Luiz Felipe Morlin Ambra

Review: Interventions for Cartilage Disease: Current State-of-the-Art and Emerging Technologies

Articular cartilage has limited intrinsic repair capabilities, and cartilage defects can progress to osteoarthritis (OA) over time (1,2). Although several other factors are involved in the development of OA, this review will focus on cartilage defects (2). Even knee joints with asymptomatic cartilage defects have shown twice the rate of further cartilage loss compared with intact knees, and worsening was demonstrated in 81% of chondral defects over only 2 years (1). Young patients with cartilage defects are frequently as symptomatic as older patients presenting with established OA (3). OA is a common cause of knee pain and disability (4), with almost half the population becoming symptomatic within their lifetimes (5), and the rates of arthritis-related joint replacement surgery continue to steadily increase. OA presents a major economic burden, being among the leading causes of disability in developed countries (6). The risk of disability attributable to knee OA is as great as that due to cardiovascular disease (7). It causes considerable pain, functional limitation, deterioration of health-related quality of life, and in some cases, symptoms of depression (8). For those who fail to respond to conservative treatment, there are several options for biologic repair and reconstruction that may ideally treat definitively or at least “bridge” the patient until he or she reaches an age that is more appropriate for arthroplasty. While overall the outcomes of primary joint replacement are among the best of any orthopedic procedure, both satisfaction with the procedure and implant survival are significantly lower in younger patients (9). One study in patients younger than age 40 years showed good and excellent Knee Society knee function scores in only 50% of patients and a failure rate of 12.5% at 8 years (10). Subsequent revision surgery is technically more challenging and less successful than a primary procedure, with a patient satisfaction rate as low as 59% (11) and 5-year survival in younger patients as low as 82% (12). Last, revision surgery is extremely costly, with average charges of

Total knee arthroplasty with computer-assisted navigation: an analysis of 200 cases,

73,000 (13). It therefore appears worthwhile to invest in procedures, such as cartilage repair, with the potential for reducing disability and delaying arthroplasty as long as possible, especially in young patients. Current recommendations for cartilage repair include treatment of symptomatic defects in patients up to age 55 years (14). Moreover, the development of concomitant surgical procedures, such as meniscus transplantation, to address articular comorbidities that previously were considered contraindications for cartilage repair have further expanded the indications (15). While providing relief for many patients who otherwise would have no treatment, cartilage repair and biologic reconstruction continue to evolve, overcoming the limitations of current technology. The major challenges concern the restoration of a biomechanically and biochemically competent extracellular matrix and intimate integration of the newly synthesized matrix with the resident surrounding tissue. This explains the special interest in biologic augmentation, such as the use of growth factors, platelet concentrates, and stem cells (for review, see ref. 16). The potential of these biologic products is based on their antiinflammatory, Luiz Felipe Ambra, MD: Universidade Federal de S~ao Paulo, Sao Paulo, Brazil, and Brigham and Women’s Hospital, Boston, Massachusetts; Laura de Girolamo, PhD: Galeazzi Orthopaedic Institute, Milan, Italy; Brian Mosier, MD: Allegheny Health Network, Pittsburgh, Pennsylvania; Andreas H. Gomoll, MD: Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts. Drs. Ambra and Girolamo contributed equally to this work. Dr. Gomoll has received research funding from JRF, Vericel, NuTech, and SBM. Address correspondence to Luiz Felipe Ambra, MD, Universidade Federal de SaGomollo Paulo, Rua Borges Lagoa 783, Fifth Floor, Sao Paulo 04023–900, Brazil. E-mail: felipeambra71@ gmail.com. Submitted for publication July 11, 2016; accepted in revised form March 7, 2017.

Prevalence of lesions associated with traumatic recurrent shoulder dislocation

Objective to evaluate the results from surgery with computer-assisted navigation in cases of total knee arthroplasty. Method a total of 196 patients who underwent total knee arthroplasty with computer-assisted navigation were evaluated. The extension and flexion spaces (gaps) were evaluated during the operation and the alignment after the operation was assessed. The Knee Society Score (KSS) questionnaire for assessing patients function was applied preoperatively and postoperatively after a mean follow-up of 22 months. Results in all, 86.7% of the patients presented good alignment of the mechanical axis (less than 3° of varus or valgus in relation to the mechanical axis) and 96.4% of the patients presented balanced flexion and extension gaps. Before the operation, 97% of the patients presented poor or insufficient KSS, but after the operation, 77.6% presented good or excellent KSS. Conclusion the navigation system made it possible to achieve aligned and balanced implants, with notable functional improvement among the patients. It was found to be useful in assessing, understanding and improving knowledge in relation to performing arthroplasty procedures.

