Tom C. Ludvigsen

Autologous Chondrocyte Implantation Compared with Microfracture in the Knee: A Randomized Trial

BACKGROUND New methods have been used, with promising results, to treat full-thickness cartilage defects. The objective of the present study was to compare autologous chondrocyte implantation with microfracture in a randomized trial. We are not aware of any previous randomized studies comparing these methods. METHODS Eighty patients without general osteoarthritis who had a single symptomatic cartilage defect on the femoral condyle in a stable knee were treated with autologous chondrocyte implantation or microfracture (forty in each group). We used the International Cartilage Repair Society, Lysholm, Short Form-36 (SF-36), and Tegner forms to collect data. An independent observer performed a follow-up examination at twelve and twenty-four months. Two years postoperatively, arthroscopy with biopsy for histological evaluation was carried out. The histological evaluation was done by a pathologist and a clinical scientist, both of whom were blinded to each patients treatment. RESULTS In general, there were small differences between the two treatment groups. At two years, both groups had significant clinical improvement. According to the SF-36 physical component score at two years postoperatively, the improvement in the microfracture group was significantly better than that in the autologous chondrocyte implantation group (p = 0.004). Younger and more active patients did better in both groups. There were two failures in the autologous chondrocyte implantation group and one in the microfracture group. No serious complications were reported. Biopsy specimens were obtained from 84% of the patients, and histological evaluation of repair tissues showed no significant differences between the two groups. We did not find any association between the histological quality of the tissue and the clinical outcome according to the scores on the Lysholm or SF-36 form or the visual analog scale. CONCLUSIONS Both methods had acceptable short-term clinical results. There was no significant difference in macroscopic or histological results between the two treatment groups and no association between the histological findings and the clinical outcome at the two-year time-point. LEVEL OF EVIDENCE Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.

A randomized trial comparing autologous chondrocyte implantation with microfracture. Findings at five years.

BACKGROUND The optimal treatment for cartilage lesions has not yet been established. The objective of this randomized trial was to compare autologous chondrocyte implantation with microfracture. This paper represents an update, with presentation of the clinical results at five years. METHODS Eighty patients who had a single chronic symptomatic cartilage defect on the femoral condyle in a stable knee without general osteoarthritis were included in the study. Forty patients were treated with autologous chondrocyte implantation, and forty were treated with microfracture. We used the International Cartilage Repair Society, Lysholm, Short Form-36, and Tegner forms to collect clinical data, and radiographs were evaluated with use of the Kellgren and Lawrence grading system. RESULTS At two and five years, both groups had significant clinical improvement compared with the preoperative status. At the five-year follow-up interval, there were nine failures (23%) in both groups compared with two failures of the autologous chondrocyte implantation and one failure of the microfracture treatment at two years. Younger patients did better in both groups. We did not find a correlation between histological quality and clinical outcome. However, none of the patients with the best-quality cartilage (predominantly hyaline) at the two-year mark had a later failure. One-third of the patients in both groups had radiographic evidence of early osteoarthritis at five years. CONCLUSIONS Both methods provided satisfactory results in 77% of the patients at five years. There was no significant difference in the clinical and radiographic results between the two treatment groups and no correlation between the histological findings and the clinical outcome. One-third of the patients had early radiographic signs of osteoarthritis five years after the surgery. Further long-term follow-up is needed to determine if one method is better than the other and to study the progression of osteoarthritis.

A Randomized Multicenter Trial Comparing Autologous Chondrocyte Implantation with Microfracture: Long-term Follow-up at 14 to 15 Years.

