John Theodoropoulos

The clinical status of cartilage tissue regeneration in humans

PURPOSEnTo provide a comprehensive overview of the basic science and clinical evidence behind cartilage regeneration techniques as they relate to surgical management of chondral lesions in humans.nnnMETHODSnA descriptive review of current literature.nnnRESULTSnArticular cartilage defects are common in orthopedic practice, with current treatments yielding acceptable short-term but inconsistent long-term results. Tissue engineering techniques are being employed with aims of repopulating a cartilage defect with hyaline cartilage containing living chondrocytes with hopes of improving clinical outcomes. Cartilage tissue engineering broadly involves the use of three components: cell source, biomaterial/membranes, and/or growth stimulators, either alone or in any combination. Tissue engineering principles are currently being applied to clinical medicine in the form of autologous chondrocyte implantation (ACI) or similar techniques. Despite refinements in technique, current literature fails to support a clinical benefit of ACI over older techniques such as microfracture except perhaps for larger (>4 cm) lesions. Modern ACI techniques may be associated with lower operative revision rates. The notion that ACI-like procedures produce hyaline-like cartilage in humans remains unsupported by high-quality clinical research.nnnCONCLUSIONSnMany of the advancements in tissue engineering have yet to be applied in a clinical setting. While basic science has refined orthopedic management of chondral lesions, available evidence does not conclude the superiority of modern tissue engineering methods over other techniques in improving clinical symptoms or restoring native joint mechanics. It is hoped further research will optimize ease of cell harvest and growth, enhanced cartilage production, and improve cost-effectiveness of medical intervention.

Anatomic Bankart Repair Compared With Nonoperative Treatment and/or Arthroscopic Lavage for First-Time Traumatic Shoulder Dislocation

PURPOSEnThe objective of this systematic review was to determine the efficacy of anatomic Bankart repair in patients with a first-time shoulder dislocation compared with either arthroscopic lavage or traditional sling immobilization.nnnMETHODSnWe searched the Cochrane Central Register of Controlled Trials, Medline, Embase, CINAHL, Web of Science, LILACS, and a clinical trials registry for ongoing and completed randomized or quasi-randomized controlled trials comparing anatomic Bankart repair with either rehabilitation or arthroscopic lavage. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed by use of a random-effects model, and risk ratio (RR) and 95% confidence intervals (CIs) were computed.nnnRESULTSnWe included 3 randomized trials and 1 quasi-randomized trial comprising 228 patients. Of the included trials, 2 compared anatomic Bankart repair with sling immobilization whereas 2 compared Bankart repair with arthroscopic lavage. A meta-analysis of all 4 trials showed that the rate of recurrent instability was significantly lower among participants undergoing anatomic Bankart repair compared with those undergoing either immobilization or arthroscopic lavage (RR, 0.18; 95% CI, 0.10 to 0.33). Subgroup analysis showed that this effect persisted when Bankart repair was compared with arthroscopic lavage alone (2 studies) (RR, 0.14; 95% CI, 0.06 to 0.31) or sling immobilization alone (2 studies) (RR, 0.26; 95% CI, 0.10 to 0.67). Western Ontario Shoulder Instability scores were better with anatomic Bankart repair compared with either arthroscopic lavage or immobilization (2 studies) (mean difference, -232; 95% CI, -317 to -146).nnnCONCLUSIONSnThere is evidence to suggest treatment of young patients with a first-time shoulder dislocation with anatomic Bankart repair with the goal of lowering the rate of recurrent instability over the long-term and improving short-term quality of life.nnnLEVEL OF EVIDENCEnLevel II, systematic review of Level I and II studies.

Short- to Medium-term Outcomes After a Modified Broström Repair for Lateral Ankle Instability With Immediate Postoperative Weightbearing

