Osteocondritis dissecans lesions of the knee restored by bone marrow aspirate concentrate. Clinical and imaging results in 18 patients.

BACKGROUND: Osteochondritis dissecans (OCD) is a common cartilage disorder that specifically affects the knees of skeletally immature and young adult patients. There have been a few treatments that have been proposed: fixation of the fragment, drilling, microfractures. The aim of this study was to analyze retrospectively clinical and imaging results obtained by treating it with one-step bone marrow-derived cells Transplantation (BMDCT) technique. METHODS: From 2007 to 2014, 18 patients (mean-age 19.1 ± 5.0 years) affected by OCD were treated with one-step BMDC transplantation. In our observational study, clinical evaluation was performed at a scheduled follow-up through IKDC, Tegner, KOOS and EQ-VAS. X-rays and MRI were conducted preoperatively and at 12 months. At final follow-up, MRI MOCART Score was evaluated. RESULTS: IKDC and KOOS clinical scores showed a progressive increase. Tegner Score at final follow-up (5.3 ± 2.7) was significantly lower compared to the pre-injury level (6.5 ± 2.1); however, these results showed a statistically significant improvement that remained over time. EQ-VAS showed a significant improvement in every follow-up measure. MRI Mocart Score showed a complete or almost complete filling of the lesion in 13 patients. CONCLUSIONS: "One-step" technique allows articular surface restoration with viable physiologic osteochondral tissue with a high clinical efficacy and imaging results. The number of cases is still limited, and further studies with larger sample sizes and greater follow-up evaluations are required to confirm our results. Nevertheless, we believe that BMDCT may represent a suitable option to treat OCD lesion in young adults.

Five years of clinical and radiological results with biplanar tibial open-wedge osteotomy: feasible option to prevent patella infera?

INTRODUCTION: High tibial osteotomy (HTO) was a treatment option for relatively young active patients with isolated medial compartment arthritis of the knee. This report showed clinical and radiological results of a new HTO technique, that uses a particular open-wedge high tibial osteotomy by incorporating the tibial tubercle into osteotomy line (TT-OWHTO) to preserve patella height. MATERIALS AND METHODS: Preoperative and postoperative function was recorded on the IKDC score, Kujala PF score, EQ-VAS and Tegner activity scale. Radiological patella height was measured with Insall-Salvati index. All this clinical and radiological recorded data on 45 active patients, with an average age of 40.2 years who underwent this procedure, allowed to do a retrospective analysis. RESULTS: All the patients reported improvement in symptoms with an average preoperative IKDC score from preoperative value 49.7-92.3 at last follow-up. Kujala PF score improves from 67.2 preoperative value to 91.4. EQ-VAS self-assessment of quality of life reported a preoperative value of 41.2-92.2 at last follow-up. There was 2.5 point average improvement in Tegner activity scale. Patella height was not altered with median preoperative value of 0.84 ± 0.1 and final follow-up value of 0.81 ± 0.2 on Insall-Salvati index. CONCLUSIONS: TT-OWHTO showed to be able to achieve good clinical and radiological results maintaining patella height unchanged and ensuring safety and reproducibility as much as the traditional technique.

Return to Sport after ACL Surgery: A Comparison between Two Different Reconstructive Techniques.

The anterior cruciate ligament reconstruction (ACLR) has become a very common surgical procedure. One of the main success indicators of the surgical procedure is the return to preinjury sporting level. In recent years, reconstructive techniques have been geared toward less morbidity and optimized ligaments process to speed up the recovery of sports activity. This study compares clinical and imaging data, to evaluate the timing of return to sport, of two populations undergoing ACLR using two different techniques: ACLR with hamstring maintaining tibial insertion (MHG) and an all-inside technique with complete hamstring detachment (DHG). Patients were clinically evaluated with Marx rating scale, International Knee Documentation Committee (IKDC) score, and Tegner activity scale at a minimum follow-up (FU) of 4 years. The two groups have homogeneous characteristics: age, sex, type, and level of sports activity. Since November 2012, 59 patients with unilateral ACL insufficiency underwent ACLR: 31 patients using the MHG technique and 28 patients using the DHG technique. In both groups, a significant improvement in the clinical scores of the administered tests was observed. The MHG group reported a higher percentage of normal knees (83.8%) compared with the DHG group (78.6%). IKDC subjective score improved at each FU. Comparing the two techniques, at 12 months' FU the MHG group achieved better IKDC results (89.6) compared with the DHG technique (84.2). Marx and Tegner score values improved over time reaching comparable results at final FU. At final FU, 98% of patients returned to the same preinjury professional sporting level. Both techniques have been able to provide good clinical results. The MHG group, however, had a resumption of sports activity of the same level and intensity slightly longer (6.3 months) than that in the DHG group (5.9 months). Furthermore, the resumption of training and athletic gestures for the type of sport practiced was earlier than the DHG group. However, in the long run the level of sporting activity leveled in both groups, demonstrating the effectiveness of both techniques.

