Xiaoqiao Huangfu

Biological augmentation of rotator cuff repair using bFGF-loaded electrospun poly(lactide-co-glycolide) fibrous membranes.

Clinically, rotator cuff tear (RCT) is among the most common shoulder pathologies. Despite significant advances in surgical techniques, the re-tear rate after rotator cuff (RC) repair remains high. Insufficient healing capacity is likely the main factor for reconstruction failure. This study reports on a basic fibroblast growth factor (bFGF)-loaded electrospun poly(lactide-co-glycolide) (PLGA) fibrous membrane for repairing RCT. Implantable biodegradable bFGF–PLGA fibrous membranes were successfully fabricated using emulsion electrospinning technology and then characterized and evaluated with in vitro and in vivo cell proliferation assays and repairs of rat chronic RCTs. Emulsion electrospinning fabricated ultrafine fibers with a core-sheath structure which secured the bioactivity of bFGF in a sustained manner for 3 weeks. Histological observations showed that electrospun fibrous membranes have excellent biocompatibility and biodegradability. At 2, 4, and 8 weeks after in vivo RCT repair surgery, electrospun fibrous membranes significantly increased the area of glycosaminoglycan staining at the tendon–bone interface compared with the control group, and bFGF–PLGA significantly improved collagen organization, as measured by birefringence under polarized light at the healing enthesis compared with the control and PLGA groups. Biomechanical testing showed that the electrospun fibrous membrane groups had a greater ultimate load-to-failure and stiffness than the control group at 4 and 8 weeks. The bFGF–PLGA membranes had the highest ultimate load-to-failure, stiffness, and stress of the healing enthesis, and their superiority compared to PLGA alone was significant. These results demonstrated that electrospun fibrous membranes aid in cell attachment and proliferation, as well as accelerating tendon–bone remodeling, and bFGF-loaded PLGA fibrous membranes have a more pronounced effect on tendon–bone healing. Therefore, augmentation using bFGF–PLGA electrospun fibrous membranes is a promising treatment for RCT.

Prediction of the Graft Size of 4-Stranded Semitendinosus Tendon and 4-Stranded Gracilis Tendon for Anterior Cruciate Ligament Reconstruction: A Chinese Han Patient Study

Background: Little information is available regarding parameters that would enable a surgeon to predict the size and length of 4-stranded semitendinosus (ST) and 4-stranded gracilis tendon (GT) grafts. Purpose: To evaluate whether certain preoperative anthropometric data enable prediction of the size of 4-stranded ST and GT autograft for anterior cruciate ligament (ACL) reconstruction. Study Design: Cohort study (prevalence); Level of evidence, 2. Methods: This study involved 235 Chinese Han patients who underwent double-bundle ACL reconstruction with 4-stranded autogenous ST and GT grafts. Preoperatively, the authors recorded height, weight, body mass index (BMI), gender, age, and sports activity. During surgery, the usable length of the ST and GT and the diameter of the 4-stranded grafts made of ST and GT were measured. Multiple regression analysis was used to determine relationships between anthropometric measurements and the length and diameter of intraoperatively measured ST and GT grafts. Results: Strongest correlations for ST and GT length and GT graft diameter were height and weight. The strongest correlations for ST graft diameter were gender and weight. Body mass index had only moderate correlations with ST and GT graft size. Self-reported activity level was not correlated. Women had significantly smaller GT and ST graft diameters and shorter tendon lengths than did men. Semitendinosus graft size was significantly larger and longer than was the GT graft (7.4 ± 0.7 mm vs 5.9 ± 0.6 mm and 279.9 ± 20.8 mm vs 251.5 ± 20.8 mm, respectively). Simple regression analysis demonstrated that height, weight, and BMI can be used to predict ST and GT autograft length and diameter. Conclusion: Several preoperative anthropometric measurements showed correlation with the length of the ST and GT and diameter of 4-stranded ST and GT grafts. The current data may provide surgeons with important preoperative information about size of ST and GT grafts and would be useful for patient counseling and alternative graft source planning.

