Robert F. LaPrade

Evidence for the Use of Cell-Based Therapy for the Treatment of Osteonecrosis of the Femoral Head: A Systematic Review of the Literature

BACKGROUNDnCell-therapy has been promoted among the therapeutic arsenal that can aid in bone formation and remodeling, in early stages of osteonecrosis of the femoral head (ONFH). The purpose of this systematic review was to assess the evidence supporting the (1) clinical efficacy; (2) structural modifying effect, as evaluated radiographically; (3) revision rates; and (4) safety of cell-therapy for the treatment of ONFH.nnnMETHODSnA systematic review was performed including studies with a level-of-evidence of III or higher. A total of 1483 articles were screened. Eleven studies met the criteria for inclusion in this review (level-of-evidence: 6 level-I, 1 level-II, and 4 level-III), including 683 cases of ONFH.nnnRESULTSnAll 10 studies that reported patient-reported outcomes showed improved outcomes in the cell-therapy groups compared with the control group. Overall, 24.5% (93/380 hips) that received cell-therapy showed radiographic progression compared with 40% (98/245 hips) in the control group. Nine of 10 studies that reported failure rates showed a lower total hip arthroplasty conversion rate in the cell-therapy group 16% (62/380 hips) compared with the control group 21% (52/252 hips). There was a low complication rate (<3%) with no major adverse effects.nnnCONCLUSIONnCell-therapies for the treatment of ONFH have been reported to be safe and suggest improved clinical outcomes with lower disease progression rate. However, there was substantial heterogeneity in the included studies, and in the cell-based therapies used. Specific clinical indications and cell-therapy standardization are required because studies varied widely with respect to cell sourcing, cell characterization, adjuvant therapies, and assessment of outcomes.

Diagnosis and treatment of multiligament knee injury: state of the art

Multiligament knee injuries constitute a complex and challenging entity, not only because of the diagnosis and reconstruction procedure itself, but also because of the rehabilitation programme after the index procedure. A high level of suspicion and a comprehensive clinical and radiographic examination are required to identify all injured structures. Concomitant meniscal, chondral and nerve injuries are common in multiligament injuries necessitating a detailed evaluation. Stress radiographs are valuable in evaluating patients preoperatively and postoperatively. The current literature supports surgical management of multiligament injuries, and reconstructions are recommended because repair of ligaments has higher failure rates. Reconstruction of all injured ligaments in one stage is advocated (if possible) in order to achieve early mobilisation and to avoid joint stiffness. Using biomechanically and clinically validated anatomic ligament reconstructions improves outcomes. In the setting of multiligament knee reconstructions, several technical aspects that require consideration are vital, such as the graft choice, the sequence of ligaments reconstruction, tunnel position and orientation to avoid tunnel interference and graft tensioning order. This review article discusses the use of stress radiographs in diagnosing ligament injuries and evaluating postoperative stability. Tunnel convergence and tensioning sequence are potential problems, and guidelines to address these are also discussed. Recovery after a multiligament reconstruction surgery typically requires 9 to 12 months of rehabilitation prior to returning to full activities. The purpose of this article is to review the specific principles of multiligament injuries, classification, diagnosis, treatment options and rehabilitation guidelines for addressing these complex injuries.

Anatomic posterior cruciate ligament reconstruction: state of the art

The posterior cruciate ligament (PCL) is recognised to be the main posterior stabiliser of the knee. PCL injuries are most commonly associated with concurrent ligament injuries and also with a high prevalence of chondral and meniscal injuries. Recent evidence of the accuracy of the stress radiographs as an objective diagnostic tool has improved assessment of surgical indications and postoperative assessment. Acute, isolated PCL injuries (grades I and II) can be treated non-operatively. However, in cases of acute grade III PCL injuries or when concurrent multiligament injuries or repairable meniscal body/root tears are present, surgery is indicated. Anatomic single-bundle PCL reconstruction (PCLR), focusing on reconstruction of the larger anterolateral bundle, is the most commonly performed procedure. Owing to the residual posterior and rotational tibial instability after a single-bundle reconstruction procedure and the inability to restore normal knee kinematics, an anatomic double-bundle PCLR has been proposed in an effort to recreate the native PCL footprint more closely and to restore normal knee kinematics. The purpose of this article is to review the specific principles of PCL anatomy, biomechanics, injury diagnosis and treatment options, with a focus on arthroscopic double-bundle PCLRs.

Return to Play After Multiple Knee Ligament Injuries

Multiple ligament knee injuries are complex and challenging pathologies that often result from traumatic knee dislocations. An appropriate diagnosis and treatment of all the damaged structures is vital for a successful outcome. Reconstruction of all injured ligaments is recommended in order to aid in early mobilization and to avoid joint stiffness or graft failure. Postoperative recovery after a multiligament knee reconstruction procedure typically requires 9–12 months of rehabilitation prior to returning to full activities. This allows proper time for the grafts to incorporate and to heal in order to prevent graft failure. A well-crafted rehabilitation plan after a multiligament knee reconstruction should focus on graft protection and functional outcomes including regaining motion, strength, and function. Once a muscular strength foundation with good dynamic neuromuscular control has been established, patients can progress to their functional sport-specific exercises. The purpose of this chapter is to give a thorough overview of key rehabilitation concepts after a multiligament knee reconstruction.