The biological respect of the posterolateral bundle in ACL partial injuries. Retrospective analysis of 2 different surgical management of ACL partial tear in a population of high-demanding sport patients.

INTRODUCTION: Most of the techniques described in the literature for the repair of chronic partial ACL tears do not spare the intact portion of the ligament. Aim of this study was to perform a retrospective analysis of the results obtained from the same ACL reconstructive surgical technique applicated by sparing or not AM bundle in a population of 42 sports patients. MATERIALS AND METHODS: From 2010 to 2012, 42 patients who suffered ACL partial tear injury with rupture of posterolateral bundle were randomly divided in two groups homogenous for sex, age and sport-level activities. The first group with 22 patients performed ACL reconstruction with ST-GR over-the-top technique sacrificing the anteromedial (Removing AMT Group) remaining bundle intact; otherwise, the second group with 20 patients performed the same ACL reconstruction using only ST and maintaining AM bundle (Sparing AMT Group). All the patients were followed up by MRI evaluation at 12 months and clinical evaluation with IKDC score, Tegner score at 6, 12, 24, 36, 48 and 60 months. KT-1000 instrument was performed at 12 months. The results were analyzed statistically to evaluate differences between the two groups in terms of subjective outcome, and stability and for all the tests P < 0.05 was considered significant. RESULTS: We did not observe any failure at final follow-up. IKDC subjective score at final follow-up in Removing AMT Group was 91.2 ± 2.3 in Sparing AMT Group was 92.4 ± 2.7. Tegner score at final follow-up was 7.2 ± 2.1 for Removing AMT Group and 7.8 ± 1.8 for Sparing AMT Group. Arthrometric evaluation performed with KT-1000 at final follow-up showed a side-to-side difference of 0.9 ± 1.3 mm in the Removing AMT Group against 0.8 ± 1.0 mm in the Sparing AMT Group. Return time to the sport was 7.1 months for Removing AMT Group otherwise 6.1 months for the Sparing AMT Group. CONCLUSIONS: Both the described techniques in this study demonstrated to be able to guarantee a successful outcome. However, although no statistically significant differences were evident in terms of subjective and objective outcome between these techniques some evident benefits were evident using the sparing bundle technique in Sparing AMT Group such as better clinical scores at the final follow-up and an earlier return to sport activity.

A useful combination for the treatment of patellofemoral chondral lesions: realignment procedure plus mesenchymal stem cell-retrospective analysis and clinical results at 48 months of follow-up.

INTRODUCTION: Osteochondral lesions of the patellofemoral joint (OLPFJ) are defects of the cartilage surface and subchondral bone, which often require surgical treatment. Reparative treatments have shown some limitations in the long-term follow-up. The one-step bone marrow-derived cells transplantation (BMDCT) achieved good to excellent results in the treatment of osteochondral lesions of the femoral condyles. The aim of this study was to report the 48-month clinical and radiological results among 28 patients with OLPFJ treated with the one-step BMDCT technique associated with the anteromedialization tibial tuberosity (AMTT). MATERIALS AND METHODS: Twenty-eight patients from 2010 to 2013 with OLPFJ underwent the BMDCT with the one-step technique associated with the AMTT. Clinical evaluation was performed at 6, 12, 18, 24, 36 and 48 months after surgery using the Kujala PF scale, the IKDC score and the Tegner activity scale. Eighteen lesions were located on patella and ten lesions on trochlea. RESULTS: The preoperative Kujala score improved from 68.2 ± 4.7 to 87.2 ± 1.2 at the mean final follow-up, while the IKDC subjective score improved from 55.1 ± 6.2 to 92.13 ± 5.5. Tegner scale showed an increase from 1.7 ± 1.3 preoperatively to 5.3 ± 2.7 at the final follow-up. MRI analysis at 24-month follow-up showed an overall good filling of the lesions. DISCUSSION AND CONCLUSIONS: The one-step BMDCT associated with the AMTT permitted good clinical results durable over time with a high rate of patients' satisfaction. These results confirm the validity of the one-step technique also in patellofemoral joint.

