Kevin C. Wang

Bone Marrow Aspirate Concentrate for Cartilage Defects of the Knee: From Bench to Bedside Evidence:

Objective To critically evaluate the current basic science, translational, and clinical data regarding bone marrow aspirate concentrate (BMAC) in the setting of focal cartilage defects of the knee and describe clinical indications and future research questions surrounding the clinical utility of BMAC for treatment of these lesions. Design A literature search was performed using the PubMed and Ovid MEDLINE databases for studies in English (1980-2017) using keywords, including [“bone marrow aspirate” and “cartilage”], [“mesenchymal stem cells” and “cartilage”], and [“bone marrow aspirate” and “mesenchymal stem cells” and “orthopedics”]. A total of 1832 articles were reviewed by 2 independent authors and additional literature found through scanning references of cited articles. Results BMAC has demonstrated promising results in the clinical application for repair of chondral defects as an adjuvant procedure or as an independent management technique. A subcomponent of BMAC, bone marrow derived–mesenchymal stem cells (MSCs) possess the ability to differentiate into cells important for osteogenesis and chondrogenesis. Modulation of paracrine signaling is perhaps the most important function of BM-MSCs in this setting. In an effort to increase the cellular yield, authors have shown the ability to expand BM-MSCs in culture while maintaining phenotype. Conclusions Translational studies have demonstrated good clinical efficacy of BMAC both concomitant with cartilage restoration procedures, at defined time points after surgery, and as isolated injections. Early clinical data suggests BMAC may help stimulate a more robust hyaline cartilage repair tissue response. Numerous questions remain regarding BMAC usage, including cell source, cell expansion, optimal pathology, and injection timing and quantity.

Acute CD47 Blockade During Ischemic Myocardial Reperfusion Enhances Phagocytosis-Associated Cardiac Repair

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Patient Understanding, Expectations, Outcomes, and Satisfaction Regarding Anterior Cruciate Ligament Injuries and Surgical Management

Patient satisfaction has become an increasingly important outcome metric in orthopaedics and medicine in general as many initiatives at both the state and national levels aim to improve the efficiency and quality of health care. Anterior cruciate ligament injuries are among the most common injuries in orthopaedics, with anterior cruciate ligament reconstruction (ACLR) surgery consistently reported as one of the most frequently performed procedures by orthopaedic surgeons. Patient-reported outcomes are frequently used to evaluate outcomes from the patients perspective, and many physicians also ask patients about their satisfaction with treatment. A growing volume of literature has investigated the relation between preoperative patient expectations and postoperative patient satisfaction. The quality of online resources, patient expectations for ACLR, and factors associated with and/or predictive of either poor or good to excellent outcomes after surgery are described. This article critically reviews the orthopaedic literature on this important topic and identifies variables that influence patient expectations and satisfaction to help treating physicians better counsel and evaluate patients and ultimately improve outcomes of and satisfaction with ACLR surgery.

Male Sex, Decreased Activity Level, and Higher BMI Associated With Lower Completion of Patient-Reported Outcome Measures Following ACL Reconstruction

Background: Patient-reported outcome (PRO) surveys have become increasingly important in both improving patient care and assessing outcomes. Purpose/Hypothesis: The purpose of this study was to evaluate which variables are associated with compliance with completing PRO surveys in patients who have undergone anterior cruciate ligament reconstruction (ACLR). The authors hypothesized that older patient age and longer time since ACLR would be associated with lower completion rates of PRO surveys preoperatively and at postoperative time points. Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent ACLR by a sports medicine fellowship–trained orthopaedic surgeon at a single institution and were electronically assigned PRO surveys through a data collection system preoperatively between December 2013 and March 2015 were included. Postoperatively, PRO surveys were sent to patients’ email addresses at 6, 12, and 24 months. Demographics, history, and operative and postoperative information were evaluated for an association with survey completion rates. Results: A total of 256 patients met the inclusion criteria. There were 140 (54.7%) male and 116 (45.3%) female patients, with an overall mean age of 28.6 ± 11.9 years. Only 19 (7.4%) patients completed all preoperative and postoperative surveys at all time points. Less than half of the patients (n = 104; 40.6%) completed both the preoperative survey and at least 1 postoperative survey. There was a steady decrease in the completion rate of PRO surveys postoperatively over time (Pearson r = –0.995, P = .005). Male patients had significantly worse compliance with completing PRO surveys preoperatively and at a minimum of 1 time point postoperatively (P = .044). Patients who did not identify as athletes or report frequent exercise (≥3 times/wk) had significantly worse compliance with completing any PRO surveys (P = .046). Lower body mass index was associated with greater odds of compliance with completing the preoperative survey and 24-month postoperative survey (odds ratio, 0.902; P = .029). Conclusion: An inverse relationship was found between the surgery-to-survey period and percentage of those completing PRO surveys, with poor overall compliance. Male sex and not self-identifying as an athlete or performing frequent physical exercise were associated with lower completion rates of PRO surveys, while lower body mass index was associated with a greater rate of completion.

