Joel L. Boyd

Adult human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial meniscectomy: a randomized, double-blind, controlled study.

BACKGROUND There are limited treatment options for tissue restoration and the prevention of degenerative changes in the knee. Stem cells have been a focus of intense preclinical research into tissue regeneration but limited clinical investigation. In a randomized, double-blind, controlled study, the safety of the intra-articular injection of human mesenchymal stem cells into the knee, the ability of mesenchymal stem cells to promote meniscus regeneration following partial meniscectomy, and the effects of mesenchymal stem cells on osteoarthritic changes in the knee were investigated. METHODS A total of fifty-five patients at seven institutions underwent a partial medial meniscectomy. A single superolateral knee injection was given within seven to ten days after the meniscectomy. Patients were randomized to one of three treatment groups: Group A, in which patients received an injection of 50 × 10⁶ allogeneic mesenchymal stem cells; Group B, 150 × 10⁶ allogeneic mesenchymal stem cells; and the control group, a sodium hyaluronate (hyaluronic acid/hyaluronan) vehicle control. Patients were followed to evaluate safety, meniscus regeneration, the overall condition of the knee joint, and clinical outcomes at intervals through two years. Evaluations included sequential magnetic resonance imaging (MRI). RESULTS No ectopic tissue formation or clinically important safety issues were identified. There was significantly increased meniscal volume (defined a priori as a 15% threshold) determined by quantitative MRI in 24% of patients in Group A and 6% in Group B at twelve months post meniscectomy (p = 0.022). No patients in the control group met the 15% threshold for increased meniscal volume. Patients with osteoarthritic changes who received mesenchymal stem cells experienced a significant reduction in pain compared with those who received the control, on the basis of visual analog scale assessments. CONCLUSIONS There was evidence of meniscus regeneration and improvement in knee pain following treatment with allogeneic human mesenchymal stem cells. These results support the study of human mesenchymal stem cells for the apparent knee-tissue regeneration and protective effects.

Controversies in the Treatment of Knee Dislocations and Multiligament Reconstruction

A systematic approach to evaluation and treatment is needed for the patient with knee dislocation. There is a paucity of high-level evidence on which to base treatment decisions. Reported controversies related to the treatment of the multiligament-injured knee include the selective use of arteriography for vascular assessment, serial physical examination with the ankle-brachial index, acute surgical treatment of all damaged structures, the selective application of preoperative and postoperative joint-spanning external fixation, arthroscopic reconstruction of the anterior cruciate ligament and posterior cruciate ligament, simultaneous open reconstruction with repair of the posterolateral corner, reconstruction and/or repair of the posteromedial corner, and the use of allograft tissue.

Home based rehabilitation for anterior cruciate ligament reconstruction.

Fifty-four patients who underwent arthroscopically assisted anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft or allograft were studied prospectively to compare a postoperative home based rehabilitation program with a clinic based program. Fifty-four patients (mean age, 30 years) were assigned randomly to the home based program (27 patients) or the clinic based program (27 patients). The home based schedule featured six physical therapy visits during a 6-month postoperative study period, whereas the clinic based schedule specified 24 physical therapy visits during those 6 months. All patients entered in the study met strict selection criteria: age older than 15 years, no previous ligament repair or reconstruction, no complicating medical conditions, no collegiate or professional athletes, reconstruction at least 6 weeks after injury, and informed consent. At the 6-month followup, no significant statistical differences were found between the two groups in range of motion, thigh atrophy, anterior drawer compliance, hopping tests, Lysholm scores, or subjective health status scores. Thus, the authors conclude that in a selected group of patients who have undergone anterior cruciate ligament reconstruction, a home based postoperative rehabilitation program is feasible, safe, and effective.