Stem Cells in Osteochondral Tissue Engineering.

Mesenchymal stem cells (MSCs) are pluripotent stem cells with the ability to differentiate into a variety of other connective tissue cells, such as chondral, bony, muscular, and tendon tissue. Bone marrow-derived MSCs are pluripotent cells that can differentiate among others into osteoblasts, adipocytes and chondrocytes.Bone marrow-derived cells may represent the future in osteochondral repair. A one-step arthroscopic technique is developed for cartilage repair, using a device to concentrate bone marrow-derived cells and collagen powder or hyaluronic acid membrane as scaffolds for cell support and platelet gel.The rationale of the "one-step technique" is to transplant the entire bone-marrow cellular pool instead of isolated and expanded mesenchymal stem cells allowing cells to be processed directly in the operating room, without the need for a laboratory phase. For an entirely arthroscopic implantation are employed a scaffold and the instrumentation previously applied for ACI; in addition to these devices, autologous platelet-rich fibrin (PRF) is added in order to provide a supplement of growth factors. Results of this technique are encouraging at mid-term although long-term follow-up is still needed.

Regenerative treatment of osteochondral lesions of distal tibial plafond.

OBJECTIVES: Osteochondral lesions of the distal tibial plafond (OLTP) are rare and far less common than osteochondral lesions of the talus. Literature data do not report clinical records with significant number of cases and follow-up. The aim of our study was to evaluate clinical and MRI outcomes following arthroscopic treatment of distal tibia osteochondral lesions and to report our results with treating these rare lesions. METHODS: Between October 2010 and November 2011, a consecutive series of 27 patients, 15 males and 12 females, were treated arthroscopically with the one-step BMDCT for OLTPs. Exclusion criteria were: age < 18 or > 50 years, patients with severe osteoarthritis (stage III according to Van Dijk classification), presence of kissing lesions of the ankle and patients with rheumatoid or hemophilic arthritis. All patients were evaluated through X-rays; MRI was performed preoperatively and at the final follow-up with MOCART score; clinical evaluation was assessed by AOFAS score at various follow-ups of 12, 24, 36, 60 and 72 months. RESULTS: No complications were observed post-surgery or during the rehabilitation period. The AOFAS score improved from 52.4 preoperatively to 80.6 at the mean final follow-up. All the patients were satisfied with the procedure. In 14 cases the MRI showed a complete filling of the osteochondral defect, in three patients a hypertrophic tissue was observed, and in the other two patients an incomplete repair of the lesion associated with a persistent slight subchondral edema was reported. A topographic study was also performed. CONCLUSIONS: Osteochondral lesions of the distal tibia represent a challenge for the orthopedic surgeon because of their difficulty diagnostic and rarities. The high incidence of good outcome in our series indicates that the one-step BMDCT could be a valid option for the treatment of this rare type of lesions. Further studies with a longer follow-up and more accurate imaging studies are necessary to confirm these results.

Tissue Bioengineering in the Treatment of Osteochondritis Dissecans of the Talus in Children With Open Physis: Preliminary Results.