Background: Anatomic techniques of ankle ligament repair have the advantage of restoring the anatomy and kinematics of the joint. This study presents a technique for anatomic reconstruction of the lateral ligament complex by way of lateral ligament advancement using suture anchors associated with immediate protected full weightbearing; 2- to 5-year clinical outcomes are reported. Hypothesis: This technique of providing an anatomic reconstruction with a secure fixation will enable early rehabilitation with immediate, protected weightbearing, with favorable outcomes. Study Design: Case series; Level of evidence, 4. Methods: Fifty-five patients with chronic lateral ankle instability who failed nonoperative management underwent modified Broström repair (lateral ligament fibular advancement) between 2005 and 2008. The anterior talofibular ligament and calcaneofibular ligament were released from the fibula and advanced using 2 double-loaded metallic suture anchors (3.5 mm). Full weightbearing in a walking boot was allowed from the first postoperative day. Patients were assessed preoperatively and at a minimum 2-year follow-up using the Foot and Ankle Outcome Score. Complication, failure (recurrent instability), and return-to-sport rates were also recorded. Results: Six patients (11%) were lost to follow-up, leaving a study group of 49 patients (23 men, 26 women). The mean age at the time of surgery was 25 years (range, 18-37 years), with a mean duration of symptoms of 1.8 years (range, 6 months to 5 years). The mean follow-up time was 42 months (range, 24-60 months). Significant improvement was seen in the Foot and Ankle Outcome Score from preoperatively to postoperatively (from 36 to 75.4, P < .001): the pain subscale improved from 35 to 75 (P < .001), the symptom subscale from 29 to 77 (P = .01), the function subscale from 45 to 77 (P < .001), the function in sports and recreation subscale from 38 to 70 (P < .001), and the foot and ankle–related quality of life subscale from 35 to 78 (P < .001). No significant difference in range of motion with the contralateral side was seen (P = .34). The failure rate was 6%, with 3 patients reporting residual instability after a traumatic retear. Two cases of superficial wound infection were seen. One case of temporary neurapraxia of the superficial peroneal nerve was observed. The return-to-sport rate was 94%. Conclusion: This study demonstrates that anterior talofibular ligament and calcaneofibular ligament advancement using suture anchor fixation is an effective procedure for the treatment of chronic lateral ankle instability and allows immediate weightbearing.

Revision Arthroscopic Bankart Repair

PURPOSEnFailed anterior shoulder stabilization procedures have traditionally been treated with open procedures. Recent advances in arthroscopic techniques have allowed for certain failed stabilization procedures to be treated by arthroscopic surgery. The aim of this systematic review was to determine the outcomes of revision arthroscopic Bankart repair.nnnMETHODSnWe searched Medline, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) for articles on revision arthroscopic Bankart repairs. Key words included shoulder dislocation, anterior shoulder instability, revision surgery, and arthroscopic Bankart repair. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data.nnnRESULTSnWe included 16 studies comprising 349 patients. All studies were retrospective (1xa0Level II study and 15 Level IV studies). The mean incidence of recurrent instability after revision arthroscopic Bankart repair was 12.7%, and the mean follow-up period was 35.4 months. The most common cause for failure of the primary surgeries was a traumatic injury (62.1%), and 85.1% of patients returned to playing sports. The reasons for failure of revision cases included glenohumeral bone loss, hyperlaxity, and return to contact sports.nnnCONCLUSIONSnWith proper patient selection, the outcomes of revision arthroscopic Bankart repair appear similar to those of revision open Bankart repair. Prospective, randomized clinical trials are required to confirm these findings.nnnLEVEL OF EVIDENCEnLevel IV, systematic review of Level II and Level IV studies.

Analysis of Irradiation on the Clinical Effectiveness of Allogenic Tissue When Used for Primary Anterior Cruciate Ligament Reconstruction

Background: It is unclear whether the use of low-dose irradiation or other tissue-processing methods, such as preservation by fresh-frozen (FF), freeze-drying (FD), or cryopreservation (CP) methods, affects the clinical outcomes of primary anterior cruciate ligament reconstruction (ACLR) using allograft. Hypothesis: Low-dose gamma irradiation (<2.5 Mrad) and method of allograft preservation do not affect subjective and objective clinical outcomes after primary ACLR in studies reviewed between November 2010 and September 2012. Study Design: Systematic review; Level of evidence, 3. Methods: A computerized search of multiple electronic databases was conducted from November 2010 to September 2012 for prospective and retrospective studies involving primary allograft ACLR. Inclusion criteria were English-language publications with a minimum average of 2 years’ follow-up. Studies were excluded if they involved revision surgery, open surgery, multiple ligament procedures, autograft, xenograft, meniscal allograft, skeletally immature patients, or grafts treated with ethylene oxide, Tutoplast, or irradiation >2.5 Mrad or if the tissue-processing methods were not specified. Clinical outcomes were evaluated using the Lysholm score, Tegner score, International Knee Documentation Committee (IKDC) score, KT-1000/2000 arthrometer score, Lachman test, and pivot-shift test, as well as by assessing complications related to graft rupture, revision surgery, and infections. Results: A total of 21 publications met the criteria, involving a total of 1453 patients, with 415 irradiated and 1038 nonirradiated allografts. Mean follow-up was 49.8 months (range, 12-170 months). Mean age of the patients was 32.2 years. Knees with nonirradiated allografts had higher mean Lysholm scores (89.8 vs 84.4; P < .05), and a higher proportion of <5-mm difference on KT-1000/2000 arthrometer (0.97 vs 0.84; P < .0001), grade 0 and 1 pivot-shift (0.99 vs 0.94; P < .0001), and grade 0 and 1 Lachman (0.94 vs 0.89; P < .01) than those with irradiated grafts. Knees with irradiated allografts had a higher proportion of grade A and B IKDC outcomes (0.91 vs 0.86; P < .05) and revision surgery (0.0250 vs 0.0022; P < .001) compared with those with nonirradiated allografts. The lack of data for FD and CP allografts meant no statistical analysis could be made comparing FF versus FD versus CP allografts. The effect of irradiation was similar within FF allografts. The effect of graft type and surgical technique could not be determined because of insufficient data. Conclusion: These results suggest that primary ACLRs using nonirradiated allografts may provide superior clinical outcomes than those using low-dose (<2.5 Mrad) irradiated grafts.