BACKGROUND The management of cartilage and osteochondral lesions in the knee remains problematic and controversial. Our group reported the 2-year and 5-year results of a randomized controlled trial comparing autologous chondrocyte implantation (ACI) and microfracture in patients with focal femoral cartilage injuries. The objective of the present study was to report the long-term results. METHODS Eighty patients with a single symptomatic chronic cartilage defect on the femoral condyle without general osteoarthritis were included in the study at the time of the index operation (January 1999 to February 2000). We used the International Cartilage Repair Society (ICRS), Lysholm, Short Form-36 (SF-36), and Tegner forms to collect data at the time of inclusion and at follow-up evaluations. Standing weight-bearing radiographs were evaluated for evidence of osteoarthritis according to the method described by Kellgren and Lawrence. For the long-term follow-up in 2014, we used the Synaflexer frame to standardize the radiographs. The operation was considered to have failed if a reoperation was performed because of symptoms from a lack of healing of the treated defect. RESULTS At the long-term follow-up evaluation, no significant differences between the treatment groups were detected with respect to the results on the clinical scoring systems. At the 15-year evaluation, there were 17 failures in the ACI group compared with 13 in the microfracture group. We observed that more total knee replacements were needed in the ACI group than in the microfracture group (6 compared with 3). The surviving patients in both groups, i.e., those who had not had a failure, had significant improvement in the clinical scores compared with baseline. Fifty-seven percent of the surviving patients in the ACI group and 48% of such patients in the microfracture group had radiographic evidence of early osteoarthritis (a Kellgren and Lawrence grade of ≥2); the difference was not significant. CONCLUSIONS The survivors in both groups improved their clinical scores in the short, medium, and long-term evaluations, and no significant difference between the groups was found at the long-term follow-up. The risk of treatment failure and the frequency of radiographic osteoarthritis are problematic. Our findings raise serious concerns regarding the efficacy of these procedures in delaying osteoarthritis and preventing further surgery. Continued basic and clinical research is needed in this field. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Failed Autologous Chondrocyte Implantation Complete Atraumatic Graft Delamination after Two Years

Full-thickness chondral lesions occur in 5% to 10% of knees with injuries involving acute hemarthrosis. Because of subsequent pain and decreased function and because chondral lesions often progress to osteoarthritis, cartilage repair procedures have become common and have been intensively investigated. Many factors contribute to the choice of treatment for symptomatic unipolar full-thickness chondral lesions, and each cartilage repair technique has its own reported complications. Complications after autologous chondrocyte implantation are rare and usually occur in the first 8 months postoperatively. Minas found a 37% rate of complications (26 of 70) that necessitated surgery. In addition to loss of range of motion in the early phase, symptoms of pain and effusion later developed as a result of periosteal hypertrophy, for which further interventions were performed. Minas reported a failure rate of 7% (5 of 70); three failures were due to falls during the recovery period and two were due to adhesions to the graft in knees with multiple transplantations. There are no reports available, to the authors’ knowledge, about an atraumatic complete graft delamination occurring 2 years after autologous chondrocyte implantation. We report on one patient who had complete resolution of his complaints, even during strenuous activities, after an autologous chondrocyte implantation but was admitted to the hospital with a locked knee 2 years after the implantation. CASE REPORT

External fixation versus percutaneous pinning for unstable Colles' fracture Equal outcome in a randomized study of 60 patients

60 patients > 20 years of age, with comminuted distal radial fractures of type Older 3 or 4, were randomly allocated to two treatment groups: external fixation a.m. Hoffmann or percutaneous Kirschner wire pinning combined with immobilization in a plaster cast. The groups were similar in age, gender, fracture type and dislocation. All patients were immobilized for 6 weeks and the outcome was assessed after 6 months. The groups showed similar results with respect to radiographic parameters and function. All fractures healed and no difference in complication rate was observed. We conclude that most unstable distal radial fractures, classified as Olders type 3 and 4, can be treated with percutaneous pinning and a plaster cast, which is simpler and cheaper than external fixation.

Demographics and Injuries Associated With Knee Dislocation: A Prospective Review of 303 Patients:

Background: Information on the incidence, injury mechanisms, ligament injury patterns, and associated injuries of knee dislocations is lacking in the literature. There is a need to characterize ligament injury patterns and associated injuries in knee dislocations to avoid missing common associated diagnoses and to plan surgical treatment. Purpose: To evaluate patient demographics, ligament injury patterns and associated injury patterns, and associated injuries in patients with knee dislocation. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 303 patients with knee dislocations treated at a single level 1 trauma center were followed prospectively. Injury mechanism; ligament injury patterns; associated neurovascular, meniscal, and cartilage injuries; and surgical complications were recorded. The Schenck knee dislocation classification was used to classify the ligament injury patterns. Results: The mean age at injury was 37.8 ± 15.3 years. Of the 303 patients included, 65% were male and 35% were female. There was an equal distribution of high-energy and low-energy injuries. Injury to 3 major ligaments was the most common, with Schenck classification type KD III-M constituting 52.4% of the injuries and KD III-L comprising 28.1%. Meniscal injuries and cartilage injuries occurred in 37.3% and 28.3% of patients, respectively. Patients with acute injuries had significantly lower odds of a cartilage injury than those with chronic injuries (odds ratio [OR], 0.28; 95% CI, 0.15-0.50; P < .001). Peroneal nerve injuries were recorded in 19.2% of patients (10.9% partial and 8.3% complete deficit), while vascular injuries were recorded in 5%. The odds of having a common peroneal nerve injury were 42 times greater (P < .001) among those with posterolateral corner injury (KD III-L) than those without. The odds for popliteal artery injury were 9 times greater (P = .001) among those with KD III-L injuries than other ligament injury types. Conclusion: Medial-sided bicruciate injuries were the most common injury pattern in knee dislocations. Cartilage injuries were common in chronically treated patients. There was a significant risk of peroneal nerve injury with lateral-sided injuries.

