Vincenzo Condello

Matrix-Assisted Autologous Chondrocyte Transplantation for the Repair of Cartilage Defects of the Knee Systematic Clinical Data Review and Study Quality Analysis

Background The clinical application of the second-generation tissue-engineering approach for the treatment of cartilage lesions has been documented for different types of scaffolds, but systematic information on clinical efficacy and long-term results is not available. Purpose To analyze and assess the quality of clinical studies on different products in the emerging field of matrix-assisted auto-logous chondrocyte transplantation. The secondary purpose of this review was to improve the quality assessment of studies by modifying the Coleman methodology score (CMS). Study Design Systematic review. Methods For this review, a literature search was performed to identify all published and unpublished clinical studies of matrixassisted (second-generation) autologous chondrocyte transplantation using the following medical electronic databases: MED-LINE, MEDLINE preprints, EMBASE, CINAHL, Life Science Citations, and British National Library of Health, including the Cochrane Central Register of Controlled Trials (CENTRAL). The search period was January 1, 1995, to July 1, 2008. To better assess cartilage-related studies, a modification of the CMS was proposed. Results Eighteen studies were included in the analysis, reporting on 731 patients with an average follow-up of 27.3 months (6.5-60.0 months). Of the 18 studies, 2 were randomized controlled studies, 3 were prospective comparative studies, 11 were prospective cohort studies or prospective case series, and 2 were retrospective case series. Original CMSs for these studies (55.1 6 1.6) were significantly higher than those of cartilage repair studies in general (43.5 6 1.6, P <.0001) reported in 2005. The statistical analysis indicated that the modified CMS showed higher correlations and lower variability of correlations among 3 reviewers. Conclusion The quality of the currently available data on second-generation autologous chondrocyte transplantation is still limited by study designs. The modified CMS has demonstrated better sensitivity and reproducibility with respect to the original score, so it can be recommended for cartilage clinical studies evaluation.

Second-Generation Autologous Chondrocyte Implantation: Results in Patients Older Than 40 Years

Background Aging is responsible for degenerative changes in all cartilage elements, thus impairing its properties and healing potential. Most studies on surgical procedures for cartilage focus on young patients because these procedures are generally not considered suitable for older patients. Purpose To analyze the clinical outcome of cartilage lesion treatment using second-generation autologous chondrocyte implantation (ACI) techniques in patients more than 40 years old with no clear signs of osteoarthritis, to understand their real potential in relation to aging, the failure rate, and complications in older patients. Study Design Case series; Level of evidence, 4. Methods Sixty-one patients with grade III to IV cartilaginous lesions of the condyles with no clear signs of osteoarthritis and a minimum age of 40 years were treated with second-generation ACI and prospectively evaluated at 5 years’ follow-up. Twenty-two patients were treated with arthroscopic Hyalograft C implantation, and 39 underwent the open Chondro-Gide MACI procedure. Results A significant improvement in both subjective and objective evaluations was observed. The International Knee Documentation Committee (IKDC) subjective score improved from 36.8 ± 8.4 to 68.1 ± 21.8 at the final evaluation. The failure rate was 20%. A faster improvement was observed in the group treated with the arthroscopic Hyalograft C technique, whereas similar scores were found at the 24-month follow-up and final evaluation. Conclusion A clinical improvement was found in patients more than 40 years old, who in most cases benefited from second-generation ACI with good results lasting at medium-term follow-up. However, the results were inferior with respect to those previously found for younger populations, and the failure rate at medium-term follow-up was also higher. These findings were consistent in the 2 treatment groups. The only difference was the faster recovery when the arthroscopic approach was used.

The role of meniscal tissue in joint protection in early osteoarthritis

It is widely accepted that partial meniscectomy leads to early onset of osteoarthritis (OA). A strong correlation exists between the amount and location of the resected meniscus and the development of degenerative changes in the knee. On the other hand, osteoarthritic changes of the joint alter the structural and functional integrity of meniscal tissue. These alterations might additionally compromise the limited healing capacity of the meniscus. In young, active patients without cartilage damage, meniscus therapy including partial meniscectomy, meniscus suture, and meniscus replacement has proven beneficial effects in long-term studies. Even in an early osteoarthritic milieu, there is a relevant regenerative potential of the meniscus and the surrounding cartilage. This potential should be taken into account, and meniscal surgery can be performed with the correct timing and the proper indication even in the presence of early OA.Level of evidence IV.

Early osteoarthritis of the patellofemoral joint

AbstractPatellofemoral joint cartilage lesions are associated with a variety of clinical situations including blunt trauma, lateral patella dislocations, or as a secondary development in the setting of abnormal joint loading. There is a need for more clarity on how to best address these lesions. Most specifically, when is it necessary to surgically treat these lesions of the patella and trochlea and which technique to use? This review will focus on the spectrum of patellofemoral disease/injury and their treatment strategies, with special emphasis on cartilage damage and early osteoarthritis. Chapter sections will review the most common scenarios of cartilage damage in the patellofemoral joint, with an attempt to summarize current treatment, their outcomes, remaining challenges and unanswered questions. Level of evidence V.