Advances in Treatment of Complex Knee Injuries

Multi-ligament knee injuries constitute a challenging entity, because of the complexity of diagnosis, associated injuries, reconstruction procedures, and the postoperative rehabilitation program. A comprehensive clinical and radiographic examination is essential to identify all injured structures and to develop a detailed plan of treatment. Reconstruction of all injured ligaments and concomitant injuries in one stage is advocated in order to achieve early mobilization and to avoid joint stiffness. During multi-ligament knee reconstruction surgery, detailed planning of all steps is mandatory. Several technical aspects require consideration, such as the graft choice, the sequence of ligament reconstruction, tunnel position and orientation to avoid tunnel convergence, graft tensioning order, and the postoperative rehabilitation protocol. Detailed preoperative planning and close attention to details during surgery are key to achieving successful outcomes. Rehabilitation after a multi-ligament reconstruction surgery typically requires 9–12 months, after which returning to full activities can be permitted. In this chapter, the principles of multi-ligament injuries including patient demographics and associated injuries, diagnosis and treatment approaches, surgical pearls for avoiding tunnel convergence, and the graft tensioning sequence, outcomes, and prevalence of osteoarthritis after knee dislocation surgery and future perspectives are discussed.

Orthobiologics: Today and Tomorrow

Biologic-based therapy for cartilage pathology has gained considerable recognition due to being minimally invasive, offering capacity for faster healing, and potential for rapid recovery. These therapies include tissue-specific cell culture, marrow-venting procedures, platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), and cell-based therapies. Reports thus far have yielded promising results with a relatively robust safety profile. Although important advances have been made in the field, further well-designed clinical trials are required. Current limitations include their high cost and limited long-term evidence of efficacy. This chapter aims to review the existing literature for biologic-based treatment options for cartilage and identify potential avenues for development.

Anatomy and Biomechanics of the Native Knee and Its Relevance for Total Knee Replacement

The purpose of this article is to perform a 360° review of the anatomy and biomechanics of the native knee and its relevance for total knee replacement. Comprehensive knowledge of the anterior and posterior cruciate ligaments and the ligaments and tendons on the medial and lateral sides of the knee is foundational for recreating normal kinematics in a pathologic state. Lower limb misalignments produced by pathologies such as osteoarthritis and rheumatologic conditions can alter the medial and lateral length and tension of the ligaments that are important to address when balancing soft tissues during an arthroplasty procedure. Moreover, careful handling and preservation of the ligament complex during the tibial osseous cuts is key for a successful procedure. Thus, the pertinent anatomy of these structures is described and reinforced by figures that capture the intricate soft tissue and bony landmarks of the knee. An instinctive understanding of the anatomy is essential to then delve deeper into how the structures cooperate biomechanically and how to optimize restoration of the intact ability to stabilize the knee joint.

Outside-in Meniscal Repair: Technique and Outcomes

The menisci are cartilaginous structures that play a critical role in maintaining joint stability, load distribution, and joint lubrication. Injury to the menisci has been found to significantly alter the complex biomechanics of the knee and thus affect the health and longevity of the native joint. While early treatment of meniscal tears focused primarily on removal of the injured tissue, recent attention on the long-term consequences of partial and total meniscectomy has led to increased attempts at meniscal repair whenever possible. Meniscal tears involving the anterior horn are increasingly recognized as an important pathology. Due to the location of anterior horn tears and the technical difficulty in accessing this location arthroscopically, an outside-in repair technique is ideal for treatment of these lesions. This chapter details the surgical technique of outside-in repair of anterior horn meniscal tears, rehabilitation, and outcomes of this procedure.

Overview of Orthobiology and Biomechanics

Please provide affiliation for the authors “Jorge Chahla”; “Robert F. LaPrade”; “Mark Cinque”.

Peripheral Meniscal Tears: How to Diagnose and Repair

Peripheral meniscal tears are among the most common causes of meniscal pathology, particularly occurring in conjunction with anterior cruciate ligament (ACL) injury or deficiency. Although the diagnosis can be challenging in the clinical setting, effective history taking, physical exam, and diagnostic imaging have been shown to be valuable, especially when used in combination. Several physical examination maneuvers are effective in leading to a diagnosis of a torn meniscus, which are then followed by imaging studies to aid in the evaluation of meniscal injury and associated pathology. The current gold standard imaging modality for meniscus pathology is magnetic resonance imaging (MRI), but other modalities have been used with moderate success. Given their location in the most vascular portion of the meniscus, the best method for managing peripheral tears has been debated and widely studied. New techniques have been developed with the objectives of lowering complications, minimizing invasive procedures, and restoring the biomechanical properties of the menisci. With their high potential for healing, peripheral tears have been reported to have excellent outcomes after early repair and effective rehabilitation protocols.