral retinacular release in 13 cases, capsuloplasty in 3 cases, and trochleoplasty in 1 case. Different combinations of surgical procedures were adopted according to the pathological features. Subjective outcome was assessed with the visual analog scale (VAS), Kujala score, subjective International Knee Documentation Committee (IKDC) score, Tegner score, and Crosby and Insall scale. Radiographic exams were used to assess the patellar tilt by the Laurins angle and patellofemoral osteoarthritis (OA) according to the Iwano radiological OA scale. Results  Forty patients were evaluated. Subjectively, 60% of patients achieved a result judged good, 34% sufficient, and 6% poor. There were only two cases of recurrence of instability. Mean score results were Kujala score 73.4 ± 9.9 (range, 55–95), VAS 4.5 ± 1.2 (range, 1–6), IKDC 64.8 ± 7.9 (range, 51–88), and Tegner score 4. Only nine patients returned to sports activities). Ten patients developed a grade I patellofemoral OA, 8 patients a grade II, and 22 patients a grade III. Average patellar tilt was 10° ±  3.9°. Conclusion  This retrospective study showed that the traditional surgical procedure was successful for the treatment of patellar instability, but it did not prevent symptomatic patellofemoral OA. Level of Evidence  Level IV, retrospective case series.

Tuberculosis of the Knee: A Case Report and Literature Review

Tuberculosis (TB) is currently in resurgence due to immigration from endemic areas. Skeletal TB frequently mimics more common etiologies and can be difficult to diagnose. A case of TB knee arthritis in a young woman with painful and swelling knee is reported here. Arthrotomy was performed and inflamed synovial tissue was found, with multiple rice bodies in the eroded lateral femoral condyle. The patient was treated with an antituberculosis polytherapy and at 1-year follow-up, she reported relief from pain and swelling. We believe that all surgeons assessing patients from TB endemic regions have to adopt an updated approach to TB treatment. Thus, a literature review is also reported here on the current strategies used in different knee TB cases.

Second Generation Needling Techniques for the Treatment of Chondral Defects in Animal Model

Purpose  To compare the macroscopic, histological, and immunohistochemical characteristics of the repair tissue of chondral defects treated with microfracture and nanofracture in an ovine model. Methods  Full-thickness chondral lesions were created in the medial femoral condyle of both knees in four adult sheep and were treated with microfracture on one side and with nanofracture on the contralateral side. Chondral repair was assessed after 12 months by macroscopic, histological, and immunohistochemical analyses. Results  Histological cartilage repair significantly improved in the samples treated with nanofracture for cellular morphological characteristics and cartilage architecture. The immunohistochemical analysis showed a significantly higher immunoreactivity to type II collagen in the defects treated with nanofracture. Conclusion  Nanofracture provided better repair tissue than microfracture, with a more satisfactory cartilage architecture renovation and tissue having greater type II collagen content. Clinical Relevance  Mesenchymal stem cell stimulation is the most frequently used primary cartilage repair procedure. Nanofracture represents a novel technique to stimulate bone marrow that results into a successful repair of chondral defects.

Management of Collateral Ligament Injuries (Medial and Lateral) in Competitive Athletes

Medial collateral ligament (MCL) is the principal passive restraint to valgus forces applied to the knee and, along with other anatomic structures such as hamstrings muscles, is responsible for the stability of the medial compartment of the knee on the coronal plane. In a sportsmen population, MCL is frequently ruptured alone or in association with menisci and cruciate ligaments. The wide area of the lesion’s surface and the relatively high blood supply of the MCL explain the very high rate of spontaneous healing without need of surgical reparation or reconstruction. Return to play will be possible only at the resolution of pain and after having achieved a sufficient stability at the clinical exam. Surgical reparation in athletes can find an indication in the presence of a bony avulsion, in multiligamentous injuries, and in the presence of an isolated complete tear involving both midsubstance and tibial insertion. In the case of a clinically relevant chronic medial instability, the surgical indication is mandatory. Although isolated lateral collateral ligament (LCL) lesions are extremely rare, a varus instability-associated component is frequently noticed in the presence of a posterolateral instability or in multiligamentous injuries. Grade I and II lesions of the LCL and PLC are generally treated conservatively with full extension long-leg knee brace. In grade III injury of LCL and PLC, the risk of developing a chronic instability is very high, and the treatment of these lesions is mainly surgical.

Synovitis of the Knee

Etymologically, the word synovitis generally refers to acute or chronic inflammation of the synovial membrane. Today, however, the term is used to refer to a disease process (not necessarily inflammatory) that may originate from the synovial membrane and involve the structures of the joint. Synovitis can have different causes: traumatic, autoimmune, infectious, dysmetabolic or neoplastic, and it is typically characterised by the presence of varying degrees of swelling, pain, redness, heat and functional impairment. The knee is a frequent target of this disease, and it is the joint most likely to be affected by special forms of synovitis such as pigmented villonodular synovitis and synovial chondromatosis. Inflammatory and degenerative joint diseases are usually diagnosed on the basis of clinical and imaging data. However, these data are not always sufficient, especially in the event of a monoarticular onset; in such cases, the use of histopathology and a synovitis score will increase the diagnostic accuracy. There exist various histological scoring systems for synovitis, and the one proposed by Krenn, which is essentially applicable to all forms of synovitis, is the most commonly used. It is a numerical scoring system based on semi-quantitative grading of three key features of synovitis: enlargement of the lining cell layer, activation of stromal cells (as shown by the cellular density of the synovial stroma) and leukocytic infiltration. Each of these three components is assigned a score from 0 to 3, resulting in an overall score of between 0 and 9. Through the analysis of numerous large samples, mean Krenn scores have been established for normality (1.0), post-traumatic arthritis (2.0), osteoarthritis (2.0), psoriatic arthritis (3.5), reactive arthritis (5.0) and rheumatoid arthritis (5.0) [15]. A strong correlation has since emerged between the synovitis score, immunohistochemistry findings (Ki-67, CD68) and the clinical severity of the disease [7, 26]. The use of the synovitis score has proved to be useful in defining forms lacking the typical histological features, allowing them to be distinguished on the basis of the intensity and severity of the synovial inflammation.

Arthroscopic Treatment of Knee Stiffness

A loss of range of motion, commonly defined as stiffness, is a relatively common complication after knee surgery or traumatic injury [1]. The high incidence of postoperative knee stiffness observable in the past reduced significantly with improvement of surgical techniques and rehabilitation protocols [2]. Any symptomatic loss of knee flexion or extension compared with the opposite normal knee should be considered and treated as knee stiffness. In order to address conservative or surgical therapy, the cause, the type and the degree of stiffness must be identified and staged.