Magnetic resonance imaging and magnetic resonance arthrography of the shoulder: dependence on the level of training of the performing radiologist for diagnostic accuracy

PurposeDiscrepancies were identified between magnetic resonance (MR) imaging and clinical findings in patients who had MR imaging examinations evaluated by community-based general radiologists. The purpose of this study was to evaluate the diagnostic performance of MR imaging examinations of the shoulder with regard to the training level of the performing radiologist.MethodsA review of patient charts identified 238 patients (male/female, 175/63; mean age, 40.4xa0years) in whom 250 arthroscopies were performed and who underwent MR imaging or direct MR arthrography in either a community-based or hospital-based institution prior to surgery. All MR imaging and surgical reports were reviewed and the diagnostic performance for the detection of labral, rotator cuff, biceps, and Hill–Sachs lesions was determined. Kappa and Student’s t test analyses were performed in a subset of cases in which initial community-based MR images were re-evaluated by hospital-based musculoskeletal radiologists, to determine the interobserver agreement and any differences in image interpretation.ResultsThe diagnostic performance of community-based general radiologists was lower than that of hospital-based sub-specialized musculoskeletal radiologists. A sub-analysis of re-evaluated cases showed that musculoskeletal radiologists performed better. κ values were 0.208, 0.396, 0.376, and 0.788 for labral, rotator cuff, biceps, and Hill–Sachs lesions (t test statistics: pu2009=u2009<0.001, 0.004, 0.019, and 0.235).ConclusionsOur results indicate that the diagnostic performance of MR imaging and MR arthrography of the shoulder depends on the training level of the performing radiologist, with sub-specialized musculoskeletal radiologists having a better diagnostic performance than general radiologists.

Combined arthroscopic and open synovectomy for diffuse pigmented villonodular synovitis of the knee.

AbstractPurposenThere are few reports detailing recurrence rates or functional outcomes after combined arthroscopic and open synovectomy to treat diffuse pigmented villonodular synovitis (DPVNS) of the knee.MethodsPatients with DPVNS of the knee treated with combined synovectomy, followed for a minimum of 12xa0months at a tertiary orthopaedic oncology centre, were identified. We extracted data pertaining to demographics, complications, clinical outcomes and recurrence. Functional status was evaluated prospectively using the Toronto Extremity Salvage Score (TESS) and the Musculoskeletal Tumor Society (MSTS) 1987 and 1993 surveys. Data were reported descriptively as mean (SD) unless otherwise specified.ResultsFifteen patients [80xa0% female; mean age 38.9 (SD 14.2) years] representing 15 knees were treated with combined synovectomies and followed for 81 (SD 55) months. Posterior arthroscopy was utilized in 73xa0% of patients. External beam radiation was utilized post-operatively in 73xa0% of patients. Two patients (13xa0%) experienced symptomatic disease recurrence. The mean post-operative knee range of motion was 1° (range 0–10°) to 115° (range 90–135°). TESS and MSTS 1987/1993 scores all suggested excellent patient function. Post-operative complications included one posterior wound dehiscence, one case of femoral condyle avascular necrosis and one patient with lymphedema.ConclusionsCombined synovectomy resulted in a low rate of symptomatic disease recurrence and good to excellent functional outcomes for diffuse PVNS of the knee. A literature review identified this as largest case series focusing on combined synovectomies for DPVNS of the knee and the only one describing functional outcomes or the use of external beam radiotherapy.Level of evidenceRetrospective case series, Level IV.

Maximum load to failure and tensile displacement of an all-suture glenoid anchor compared with a screw-in glenoid anchor