Anatomic Posterolateral Corner Reconstruction With Autografts

Objective: To evaluate the prevalence of lesions associated with traumatic anterior shoulder instability and the relationships between the prevalence of these lesions and the number of episodes and time since symptoms started. Method: Fifty-seven patients aged 18 to 40 years, with traumatic anterior shoulder instability, more than one episode of shoulder dislocation and at least six months since the first dislocation, who required surgery to treat the instability, were selected. Arthroscopic inspection was performed on all the patients to assess any associated lesions. Results: The prevalence of lesions was assessed, and Bankart lesions were the most prevalent, followed by Hill-Sachs lesions, while rotator cuff injuries were the least prevalent. There was no correlation from comparison between the number of episodes of dislocation and the prevalence of associated lesions. On the other hand, in relation to the time since symptoms started, the patients who had had symptoms for longer times had fewer Hill-Sachs lesions. Conclusion: It was not possible to affirm that, in patients with chronic shoulder instability, the numbers of associated lesions increased with the time since symptoms started, or with the number of episodes of dislocation.

Bone plug versus Suture-Only Fixation of Medial Meniscus Allograft Transplantation. Biomechanical Study

Anatomic posterolateral corner reconstruction reproduces 3 main structures: the lateral collateral ligament, the popliteofibular ligament, and the popliteus tendon. The LaPrade technique reproduces all 3 main stabilizers. However, it requires a long graft, limiting its indication to clinical settings in which allograft tissue is available. We propose a surgical procedure that is a modification of the LaPrade technique using the same tunnel placement, hamstring autografts, and biceps augmentation when necessary. It relies on artificial graft lengthening provided by the loop of the suspensory fixation device fixed at the anterior tibial cortex. The final reconstruction reproduces the popliteus tendon with the bulkiest end of the semitendinosus; the popliteofibular ligament with a strand of the semitendinosus and a strand of the gracilis; and the lateral collateral ligament with a strand of the semitendinosus and a strand of the gracilis, which can also be augmented with a biceps strip.

Comprehensive Approach to Patellofemoral Chondral Lesion Treatments

Objectives: Our objective was to evaluate the contact load characteristics of medial meniscus allograft transplantation performed by bone-plug versus soft-tissue suture-only fixation in cadaveric knees. Our null hypothesis was that there would not be significant differences between the two fixation groups with regard to load contact pressures and distribution. Methods: Experimental laboratory study in nine fresh-frozen human cadaveric knees (mean age 46.3 years, range 41-50; 5 female). None had cartilage, ligament or meniscal lesions as evaluated by XR and MRI exam. Fresh-frozen, size- and side-matched medial meniscus allografts were obtained based on XR measurements (Pollard method). The knees were secured in a load apparatus where rotation, flexion, extension and tilt were adjusted to ensure correct knee alignment during loading. The tibiofemoral joint surface was oriented parallel to the floor while the femur was placed in three positions: 0, 30 and 60 degrees. A 700N load was applied axially through the knee. Mean and Peak Contact Pressure and contact area were measured with an I-scan pressure sensor-4011 (Tekscan, Boston / MA) placed underneath the medial meniscus through a small capsular incision. The same protocol was applied for each condition: native meniscus, meniscectomy, meniscal allograft transplantation with bone plug (MAT-bone) and with suture-only fixation (MAT-suture). Two measurements were taken under each testing condition. Meniscus transplants were first secured with bone plugs and capsular sutures, and measurements taken. Then, the bone plugs were carefully removed from the meniscal roots and the recipient slots in the tibial plateau filled with cement. The roots were then re-secured with trans-tibial suture-only fixation. The results of mean and peak contact stress and contact area were compared between intact, meniscectomized, MAT-bone and MAT-suture using analysis of variance (ANOVA). The level of significance was set at lower than p0.05. Results: Meniscectomy significantly increased mean contact pressure and the contact area was significant reduced in comparison with the native condition at 0,30 and 60 degrees (p.001). Although the peak contact pressure was higher in the meniscectomy group, it was not statistically significant. Suture-only fixation resulted in slightly higher contact pressure and smaller contact area than bone plug fixation. No significant differences were found for mean and peak contact pressures and contact area between MAT-bone and MAT-suture. Also, regardless of technique, no significant differences were found between transplanted meniscus and native condition. The only exception occurred in 0 degrees of flexion, where MAT-suture demonstrated a statistically significant smaller contact area when compared with the native meniscus (p.016). Conclusion: This study demonstrated that meniscal allograft transplantation can restore load parameters close to the native condition. No significant differences were detected between bone-plug and soft-tissue fixation. This study is unique in utilizing size-matched meniscal transplants and using the same transplant for bone plug and suture-only fixation, thus reducing confounding factors.

Cell-seeded Autologous Chondrocyte Implantation (cs-ACI) - A Simplified Implantation Technique with Maintained Clinical Outcomes

Cartilage lesions frequently involve the patellofemoral joint. Damage from blunt trauma, patellar dislocation and/or degenerative pathology frequently results in gradual articular cartilage deterioration leading to debilitating joint pain, functional impairment, and osteoarthritis. Currently, the standard surgical procedure for end-stage degenerative joint disease is joint arthroplasty. Due to the limitations imposed by the arthroplasty, a biological restoration approach earlier in the disease process is desirable for young and active patients. The pathoanatomy, biomechanics and cartilage thickness are unique to the patellofemoral compartment and must be addressed in a comprehensive manner concomitantly with cartilage restoration. Recognition and correction of these unique features of the PF compartment are critical to the optimization of clinical outcomes.