The Role of Medial Retinaculum Plication Versus Medial Patellofemoral Ligament Reconstruction in Combined Procedures for Recurrent Patellar Instability in Adults

Background: The comparative clinical outcome of medial retinaculum plication (MRP) versus medial patellofemoral ligament reconstruction (MPFLR) for recurrent patellar instability in adults is unknown. Hypothesis: Arthroscopic MRP can yield similar results to MPFLR for recurrent patellar instability in adults. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: One hundred patients with recurrent patellar instability were randomly divided into 2 groups receiving either arthroscopic MRP or MPFLR. Lateral release and anteromedial or distal tibial tubercle transfers were also performed as indicated. Follow-ups were performed at 12, 24, and 60 months postoperatively, and computed tomography (CT) was performed immediately after the operation and at follow-up. The passive patella glide test was performed before surgery and at each follow-up point. The degree of knee function was evaluated preoperatively and at 2 and 5 years postoperatively using the International Knee Documentation Committee (IKDC), Lysholm, and Kujala rating scales. Survival analysis was performed, and redislocation or multiple episodes of patellar instability were considered as indicating failure. Results: Forty-three patients in the MRP group and 45 patients in the MPFLR group were followed for 5 years and received complete evaluations. The correction of the static patellar position deteriorated over time in both groups, but significantly better results were observed for the MPFLR group. The results of the passive patella glide test indicated more stable patellae in the MPFLR group at each follow-up point. Functional evaluations at 2 and 5 years (final Lysholm score, 69.3 ± 6.9 vs 86.9 ± 6.1; Kujala score, 73.8 ± 5.5 vs 87.4 ± 5.7) revealed statistically significant superior results in the MPFLR group. Finally, 4 patients (9.3%) in the MRP group and 1 (2.2%) in the MPFLR group experienced episodes of redislocation, and 7 patients (16.3%) in the MRP group and 3 (6.7%) in the MPFLR group experienced multiple episodes of patellar instability (P = .037). Kaplan-Meier survival analysis and a log-rank test indicated better results and a significantly higher survival rate (P = .006) in the MPFLR group. Conclusion: MPFLR results in better static patellar position and functional outcome than MRP in the treatment of recurrent patellar dislocation in adults.

The effect of platelet-rich plasma on patterns of gene expression in a dog model of anterior cruciate ligament reconstruction

BACKGROUND Autologous platelet-rich plasma (PRP) has been investigated as a potential promoter of tendon healing and has an enhancing effect on the anterior cruciate ligament (ACL) graft maturation process. However, the influence of PRP on the synthesis and degradation of the extracellular matrix during the ACL graft remodeling process has never been investigated. MATERIALS AND METHODS Healthy and mature beagle dogs were randomly assigned to one of four groups: in group I (PRP group), ACL grafts were treated with PRP; in group II (control group), ACL grafts were treated with saline; in group III (sham group), only the knee joints were exposed; in group IV (normal control group), no surgery was performed to the knees. Ligament tissue was dissected at 2, 6, and 12 wk after surgery, and real-time PCR was performed using primers for growth factor-β1 (TGF-β1), collagen type1A1 (COL1Al), collagen type3A1 (COL3A1), decorin, biglycan, matrix metalloproteinase-1 (MMP-1), matrix metalloproteinase-13 (MMP-13), and tissue inhibitor of metalloproteinase-1 (TIMP-1). RESULT In group I, the messenger RNA (mRNA) levels of collagen type 1A1, biglycan, and MMP-1 all increased 2, 6, and 12 wk after surgery, compared with group II (P < 0.05). At 2 and 6 wk after surgery, increased levels of COL3A1, MMP-1, and MMP-13 mRNA were also detected in group I (P < 0.05). Increased levels of TGF-β1 mRNA was observed at 6 and 12 wk in group I after surgery (P < 0.05). CONCLUSIONS During the graft remodeling process, we observed a time-dependent change of gene expression following ACL reconstruction surgery. Furthermore, our results demonstrate that PRP alters the expression of some target genes at certain time points, especially during the early stages of graft remodeling, which might explain the enhancing effect of PRP on the ACL graft maturation process.