BACKGROUND: Juvenile osteochondritis dissecans of the talus (JOCDT) is a focal idiopathic lesion primarily of the subchondral bone leading to subsequent cartilaginous damage. The majority of the papers dealing with JOCDT reported heterogeneous case studies of patients treated with different cartilage repair techniques. The purpose of this paper is to retrospectively review both clinical and radiologic results among 7 patients affected by JOCDT treated with arthroscopic bone marrow aspirate concentrate (BMAC) transplantation with the 1-step technique. METHODS: Both standard anterior-posterior and lateral radiographs and a 1.5 T magnetic resonance imaging of the affected ankle were preoperatively performed in all the patients. The American Orthopaedic Foot and Ankle Society (AOFAS) score and the visual analogue scale were administered to the patients preoperatively and at the final follow-up. RESULTS: Patients were followed up to an average of 48.1±18.4 months. According to the Berndt and Harty classification, 6 lesions were found to be in stage III and 1 lesion in stage IV. The average preoperative AOFAS score was 58.8±7.6 points. At the mean follow-up of 48.1 months the average AOFAS score improved to 95.7±5.4 points (P<0.05). Visual analogue scale improved from 6.3 preoperatively to 0.4 at final follow-up (P<0.05). Complete radiographic healing, in terms of complete bony filling, was observed in 3 of 7 cases. The magnetic resonance imaging analysis showed a complete filling of the osteochondral defect in 4 patients, whereas in 1 patient a hypotrofic tissue was observed. CONCLUSIONS: BMAC transplantation is able to provide good to excellent results in the treatment of JOCDT. The 43% of our patients showed a complete radiographic healing, but all the patients were satisfied with the procedure. Because of the rareness of the lesion, further studies involving more patients and with a longer follow-up are required, to establish the advantage of performing a regenerative procedure like the BMAC transplantation in a pediatric population. LEVEL OF EVIDENCE: Level IV.

High tibial osteotomy for the treatment of medial osteoarthritis of the knee with new iBalance system: 2 years of follow-up.

BACKGROUND: A new system for performing open-wedge high tibial osteotomy (HTO), the iBalance HTO System-Arthrex, has been recently developed in order to make the surgery more reproducible and safe. The aim of this study was to determine the short-term outcomes of the iBalance technique in medial compartment osteoarthritis and varus malalignment of the knee. METHODS: Fifteen patients with a mean age of 50.7 years (SD 5.09), affected by symptomatic varus knee, with medial compartment osteoarthritis (1-2 Ahlbäck degree), were treated with iBalance HTO between July 2011 and February 2012 and evaluated retrospectively. Patients were assessed against the following benchmarks: subjective International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and VAS for pain and Tegner scores, along with X-rays and MRI, before surgery and after a 2-year follow-up. RESULTS: No severe intraoperative complications or implant failures occurred. The mean preoperative scores were as follows: subjective IKDC 66.8 (SD 1.18), KOOS 61.3 (SD 0.86), Vas for pain 8.6 (SD 1.72) and Tegner 4.1 (SD 2.06), while at follow-up the scores were 73.6 (SD 1.01), 88.1 (SD 1.23), 2.9 (SD 2.35) and 3.1 (SD 1.83), respectively. Correction ranged between 3° and 8°. All patients showed complete articular recovery, no loss of correction, no substantial variation in A/P slope and no hardware problems. CONCLUSIONS: iBalance proved to be effective and safe and produced good overall results. Consolidation and osseointegration of the system took place rapidly, while recovery was precocious, comparable with traditional methods and with no severe complications. LEVEL OF EVIDENCE: Case series, Level IV.

Arthroscopic Treatment and Prognostic Classification of Anterior Soft Tissue Impingement of the Ankle.

BACKGROUND: Anterior soft tissue impingement of the ankle has been described based on the etiology and location, but no classification has been reported. Arthroscopic treatment is usually considered effective, even if the behavior of the different forms of impingement is not clear. The purpose of this study was to analyze the factors affecting long-term results. METHODS: Forty-two patients with a mean age of 32.6 years were arthroscopically treated between 2004 and 2008. Impingement lesions were identified according to clinical examination and confirmed by MRI. Soft tissue impingement was detected and classified according to location (anteromedial, anterolateral, syndesmotic or diffuse). Patient data, foot morphology, and previous trauma or surgery were recorded. Patients were evaluated after a mean of 90.1 months' follow-up with the American Orthopaedic Foot & Ankle Society (AOFAS) scoring system. RESULTS: The mean AOFAS score improved from 40.6 preoperatively to 82.6, 78.4, and 74.8, respectively, at the 2-, 4-, and 6-year follow-ups (P < .05). The anterolateral form showed higher scores compared to the diffuse or anteromedial forms. Age, foot morphology, and previous trauma or surgery did not affect the results. Body mass index of more than 26 and male gender were associated with worse outcomes. CONCLUSION: Arthroscopic debridement proved effective in the treatment of soft tissue impingement. Furthermore, we were able to classify the location of the anterior soft tissue impingement of the ankle, which may have prognostic importance. LEVEL OF EVIDENCE: Level IV, case series.