Factors Influencing Patient Selection of a Foot and Ankle Surgeon

An increasingly consumer-centric health insurance market has empowered patients to select the providers of their choice. There is a lack of studies investigating the rationale by which patients select a foot and ankle surgeon. In the present study, 824 consecutive new patients seeking treatment from 3 foot-ankle surgeons were consecutively administered an anonymous questionnaire prior to their first appointment. It included rating the importance of 15 factors regarding specialist selection on a 1 to 10 scale, with 10 designated “Very important” and 1 designated “Not important at all.” The remaining questions were multiple choice regarding patient perspectives on other surgeon aspects (appointment availability, waiting room times, clinic proximity, etc). Of 824 consecutive patients administered the survey, 305 (37%) responded. Patients rated board certification (9.24 ± 1.87) and on-site imaging availability (8.48 ± 2.37)—on a 1 to 10 scale, with 10 designated “Very important— as the 2 most important criteria in choosing a foot and ankle surgeon. Patients rated advertisements as least important. Among the patients, 91% responded that a maximum of 30 minutes should elapse between clinic check-in and seeing their physician; 61% responded that a maximum of 20 minutes should elapse between clinic check-in and seeing their physician. In the context of an increasingly consumer-driven paradigm of health care delivery and reimbursement, it is important to understand patients’ preferences in specialist selection. Levels of Evidence: Level III: Prospective questionnaire

Preoperative Tibial Subchondral Bone Marrow Lesion Patterns and Associations With Outcomes After Isolated Meniscus Allograft Transplantation

Background: The association between preoperative tibial subchondral bone marrow lesion (BML) patterns and outcomes after isolated meniscus allograft transplantation (MAT) are unknown. Purpose: To determine (1) if a superior classification means exists (ie, high interrater reliability [IRR]) for grading tibial subchondral BML before isolated MAT and (2) whether quality and/or severity of preoperative tibial subchondral BML patterns was associated with clinical outcomes and/or failure rates after isolated MAT. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent isolated MAT with a single surgeon between October 2006 and February 2017 were identified. Three means were evaluated to quantify the degree of subchondral BML in the affected tibial-sided compartment: Welsch et al, based on maximum diameter of the lesion; Costa-Paz et al, based on appearance and location of the lesion; and Filardo et al, based on severity of findings. IRR was generated and compared among the 3 classifications. The preoperative magnetic resonance imaging (MRI) subchondral BML grading scheme with the highest IRR was then used to assess for associations with postoperative outcomes for those patients with >2-year follow-up, per a Spearman correlation matrix with each reviewer’s grades. Results: In total, 60 MRI scans were available for subchondral BML grading. Grader 1 identified the presence of subchondral BML in the tibia of the affected compartment in 40 (66.7%) of the available MRI scans, as compared with 38 (63.3%) for grader 2. The calculated IRRs with the Welsch et al and Costa-Paz et al classifications were rated “strong/almost perfect” agreement. A significant correlation was demonstrated between grader 1 with the Welsch et al grading scheme and outcome measures of KOOS pain (Knee injury and Osteoarthritis Outcome Score; negative correlation, P = .05), WOMAC pain (Western Ontario and McMaster Universities Osteoarthritis Index; positive correlation, P = .026), and Marx Activity Rating Scale (negative correlation, P = .019). A significant correlation was demonstrated between grader 2 with the Costa-Paz et al grading scheme and postoperative satisfaction (positive correlation, P = .018). There were no significant differences in survivorship based on gradings. Conclusion: Nearly two-thirds of patients who undergo isolated MAT have subchondral BML on preoperative MRI. Our findings suggest that increasing BML size (Welsch et al) is correlated with worse postoperative pain measures (KOOS pain, WOMAC pain) and worse activity ratings (Marx Activity Rating Scale). Additionally, increasing disruption or depression of the normal contour of the cortical surface, with or without lesion contiguity with the subjacent articular surface (Costa-Paz et al), is correlated with greater postoperative satisfaction.

Factors Influencing Patient Selection of an Orthopaedic Sports Medicine Physician