Load distribution in early osteoarthritis.

Abstract Total knee replacement is an accepted standard of care for the treatment of advanced knee osteoarthritis with good results in the vast majority of older patients. The use in younger and more active populations, however, remains controversial due to concerns over activity restrictions, implant survival, and patient satisfaction with the procedure. It is in these younger patient populations that alternatives to arthroplasty are increasingly being explored. Historically, osteotomy was utilized to address unicompartmental pain from degeneration and overload, for example, after meniscectomy. Utilization rates of osteotomy have fallen in recent years due to the increasing popularity of partial and total knee arthroplasty. This article explores the indications and outcomes of traditional unloading osteotomy, as well as newer options that are less invasive and offer faster return to function. Level of evidence V.

Distal Realignment: Medialization of Tibial Tuberosity: The Elmslie-Trillat Technique

Patellofemoral problems are probably the most common knee complaints in adolescents and adults. The vague and general term “chondromalacia patellae” has been widely used in the past to describe retro-patellar pain and instability. The term patellofemoral malalignment (PFM) was introduced in 1979 by Insall [17] and since then, it indicates a wide range of pathological conditions from abnormal tracking of the patella on the trochlea with unbalanced transmitted loads on the cartilage, to acute and recurrent dislocation of the patella, which explains the anterior knee pain and patellar instability. This theory has influenced the development of several surgical procedures to correct the malalignment. At present only a small percentage of patients with patellofemoral pain are candidates for surgical correction of the malalignment [25]. According to Dejour et al. [11, 12], patellofemoral disorders can be classified into three major categories. Objective patellar instability is defined as true patellar dislocation or subluxation when trochlear dysplasia is present, potential patellar instability includes trochlear dysplasia when true patellar dislocation or subluxation has never occurred, and the third group covers patello-femoral pain syndrome.

Meniscal Augmentation and Replacement (Menaflex, Actifit, and NUsurface)

In the last decades, the surgical treatment of meniscal injury or damage has shifted from a total meniscectomy to a partial meniscectomy or repair. Rather than a removal of meniscal tissue, the goal of novel surgical techniques is to preserve as much functional meniscal tissue as possible. Recently, attempts have been made to promote meniscal healing, as well as the replacement of damaged menisci with allografts, scaffolds, meniscal implants, or substitutes. This chapter will focus on meniscal augmentation and on three types of meniscal replacement devices. These substitutes are the biological Menaflex™ or collagen meniscal implant (CMI), the biomimetic Actifit™ meniscal scaffold, and the nonbiological NUsurface® meniscal substitute.

Allograft tendons are a safe and effective option for revision ACL reconstruction: a clinical review

Revision anterior cruciate ligament reconstruction remains a challenge, especially optimising outcome for patients with a compromised knee where previous autogenous tissue has been used for reconstruction. Allograft tissue has become a recognized choice of graft for revision surgery but questions remain over the risks and benefits of such an option. Allograft tendons are a safe and effective option for revision ACL reconstruction with no higher risk of infection and equivalent failure rates compared to autografts provided that the tissue is not irradiated, or any irradiation is minimal. Best scenarios for use of allografts include revision surgery where further use of autografts could lead to high donor site morbidity, complex instability situations where additional structures may need reconstruction, and in those with clinical and radiologic signs of autologous tendon degeneration. A surgeon needs to be able to select the best option for the challenging knee facing revision ACL reconstruction, and in the light of current data, allograft tissue can be considered a suitable option to this purpose.Level of evidence IV.

Medial vs lateral unicompartmental knee arthrroplasty: clinical results

Background and aim of the work : The international literature and analysis of the prosthetic registers highlight a significant relationship between the alignment of the components and the survival of prosthetic implants of the knee. The patient specific instrumentation (PSI) technology exploits the data obtained with the MRN for the production of cutting blocks (CB) useful to a TKA. Revisiting the recent international literature, comparing the results of the conventional method and PSI, numerous studies confirm a statistically significant difference of inliers (± 3 degrees) for HKA. The purpose of this retrospective study was to investigate whether these statistically significant difference is also present in our group. Methods : Postoperative radiographic measures of alignment based on a mechanical limb axis (hip-knee-ankle angle, HKA) of 180° were sought. A range of 180° ± 3° varus/valgus was defined as optimal for mechanical axis. Results: The percentage of knees that had a HKA within ±3° of the desired value was 92.2. Conclusion: the CB did accurately produce the desired HKA. The PS system is an effective and reproducible, whose organizational effort is fully justified.