Over-the-Top Anterior Cruciate Ligament Reconstruction Using Single- or Double-Strand Hamstrings Autograft.

The purpose of this study is to (1) report the long-term clinical and radiographic outcomes of a nonanatomical anterior cruciate ligament (ACL) reconstruction using an over-the-top (OTT) femoral route and (2) compare single-strand (1SHG) and double-strand (2SHG) hamstrings graft reconstruction. Fifty-one consecutive patients (mean age, 29.2±3.8 years) underwent nonanatomical ACL reconstruction using OTT femoral passage. Twenty patients underwent 1SHG reconstruction and 31 underwent 2SHG reconstruction. International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner score, and KT-1000 (Medmetric Corporation, San Diego, California) evaluation were recorded at a mean follow-up of 12.1±1.6 years. At final follow-up, radiographic evaluation was performed according to the IKDC grading system. Mean IKDC subjective score at follow-up was 76.6±21.9 in the 1SHG group and 88.9±10.0 in the 2SHG (P=.009). Average KOOS was 82.6±18.7 in the 1SHG group and 92.4±9.2 in the 2SHG group (P=.016). Objective IKDC evaluation showed a higher percentage of normal knees in the 2SHG group (P=.018). Pivot shift testing revealed a significantly higher number of normal knees in the 2SHG group (P=.001). Radiographs showed fewer degenerative changes in the 2SHG group at final follow-up in the medial (P=.01) and lateral (P=.037) compartments. Nonanatomical ACL reconstruction using the OTT technique provided satisfactory results in terms of control of both static and dynamic instability at long-term follow-up, thus preventing degenerative joint disease. The 2SHG group showed better subjective and functional outcomes with fewer degenerative changes compared with the 1SHG group at long-term follow-up.

Survivorship of bipolar fresh total osteochondral ankle allograft.

BACKGROUND: Severe posttraumatic ankle arthritis poses a reconstructive challenge in the young and active patient. Bipolar fresh total osteochondral allograft (BFTOA) may represent an intriguing alternative to arthrodesis and prosthetic replacement. The purpose of this article was to evaluate the outcomes of BFTOA performed through an anterior approach to the ankle and to investigate the parameters influencing the results. METHODS: A total of 26 patients (18 males and 8 females with a mean age of 34.9 ± 7.7 years) underwent BFTOA. The allograft was prepared with the help of specifically designed jigs and the surgery was performed using a direct anterior approach. Patients were evaluated clinically and radiographically at 2, 4, 6, and 12 months after the operation, and at a mean 40.9 ± 14.1 months of follow-up. Radiographic evaluation included the measurement of allograft size matching and alignment. RESULTS: The AOFAS score improved from 26.6 ± 6 preoperatively to 77.8 ± 8.7 after a mean follow-up of 40.9 ± 14.1 months (P < .0005). Six failures occurred. Joint degeneration was classified as 2 in 12 and as 3 in 14 patients. A statistically significant correlation between low degrees of distal tibial slope and better clinical outcomes was observed (P = .049). CONCLUSION: BFTOA appears to be a viable option to arthrodesis or arthroplasty. Precise allograft sizing, stable fitting, and fixation and delayed weight-bearing were key factors for a successful outcome. In this series the correct alignment of the tibial graft, in terms of slope, was found to play a crucial role in the allograft survivorship. LEVEL OF EVIDENCE: Level IV, case series.

Treatment of juvenile osteochondritis dissecans of the talus: current concepts review.