Platelet-rich plasma enhances autograft revascularization and reinnervation in a dog model of anterior cruciate ligament reconstruction

BACKGROUND Autologous platelet-rich plasma (PRP) has been investigated as a potential promoter of tendon healing that affects the anterior cruciate ligament (ACL) graft maturation process. However, the influence of PRP on revascularization and reinnervation during the ACL graft remodeling has never been investigated. MATERIALS AND METHODS We randomly assigned healthy and mature beagles to one of four groups. In group 1 (PRP group), we treated the ACL grafts with PRP. In group 2 (control group), we treated the ACL grafts with saline. In group 3 (sham group), we exposed only the knee joints. In group 4 (normal control group), no surgery was performed on the knees. We dissected the ligament tissue at 2, 6, and 12 wk after surgery and performed real-time polymerase chain reaction using primers for cluster of differentiation molecule 31, vascular endothelial growth factor, thrombospondin-1 (TSP-1), neurotrophin-3, growth-associated protein-43 (GAP-43), and nerve growth factor. RESULTS We observed the increased expression of vascular endothelial growth factor, TSP-1, neurotrophin-3, GAP-43, and nerve growth factor mRNA in group 1 at 2, 6, and 12 wk after surgery, compared with that in group 2 (P < 0.05). We also detected increased levels of cluster of differentiation molecule 31 expression in group 1 (P < 0.05) at 2 and 6 wk after surgery. The levels of TSP-1 and GAP-43 mRNA were significantly increased in group 3 compared with those in group 4 at 2 wk after surgery (P < 0.05). CONCLUSIONS During graft remodeling, we observed a time-dependent change in gene expression after ACL reconstruction surgery. In addition, these results demonstrate that PRP alters the expression of some target genes at certain times, particularly during the early stages of graft remodeling. Platelet-rich plasma could promote revascularization and reinnervation, which might explain the enhancing effect of PRP on ACL graft maturation.

Arthroscopic Glenoid Bone Grafting With Nonrigid Fixation for Anterior Shoulder Instability 52 Patients With 2- to 5-Year Follow-up

Background: The healing rate and clinical outcomes of glenoid bone grafting with nonrigid fixation for patients with recurrent anterior shoulder instability are unknown. Hypothesis: Glenoid bone grafting with nonrigid fixation can yield satisfactory results for patients with recurrent anterior shoulder instability with regard to graft healing and the restoration of shoulder stability. Study Design: Case series; Level of evidence, 4. Methods: A total of 52 patients with recurrent anterior shoulder instability underwent Bankart or bony Bankart repair as well as arthroscopic glenoid bone grafting. Allogenic bicortical iliac grafts were used. Instead of firm fixation, the grafts were tethered to the glenoid by sutures from anchors placed in the glenoid surface. Follow-up occurred at 3, 6, 12, and 24 months. Computed tomography and magnetic resonance imaging examinations were performed immediately after surgery and at each follow-up visit to evaluate the healing of the graft and the changes in the repaired capsule-labrum structure. Functional evaluations were taken at 24 months with the Oxford Shoulder Instability Score and the Rowe Score for Shoulder Instability. For the patients who underwent surgery 2.5 years earlier, an additional review was conducted to evaluate the latest stability status of the shoulder. Failure was defined as recurrence of dislocation or instability. Results: The mean follow-up time was 39 months (range, 24-64 months). In all cases, the grafts healed to the glenoid at 3 or 6 months, and glenoid remodeling was complete within 12 months; in most cases, a robust bone-capsule structure formed on the anterior side of the glenoid. The glenoid defect area changed from 32.7% ± 8.7% (range, 10.7% to 53.9%) to −16.3% ± 3.3% (range, −26.7% to 5.9%), and the glenoid defect width changed from 28.3% ± 8.7% (range, 10.4% to 54.5%) to −16.9% ± 7.3% (range, −33.4% to 2.8%). Compared with the presumed normal glenoid, the final glenoid surface area increased in 94.2% of patients and final glenoid width increased in 96.2% of patients. One patient experienced redislocation and 2 experienced a sense of instability without dislocation, which resulted in a failure rate of 5.8%. Six patients exhibited slight pain. The Oxford score improved from 29.7 ± 5.6 preoperatively to 42.4 ± 3.3 at 2 years postoperatively, and the Rowe score improved from 34.7 ± 6.1 preoperatively to 91.8 ± 2.8 at 2 years postoperatively. Conclusion: In this study, arthroscopic glenoid bone grafting with nonrigid fixation in combination with Bankart repair resulted in 100% graft healing and the satisfactory restoration of shoulder stability.