AbstractPurposenThe purpose of this study was to evaluate the biomechanical behavior of an all-suture glenoid anchor in comparison with a more conventional screw-in glenoid anchor, with regard to maximum load to failure and tensile displacement.MethodsAll mechanical testing was performed using an Instron ElectroPuls E1000 mechanical machine, with a 10xa0N pre-load and displacement rate of 10xa0mm/min. Force–displacement curves were generated, with calculation of maximum load, maximum displacement, displacement at 50xa0N and stiffness. Pretesting of handset Y-Knots in bone analog models revealed low force displacement below 60xa0N of force. Subsequently, three groups of anchors were tested for pull out strength in bovine bone and cadaver glenoid bone: a bioabsorbable screw-in anchor (Bio Mini-Revo, ConMed Linvatec), a handset all-suture anchor (Y-Knot, ConMed Linvatec) and a 60xa0N pre-tensioned all-suture anchor (Y-Knot). A total of 8 anchors from each group was tested in proximal tibia of bovine bone and human glenoids (age range 50–90).ResultsIn bovine bone, the Bio Mini-Revo displayed greater maximum load to failure (206xa0±xa077xa0N) than both the handset (140xa0±xa051xa0N; Pxa0=xa00.01) and the pre-tensioned Y-Knot (135xa0±xa046xa0N; Pxa0=xa00.001); no significant difference was seen between the three anchor groups in glenoid bone. Compared to the screw-in anchors, the handset all-suture anchor displayed inferior fixation, early displacement and greater laxity in the bovine bone and cadaveric bone (Pxa0<xa00.05). Pre-tensioning the all-suture anchor to 60xa0N eliminated this behavior in all bone models.ConclusionsHandset Y-Knots display low force anchor displacement, which is likely due to slippage in the pilot hole. Pre-tensioning the Y-Knot to 60xa0N eliminates this behavior.Level of evidenceI.

Does Platelet-Rich Plasma Lead to Earlier Return to Sport When Compared With Conservative Treatment in Acute Muscle Injuries? A Systematic Review and Meta-analysis

PURPOSEnTo compare the time to return to sport and reinjury rate after platelet-rich plasma (PRP) injection versus control therapy (i.e., physiotherapy or placebo injection) in patients with acute grade I or II muscle strains.nnnMETHODSnAll eligible studies comparing PRP against a control in the treatment of acute (≤7xa0days) grade I or II muscle strains were identified. The primary outcome was time to return to play. The secondary outcome was the rate of reinjury at a minimum of 6xa0months of follow-up. Subgroup analysis was performed to examine the efficacy of PRP in hamstring muscle strains alone. The checklist to evaluate a report of a nonpharmacologic trial (CLEAR-NPT) was used to assess the quality of studies.nnnRESULTSnFive randomized controlled trials including a total of 268 patients with grade I and II acute muscle injuries were eligible for review. The pooled results revealed a significantly earlier return to sport for the PRP group when compared with the control group (mean difference,xa0-5.57xa0days [95% confidence interval,xa0-9.57 toxa0-1.58]; Pxa0= .006). Subgroup analysis showed no difference in time to return to sport when comparing PRP and control therapy in grade I and II hamstring muscle strains alone (Pxa0= .19). No significant difference was noted in the rate of reinjury between the 2 groups (Pxa0= .50) at a minimum of 6xa0months of follow-up.nnnCONCLUSIONSnEvidence from the current literature, although limited, suggests that the use of PRP may result in an earlier return to sport among patients with acute grade I or II muscle strains without significantly increasing the risk of reinjury at 6xa0months of follow-up. However, no difference in time to return to sport was revealed when specifically evaluating those with a grade I or II hamstring muscle strain.nnnLEVEL OF EVIDENCEnLevel II, meta-analysis of level I and II studies.

Reliability and Validity of the Arthroscopic International Cartilage Repair Society Classification System: Correlation With Histological Assessment of Depth

PURPOSEnTo determine the interobserver reliability of the International Cartilage Repair Society (ICRS) grading system of chondral lesions in cadavers, to determine the intraobserver reliability of the ICRS grading system comparing arthroscopy and video assessment, and to compare the arthroscopic ICRS grading system with histological grading of lesion depth.nnnMETHODSnEighteen lesions in 5 cadaveric knee specimens were arthroscopically graded by 7 fellowship-trained arthroscopic surgeons using the ICRS classification system. The arthroscopic video of each lesion was sent to the surgeons 6xa0weeks later for repeat grading and determination of intraobserver reliability. Lesions were biopsied, and the depth of the cartilage lesion was assessed. Reliability was calculated using intraclass correlations.nnnRESULTSnThe interobserver reliability was 0.67 (95% confidence interval, 0.5-0.89) for the arthroscopic grading, and the intraobserver reliability with the video grading was 0.8 (95% confidence interval, 0.67-0.9). A high correlation was seen between the arthroscopic grading of depth and the histological grading of depth (0.91); on average, surgeons graded lesions using arthroscopy a mean of 0.37 (range, 0-0.86) deeper than the histological grade.nnnCONCLUSIONSnThe arthroscopic ICRS classification system has good interobserver and intraobserver reliability. A high correlation with histological assessment of depth provides evidence of validity for this classification system.nnnCLINICAL RELEVANCEnAs cartilage lesions are treated on the basis of the arthroscopic ICRS classification, it is important to ascertain the reliability and validity of this method.