Juvenile osteochondritis dissecans of the talus (JODT) affects the subchondral bone primarily and, in a skeletally immature population, articular cartilage secondarily. It probably consists of aseptic bone necrosis whose spontaneous healing is impaired by microtraumas, resulting in an osteochondral injury and, in some cases, in osteoarthritis. In many cases the clinical presentation is asymptomatic. Mild chronic pain is frequent, sometimes accompanied by swelling, stiffness or locking. Few data are currently available on this topic and, moreover, most existing data were obtained from mixed groups and populations; it is therefore difficult to outline a scheme for the treatment of JODT. However, the most suitable treatment in the first stages of the disease is conservative. The presence of a loose body is an indication for surgical fixation, drilling or regenerative procedures, depending on the presence/extent of subchondral bone sclerosis and the surgeon's experience. Drilling has been shown to promote the healing of lesions with minimal surgical trauma. Microfractures, since they induce fibrocartilage repair, are to be considered only for small injuries. Mosaicplasty and osteochondral autograft transplantation may cause donor site morbidity and are techniques little reported in JODT. Regenerative techniques and fresh allografts give good results in osteochondral lesions, but further studies are required to describe the results that can be obtained in JODT alone.

One-step arthroscopic technique for the treatment of osteochondral lesions of the knee with bone-marrow-derived cells: three years results.

Osteochondral lesions of the knee (OLK) are a common cause of knee pain and associated diseases. A new bone-marrow-derived mesenchymal stem cells technique has been developed for the treatment of OLK. 30 patients with OLK underwent arthroscopic one-step procedure. The bone marrow was harvested from the patients' posterior iliac crest and arthroscopically implanted with a scaffold into the lesion site. Clinical inspection and MRI were performed. Mean International Knee Documentation Committee (IKDC) score before surgery was 29.9 ± 13.2 and 85.4 ± 4.2 at 29 ± 4.1 months (p < 0.0005), while Knee injury and Osteoarthritis Outcome Score (KOOS) before surgery was 35.1 ± 11.9 and 87.3 ± 7.3 at 29 ± 4.1 months (p < 0.0005). Control MRI and bioptic samples showed an osteochondral regeneration of the lesion site. The one-step technique appears to be a good and reliable option for treatment of OLK at three years of follow-up. Level of evidence Case series, Level IV.

One-step bone marrow-derived cell transplantation in talarosteochondral lesions: mid-term results.

PURPOSE: to verify the capability of scaffold-supported bone marrow-derived cells to be used in the repair of osteochondral lesions of the talus. METHODS: using a device to concentrate bone marrow-derived cells, a scaffold (collagen powder or hyaluronic acid membrane) for cell support and platelet gel, a one-step arthroscopic technique was developed for cartilage repair. In a prospective clinical study, we investigated the ability of this technique to repair talar osteochondral lesions in 64 patients. The mean follow-up was 53 months. Clinical results were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) scale score. We also considered the influence of scaffold type, lesion area, previous surgery, and lesion depth. RESULTS: the mean preoperative AOFAS scale score was 65.2 ± 13.9. The clinical results peaked at 24 months, before declining gradually to settle at a score of around 80 at the maximum follow-up of 72 months. CONCLUSIONS: the use of bone marrow-derived cells supported by scaffolds to repair osteochondral lesions of the talus resulted in significant clinical improvement, which was maintained over time. LEVEL OF EVIDENCE: level IV, therapeutic case series.

Bipolar fresh osteochondral allograft of the shoulder.

PURPOSE: to describe an original technique and preliminary results of bipolar fresh osteochondral allograft implantation for the treatment of end-stage glenohumeral osteoarthritis. METHODS: three patients underwent bipolar fresh osteochondral allograft implantation to the shoulder. Clinical and radiographical evaluations were carried out periodically through to final follow-up. RESULTS: constant Score increased from 38.3 ± 2.9 pre-operatively to 78.7 ± 16.2 at 12 months, 72.3 ±15.3 at 24 months, and 59.3 ± 22.0 at 34 months. Arthritis and partial reabsorption of the implanted surfaces were evident radiographically. CONCLUSIONS: the clinical results obtained in these patients seem to support the applicability of bipolar fresh osteochondral allograft implantation in the shoulder in subjects with severe post-traumatic arthritis and intact rotator cuff. The development of arthritis of the implanted surfaces, while not impacting the clinical result, is a cause of concern. LEVEL OF EVIDENCE: level IV, therapeutic case series.