Arthroscopic Surgical Procedures Versus Sham Surgery for Patients With Femoroacetabular Impingement and/or Labral Tears: Study Protocol for a Randomized Controlled Trial (HIPARTI) and a Prospective Cohort Study (HARP)

•STUDY DESIGN: Study protocol for a randomized controlled trial and a prospective cohort. •BACKGROUND: The number of arthroscopic surgical procedures for patients with femoroacetabular impingement syndrome (FAIS) has significantly increased worldwide, but high‐quality evidence of the effect of such interventions is lacking. •OBJECTIVES: The primary objective will be to determine the efficacy of hip arthroscopic procedures compared to sham surgery on patient‐reported outcomes for patients with FAIS (HIP ARThroscopy International [HIPARTI] Study). The secondary objective will be to evaluate prognostic factors for long‐term outcome after arthroscopic surgical interventions in patients with FAIS (Hip ARthroscopy Prospective [HARP] Study). •METHODS: The HIPARTI Study will include 140 patients and the HARP Study will include 100 patients. The international Hip Outcome Tool‐33 will be the primary outcome measure at 1 year. Secondary outcome measures will be the Hip disability and Osteoarthritis Outcome Score, Arthritis Self‐Efficacy Scale, fear of movement (Tampa Scale of Kinesiophobia), Patient‐Specific Functional Scale, global rating of change score, and expectations. Other outcomes will include active hip range of motion, hip muscle strength tests, functional performance tests, as well as radiological assessments using radiographs and magnetic resonance imaging. •CONCLUSION: To determine the true effect of surgery, beyond that of placebo, double‐blinded placebo‐controlled trials including sham surgery are needed. The HIPARTI Study will direct future evidence‐based treatment of FAIS. Predictors for long‐term development and progression of degenerative changes in the hip are also needed for this young patient group with FAIS; hence, responders and nonresponders to treatment could be determined.

Failed Reverse Shoulder Arthroplasty: Case Example 1

Infection after arthroplasty is a challenging situation for orthopaedic surgeons and their patients. This chapter is a case history of infection after revision to a reverse total shoulder arthroplasty. In the shoulder, the bacteriology is different from infections in the hip and knee. However, the vast experience from infected hip and knee arthroplasties, which by far extends the number of shoulder arthroplasties, could possibly be implemented when treating infected shoulder arthroplasties. With improved surgeon awareness and the addition of longer tissue-culture incubation times, detection of failed arthroplasties with positive cultures has become more common. We aim to present a suggestion of standard treatment even though each case has to be individually considered.

Clinical Symptoms and Physical Examinations

The stiff and painful shoulder is described in many ways: frozen shoulder, stiff shoulder, and adhesive capsulitis. In this chapter, two different entities were defined: a stiff and painful shoulder, developing without any trauma or specific shoulder disease, further referred to as “frozen shoulder,” and stiff and painful shoulder occurring during or as sequence of another condition in or around the shoulder joint, further referred to as “shoulder stiffness” or “stiff shoulder.” Specific differences in history, clinical symptoms, and imaging are discussed.

Shoulder Pathology in Sports

Sports injuries are on the increase, with the increasing interest and involvement in sports around the world. In Europe there is a large diversity of sports, with many sports being more prominent in certain countries. Although injury pathology is similar (e.g. a labral tear), the injury mechanisms are often unique to that sport and the rehabilitation and demands are also unique to the sport. In this Instructional Course chapter, we hope to show you some examples of this and highlight some unique and important current issues in the sports shoulder in 2014.