Simultaneous Double-Bundle Anterior Cruciate Ligament and Posterior Cruciate Ligament Reconstruction With Autogenous Hamstring Tendons

PURPOSE The purpose of this study was to evaluate the clinical results of simultaneous double-bundle anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction. METHODS We performed arthroscopic reconstruction in 21 cases of combined ACL/PCL rupture, 14 chronic and 7 acute, with autogenous hamstring tendons in 1 stage, both in a double-bundle and 4-tunnel manner. The semitendinosus tendon and gracilis tendon from the uninjured leg were used to make two 4-stranded grafts to reconstruct the PCL, and those from the injured leg were used to make two 4-stranded grafts to reconstruct the ACL. The grafts were suspended with a mini-plate and buttons. The patients were followed up for a minimum of 2 years and evaluated according to the International Knee Documentation Committee (IKDC) and Lysholm rating scale. The anterior-posterior knee laxity was assessed by KT-1000 examination (MEDmetric, San Diego, CA). RESULTS At the last follow-up, all patients showed normal knee extension. One patient had a 10 degrees flexion limitation, and four had a 5 degrees flexion limitation. KT-1000 examination showed that the side-to-side difference in overall anterior-posterior laxity at 70 degrees flexion was 0 to 2 mm in 16 patients, 3 to 5 mm in 4 patients, and 6 to 10 mm in 1 patient; the side-to-side difference in overall anterior-posterior laxity at 25 degrees flexion was 0 to 2 mm in 14 patients, 3 to 5 mm in 6 patients, and 6 to 10 mm in 1 patient. The IKDC subjective, Lysholm, and Tegner scores were 85.5 +/- 5.8, 91.9 +/- 4.2, and 5.0 +/- 1.9, respectively. According to the last IKDC evaluation, the results were graded as normal in 13 patients (61.9%), nearly normal in 7 patients (33.3%), and abnormal in 1 patient (4.8%). CONCLUSIONS Simultaneous double-bundle ACL and PCL reconstruction with autogenous hamstring tendons can yield normal results in 61.9% of patients and nearly normal results in 33.3% at a minimum of 2 years. LEVEL OF EVIDENCE Level IV, therapeutic case series.

The Biomechanical and Clinical Application of Using the Anterior Half of the Peroneus Longus Tendon as an Autograft Source

Background: The shortage of autogenous grafts has often times been a problem in knee ligament reconstruction. There are little data concerning the use of the anterior half of the peroneus longus tendon (AHPLT) as an autograft. Hypothesis: The AHPLT is a suitable graft with respect to its strength, safety, and donor site morbidity. Study Design: Descriptive laboratory study and case series; Level of evidence, 4. Methods: The safety and efficacy of using the AHPLT as an autograft source were evaluated. A cadaveric study was first done to reveal the anatomic profile of the AHPLT, to test its failure load, and to compare it with that of the semitendinosus and gracilis tendons. Then, a cadaveric harvest study was performed to show it was safe and reproducible. The space between the tendon stripper and the peroneal nerve during harvesting of the AHPLT was evaluated. Lastly, a clinical study was performed to evaluate donor site morbidity. The preoperative and postoperative foot and ankle functions of 92 patients who underwent a variety of knee ligament reconstructions with the AHPLT were followed for more than 2 years and were then evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) scale and the Foot and Ankle Disability Index (FADI) to determine the influence of tendon removal on ankle and foot function. Results: The average failure load of the AHPLT was 322.35 ± 63.18 N, accounting for 97.69% ± 19.48% and 147.94% ± 41.30% of the semitendinosus and gracilis tendons, respectively. During tendon harvesting, the distance between the head of the tendon stripper and the branching point of the deep peroneus nerve was 4.6 to 10.4 cm. The clinical study showed that the preoperative and postoperative AOFAS scores were 97.4 ± 2.0 and 97.2 ± 1.6 (P = .85), respectively, while the FADI scores preoperatively and postoperatively were 96.8 ± 2.2 and 96.9 ± 2.5 (P = .91), respectively. No signs of peroneus nerve injury, peroneus longus tendon rupture, or tendinopathy were found. Conclusion: The AHPLT is acceptable for use as an autograft with respect to its strength, safety, and donor site morbidity.