Autograft Versus Allograft: An Economic Cost Comparison of Anterior Cruciate Ligament Reconstruction

PURPOSE The purpose of this study was to compare the costs associated with anterior cruciate ligament (ACL) reconstruction with either bone-patellar tendon-bone (BPTB) autograft or BPTB allograft. METHODS Surgical costs are reported, including supply costs, based on invoice costs per item used per procedure, and personnel costs calculated as cost per minute. All operations were performed at an ambulatory surgery center between March 2005 and March 2006. A total of 160 patients underwent primary ACL reconstruction with either BPTB autograft (n = 106) or BPTB allograft (n = 54). Procedure cost data were retrieved from a financial management database and divided into various categories for comparison of the 2 groups. Payment data were provided by the surgery centers billing office. RESULTS The total mean cost per case was

Diagnosis and management of knee dislocations

4,147 ±

Correlating MRI Findings With Disability in Syndesmotic Sprains of NFL Players

943 in the allograft group compared with

Surgical treatment of acute and chronic anterior and posterior cruciate ligament and lateral side injuries of the knee.

3,154 ±

Bilateral Anterior Cruciate Ligament Reconstruction as a Single Procedure Evaluation of Cost and Early Functional Results

704 in the autograft group; this was statistically significant (P < .001). The mean operating room time was 12 minutes greater in autograft cases (P = .006). Supply costs comprised a mean of 58.7% of total expenses in the autograft group and 72.2% in the allograft group. CONCLUSIONS Allograft reconstruction of the ACL was significantly more expensive than autograft reconstruction. LEVEL OF EVIDENCE Level II, economic analysis.

Anterior Cruciate Ligament Injuries in Professional Hockey Players

Abstract An acute knee dislocation is an uncommon injury, with a high rate of associated vascular and neurologic injuries as well as potentially limb-threatening complications. High-energy trauma is the most common cause of an acute knee dislocation, although lower-energy injuries, such as those sustained during athletic competition, are increasing in incidence. Injuries to the popliteal artery and common peroneal nerve are relatively common, requiring a high index of suspicion and complete neurovascular examination in a timely fashion. All cases of suspected knee dislocation should have an ankle-brachial index performed, reserving arteriography for those with an abnormal finding. Initial management consists of closed reduction, if possible, and application of a hinged brace or external fixator. Definitive management remains an area of controversy, although anatomic surgical repair or reconstruction is favored by most surgeons to help optimize knee function. Most patients treated for a knee dislocation can expect to return to their daily activities, but with less predictable returns to sporting activities.

Cost-benefit comparison: holmium laser versus electrocautery in arthroscopic acromioplasty.

Background: Syndesmotic sprains may be a significant source of missed playing time, especially in football players. Advanced imaging is frequently used to confirm the clinical diagnosis. Our purpose was to evaluate the prognostic ability of MRI in predicting time of disability. Methods: Training room records from 1993 to 2007 for three National Football League teams were reviewed. Forty-three players were diagnosed with syndesmotic ankle injuries and underwent radiographs and magnetic resonance imaging. A blinded musculoskeletal radiologist interpreted all images. Players with fractures were excluded. Results: Thirty-six professional football players were included in the final analysis. Twenty-three players had a positive squeeze test which was correlated with increased missed practices (p = 0.012) and increased missed games (p ≤ 0.01). The average number of games missed was 3.3 (range, 0 to 20) and the average number of practices missed was 16.7 (range, 0 to 114). Four players had isolated injury to the anterior tibio-fibular ligament (AITFL) (MRI Grade I). Five players had injury to the AITFL and interosseous ligament (MRI Grade II). Twenty-four players sustained injury to the AITFL, interosseous ligament, and posterior inferior tibio-fibular ligament (MRI Grade III). Three players had Grade III injuries with additional injury to the deltoid ligament (MRI Grade IV). Increasing grade of injury was positively correlated with increased number of missed games (p = 0.033) and missed practices (p = 0.002). Conclusion: MRI can be useful to help delineate the injury pattern and associated injuries, and may be useful in predicting time of disability using a grading system. Positive squeeze test can also be useful to determine prognosis. Level of Evidence: IV, Retrospective Case Series