Fresh Osteochondral Allograft Transplantation: A Suitable Option for the Treatment of Patellofemoral Joint Cartilage Lesions in the Young Patient

Objectives: The objective of this study was to investigate whether outcomes and failure rate of a simplified ACI technique (cs-ACI) were comparable to those of the more complicated traditional technique of a chondrocyte suspension injected under membrane cover (cACI). Methods: Patients were treated with cACI prior to February 2010. After this date the senior author switched to the cs-ACI technique for all patients. For the cs-ACI technique, cultured chondrocytes were seeded in the OR onto a collagen membrane, which was subsequently placed into the cartilage defect and secured with a running suture and/or fibrin glue. Thirty-nine patients treated with the cs-ACI technique fulfilled the inclusion requirements of minimum 2 year follow-up and complete data set. A comparison group was composed of 45 patients treated prior to the switch date with standard ACI (cACI) in which a suspension of cultured chondrocytes was injected into a debrided chondral defect underneath a sutured collagen cover. Prospectively collected data were retrieved from our IRB-approved database. Both groups followed an identical post-operative protocol. The outcomes were measured with the 12-Item Short-Form Health Survey (SF-12), International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm knee scale, and Tegner activity scale. We defined failure as any graft removal of more than 25% of the original defect size, for example through revision with allograft or arthroplasty. Mann-Whitney U tests were used to compare mean scores between groups preoperatively and at the latest follow-up; chi-square test was used to detect differences between groups. Graft survivorship was calculated by the Kaplan-Meier method, and distributions were compared using the log rank test. Results: Group demographics were not significantly different, except for defect size (Table 1) and average follow-up: 4 years in the cACI group and 2.5 years in the cs-ACI group. Significant improvements were seen in all scores except Tegner from the pre-operative baseline to the latest follow-up for both groups; however, no significant difference was found between groups at the latest follow-up. Failure rate at 2 years was not significantly different, while total failure rate over the entire study period was significantly lower in the cell-seeded group (cs-ACI) (5% versus 24%). The difference in Kaplan-Meier survivorship (Figure 1) failed to reach significance. Conclusion: Both ACI techniques demonstrated statistically significant and clinically meaningful improvements in patient reported outcomes that were not different between groups. Follow-up time was shorter in the cell-seeded technique, as patients in this group were treated more recently. The absolute failure rate was significantly lower in the simplified, cell-seeded technique with 5% versus 24% with the traditional technique. However, this should be interpreted in context of the shorter follow-up time and smaller defect size in the cell-seeded group, both favoring a lower failure rate. Overall, this study demonstrated that a simplified ACI technique maintained the same patient reported outcomes of a more complicated traditional technique without increases in failure.

Prevalência das lesões associadas na luxação recidivante traumática do ombro

Luiz Felipe Ambra1, Jack Farr2* and Andreas H Gomoll3 1Department of Orthopedic and Traumatology, Federal University of Sao Paulo, USA 2OrthoIndy Cartilage Restoration Center, OrthoIndy Hospital, USA 3Brigham and Women’s Center for Regenerative Medicine, Harvard Medical School Director, USA *Corresponding author: Jack F, OrthoIndy Cartilage Restoration Center, OrthoIndy Hospital, 1260 Innovation Parkway, Ste 100 Greenwood, IN 46143, USA, Tel: (317) 884-5200; Fax: (317) 884-5385; E-mail: jfarr@orthoindy.com

Anterior cruciate ligament reconstruction: how do we perform it? Brazilian orthopedic surgeons' preference.

OBJECTIVE: To evaluate the prevalence of lesions associated with traumatic anterior shoulder instability and the relationships between the prevalence of these lesions and the number of episodes and time since symptoms started. METHOD: Fifty-seven patients aged 18 to 40 years, with traumatic anterior shoulder instability, more than one episode of shoulder dislocation and at least six months since the first dislocation, who required surgery to treat the instability, were selected. Arthroscopic inspection was performed on all the patients to assess any associated lesions. RESULTS: The prevalence of lesions was assessed, and Bankert lesions were the most prevalent, followed by Hill-Sachs lesions, while rotator cuff injuries were the least prevalent. There was no correlation from comparison between the number of episodes of dislocation and the prevalence of associated lesions. On the other hand, in relation to the time since symptoms started, the patients who had had symptoms for longer times had fewer Hill-Sachs lesions. CONCLUSION: It was not possible to affirm that, in patients with chronic shoulder instability, the numbers of associated lesions increased with the time since symptoms started, or with the number of episodes of dislocation.