Risk factors for articular cartilage lesions in symptomatic discoid lateral meniscus.

PURPOSE To investigate risk factors related to articular cartilage lesions in discoid lateral meniscus (DLM) and to analyze the possible mechanisms associated with articular cartilage lesions. METHODS From October 2004 to April 2008, 103 knees in 97 patients with DLM confirmed by arthroscopy were operated on at our clinical center. Among them, 16 knees were accompanied by articular cartilage injury. Data on risk factors, including patient age, traumatic history, DLM type, presence or absence of tear, symptomatic duration, and meniscal shape, were analyzed to investigate the relation with articular cartilage lesion by logistic regression analysis. RESULTS Only symptomatic duration and meniscal shape had a significant relation with articular cartilage lesion. Symptomatic duration and meniscal shape can be regarded as risk factors, and their odds ratios were 4.983 (P < .01) and 5.356 (P < .05), respectively. CONCLUSIONS Long symptomatic duration (>6 months) and asymmetrical shape of DLM were more frequently related to articular cartilage lesions than other factors. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Recurrent Patellar Dislocation in Adolescents Medial Retinaculum Plication Versus Vastus Medialis Plasty

Background: The clinical outcome of arthroscopic medial retinaculum plication (MRP) compared with vastus medialis plasty (VMP) for recurrent patellar dislocation in adolescents is unknown. Hypothesis: Arthroscopic MRP can yield similar results to open VMP for recurrent patellar dislocation in adolescents. Study Design: Randomized controlled clinical trial; Level of evidence, 2. Methods: Sixty adolescent patients were randomly divided into 2 groups to receive arthroscopic MRP and open VMP respectively. The patients were followed up at 3, 6, 12, and 24 months postoperatively and computed tomography (CT) scans were taken immediately after operation and at 12 and 24 months postoperatively to evaluate the position of the patella. Knee function was evaluated at 24 months postoperatively according to the International Knee Documentation Committee (IKDC), Kujala, Lysholm, and Tegner rating scales. For those who underwent operation more than 3 years previously, an additional review was taken to evaluate the latest patellar stability status. Results: The final follow-up time was 56.8 ± 21.5 months (range, 24-92 months) and 59.1 ± 24.7 months (range, 24-88 months), respectively, in the MRP and VMP groups. The CT examination showed that the correction of the patellar position deteriorated over time in both groups. The final patellar position was significantly better than that before surgery in the VMP group, but not in the MRP group. The VMP group had significantly better clinical results at each follow-up compared with the MRP group. The IKDC, Lysholm, Kujala, and Tegner scores were 62.5 ± 6.2, 70.7 ± 5.1, 76.6 ± 4.8, and 3.9 ± 0.7, respectively, in the MRP group, and 71.8 ± 7.1 (P < .001), 79.4 ± 5.5 (P < .001), 82.9 ± 4.8 (P < .001), and 5.1 ± 1.4 (P < .001), respectively, in the VMP group at the 2-year follow-up. Five patients (17.9%) in the MRP group and 2 patients (7.7%) in the VMP group (P = .267) experienced episodes of redislocation at the final follow-up. Conclusion: Arthroscopic MRP is less reliable for maintaining the corrected position of the patella and for functional recovery compared with VMP for recurrent patellar dislocation in adolescents.