Background: The rise in consumer-centric health insurance plans has increased the importance of the patient in choosing a provider. There is a paucity of studies that examine how patients select an orthopaedic sports medicine physician. Purpose: To evaluate factors that patients consider when choosing an orthopaedic sports medicine physician. Study Design: Case series; Level of evidence, 4. Methods: A total of 1077 patients who sought treatment by 3 sports medicine physicians were administered an anonymous questionnaire. The questionnaire included 19 questions asking respondents to rate the importance of specific factors regarding the selection of orthopaedic sports medicine physicians on a scale of 1 (not important at all) to 10 (very important). The remaining 6 questions were multiple-choice and regarded the following criteria: preferred physician age, appointment availability, clinic waiting room times, travel distance, and medical student/resident involvement. Results: Of the 1077 consecutive patients administered the survey, 382 (35%) responded. Of these, 59% (n = 224) were male, and 41% (n = 158) were female. In ranking the 19 criteria in terms of importance, patients rated board certification (9.12 ± 1.88), being well known for a specific area of expertise (8.27 ± 2.39), and in-network provider status (8.13 ± 2.94) as the 3 most important factors in selecting an orthopaedic sports medicine physician. Radio, television, and Internet advertisements were rated the least important. Regarding physician age, 63% of patients would consider seeking a physician who is ≤65 years old. Approximately 78% of patients would consider seeking a different physician if no appointments were available within 4 weeks. Conclusion: The study results suggest that board certification, being well known for a specific area of expertise, and health insurance in-network providers may be the most important factors influencing patient selection of an orthopaedic sports medicine physician. Advertisements were least important to patients. Patient preferences varied regarding ideal physician age, clinic appointment availability, medical student/resident involvement, and travel distance in choosing an orthopaedic sports medicine physician. In the context of health care delivery and as reimbursement becomes increasingly consumer centered, understanding the process of provider selection is important.

Multiple Osteochondral Allograft Transplantation with Concomitant Tibial Tubercle Osteotomy for Multifocal Chondral Disease of the Knee

Symptomatic patellofemoral chondral lesions are a challenging clinical entity, as these defects may result from persistent lateral patellar maltracking or repetitive microtrauma. Anteromedializing tibial tubercle osteotomy has been shown to be an effective strategy for primary and adjunctive treatment of focal or diffuse patellofemoral disease to improve the biomechanical loading environment. Similarly, osteochondral allograft transplantation has proven efficacy in physiologically young, high-demand patients with condylar or patellofemoral lesions, particularly without early arthritic progression. The authors present the surgical management of a young athlete with symptomatic tricompartmental focal chondral defects with fresh osteochondral allograft transplantation and anteromedializing tibial tubercle osteotomy.

Arthroscopic Management of Isolated Tibial Plateau Defect With Microfracture and Micronized Allogeneic Cartilage–Platelet-Rich Plasma Adjunct

Articular cartilage lesions of the tibial plateau are an uncommonly encountered clinical entity, and they have been comparatively less well studied than femoral condyle or patellofemoral defects. The management of these lesions is complicated by the challenging geometry, difficult surgical approach, and proximity to important anatomic structures, and thus, treating these lesions by previously established methods, such as osteochondral allograft transplantation or osteochondral autograft transfer, can be a technically challenging endeavor. These lesions remain readily available to undergo microfracture, and this is the preferred method of management in the senior authors practice. Although less technically difficult and less invasive than other techniques, microfracture is currently limited by concerns over the long-term durability of the method. Current research seeks to improve the quality of cartilage fill stimulated by microfracture, and adjunct techniques have become increasingly popular. In this technical report, we present a technique for arthroscopic treatment of an isolated tibial plateau defect with microfracture using a micronized allogeneic cartilage (BioCartilage; Arthrex, Naples, FL) and platelet-rich plasma adjunct.

Relationship Between Quantitative MRI Biomarkers and Patient-Reported Outcome Measures After Cartilage Repair Surgery: A Systematic Review:

Background: Treatment of articular cartilage injuries remains a clinical challenge, and the optimal tools to monitor and predict clinical outcomes are unclear. Quantitative magnetic resonance imaging (qMRI) allows for a noninvasive biochemical evaluation of cartilage and may offer advantages in monitoring outcomes after cartilage repair surgery. Hypothesis: qMRI sequences will correlate with early pain and functional measures. Study Design: Systematic review; Level of evidence, 3. Methods: A PubMed search was performed with the following search terms: knee AND (cartilage repair OR cartilage restoration OR cartilage surgery) AND (delayed gadolinium-enhanced MRI OR t1-rho OR T2 mapping OR dgemric OR sodium imaging OR quantitative imaging). Studies were included if correlation data were included on quantitative imaging results and patient outcome scores. Results: Fourteen articles were included in the analysis. Eight studies showed a significant relationship between quantitative cartilage imaging and patient outcome scores, while 6 showed no relationship. T2 mapping was examined in 11 studies, delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) in 4 studies, sodium imaging in 2 studies, glycosaminoglycan chemical exchange saturation transfer (gagCEST) in 1 study, and diffusion-weighted imaging in 1 study. Five studies on T2 mapping showed a correlation between T2 relaxation times and clinical outcome scores. Two dGEMRIC studies found a correlation between T1 relaxation times and clinical outcome scores. Conclusion: Multiple studies on T2 mapping, dGEMRIC, and diffusion-weighted imaging showed significant correlations with patient-reported outcome measures after cartilage repair surgery, although other studies showed no significant relationship. qMRI sequences may offer a noninvasive method to monitor cartilage repair tissue in a clinically meaningful way, but further refinements in imaging protocols and clinical interpretation are necessary to improve utility.