How Does Autologous Breast Reconstruction Impact Downtime?

BACKGROUND: Although autologous breast reconstruction is technically quite demanding, it offers the best outcomes in terms of durable results, patient perceptions, and postoperative pain. Many studies have focused on clinical outcomes and technical aspects of such procedures, but few have addressed the impact of various flaps on patient recovery times. This particular investigation entailed an assessment of commonly used flaps, examining the periods of time required to resume daily activities. METHODS: Multiple choice questionnaires were administered to 121 patients after recovery from autologous reconstruction to determine the times required in returning to specific physical activities. To analyze results, the analysis of variance F-test was applied, and odds ratios (ORs) were determined. RESULTS: Among the activities surveyed, recovery time was not always a function of free-flap surgery. Additional treatments and psychological effects also contributed. Adjuvant chemotherapy increased average downtime by 2 weeks, and postoperative irradiation prolonged recovery as much as 4 weeks. Patient downtime was unrelated to flap type, ranging from 2.9 to 21.3 weeks for various activities in question. Deep inferior epigastric perforator (DIEP) flaps yielded the highest OR and transverse upper gracilis (TUG) flaps the lowest. CONCLUSION: Compared with superior gluteal artery perforator and TUG flaps, the DIEP flap was confirmed as the gold standard in autologous breast reconstruction, conferring the shortest recovery times. All adjuvant therapies served to prolong patient recovery as well. Surgical issues, patient lifestyles, and donor-site availability are other important aspects of flap selection.

A randomized controlled trial demonstrating sustained benefit of Autologous Matrix-Induced Chondrogenesis over microfracture at five years.

PURPOSE: Autologous Matrix-Induced Chondrogenesis (AMIC®) utilizing a type I/III collagen membrane was compared with microfracture (MFx) alone in focal cartilage lesions of the knee at one, two and five years. METHODS: Forty-seven patients (aged 37 ± 10 years, mean defect size 3.6 ± 1.6 cm2) were randomized and treated either with MFx, with sutured or glued AMIC® in a prospective multicentre clinical trial. RESULTS: After improvement for the first two years in all subgroups, a progressive and significant score degradation was observed in the MFx group, while all functional parameters remained stable for least five years in the AMIC® groups. At two and five years, MRI defect filling was more complete in the AMIC® groups. No treatment-related adverse events were reported. CONCLUSIONS: AMIC® is an effective cartilage repair procedure in the knee resulting in stable clinical results significantly better than the MFx group at five years.

Autologous osteochondral transplantation for osteochondral lesions of the talus in an athletic population.

PURPOSE: To assess clinical outcomes and return to sport in an athletic population treated with autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus. METHODS: A total of 36 patients were included in this retrospective study including 21 professional athletes and 15 amateur athletes who participated in regular moderate- or high-impact athletic activity. All patients underwent autologous osteochondral transplantation of the talus under the care of a single surgeon. At a mean follow-up of 5.9 years, patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. All patients also received pre-operative MRI with the follow-up MRI performed at 1 year and underwent assessment of return to athletic activity. RESULTS: The overall AOFAS score improved from 65.5 (SD ± 11.1) to 89.4 (SD ± 14.4) (p = 0.01). At a final follow-up, 90% of professional athletes (19 of 21) were still competing in athletic activity or still able to participate in unrestricted activity. Of the recreational athletes, 87% (13 of 15) had full return to pre-injury activity levels, while two (13%) returned to activity with restrictions or reduced intensity. MRI showed cystic change in 33% of patients post-operatively; however, this did not appear to affect outcomes (n.s.). Donor site symptoms were seen in 11% of the cohort at final follow-up, despite high function at donor knee. CONCLUSION: The results of our study indicate that AOT procedure is able to achieve good outcomes in an athletic population at a midterm follow-up. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Patellofemoral osteoarthritis is prevalent and associated with worse symptoms and function after hamstring tendon autograft ACL reconstruction.

OBJECTIVES: To evaluate the compartmental distribution of knee osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR), to determine if patellofemoral or tibiofemoral OA is more strongly associated with knee symptoms and function, and to evaluate the contribution of associated injuries and surgical delay to the development of OA. METHODS: This cross-sectional study recruited 70 participants who underwent hamstring tendon (HT) ACLR 5-10 years previously. Radiographic OA was assessed according to the Osteoarthritis Research Society International (OARSI) criteria. Knee symptoms were assessed with the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Anterior Knee Pain Scale (AKPS), while function was assessed with three lower limb tasks (hop-for-distance, one-leg rise and side-hop). Multivariate and binary logistic regression analyses were performed to assess the relationship between OA and symptomatic/functional outcomes and associated injuries/surgical delay, respectively. RESULTS: Radiographic OA was observed in the patellofemoral (47%) and tibiofemoral joints (31%). Pain, symptoms and quality of life on the KOOS and the AKPS were associated with severity of patellofemoral OA (standardised regression coefficient (ß)=-0.3 to -0.5, p=0.001-0.042), whereas only the KOOS-pain subscale was associated with tibiofemoral OA (ß=-0.3, p=0.037). For each functional task, greater patellofemoral OA severity was associated with worse performance, independent of tibiofemoral OA severity (ß=-0.3 to -0.4, p=0.001-0.026). Medial meniscal and patellofemoral chondral lesions at surgery were associated with tibiofemoral and patellofemoral OA development at follow-up, respectively, while a longer surgery delay was associated with patellofemoral OA. CONCLUSIONS: Patellofemoral OA is common following HT ACLR and is associated with worse knee-related symptoms, including anterior knee pain, and decreased functional performance.

[Post-treatment rehabilitation after autologous chondrocyte implantation: State of the art and recommendations of the Clinical Tissue Regeneration Study Group of the German Society for Accident Surgery and the German Society for Orthopedics and Orthopedic Surgery]. / Nachbehandlung bei der autologen Chondrozytentransplantation: Eine Bestandsaufnahme und Empfehlung der AG Klinische Geweberegeneration der DGU/DGOOC.

BACKGROUND: Over the course of the past two decades autologous chondrocyte implantation (ACI) has become an important surgical technique for treating large cartilage defects. The original method using a periostal flap has been improved by using cell-seeded scaffolds for implantation, the matrix-based autologous chondrocyte implantation (mb-ACI) procedure. MATERIAL AND METHODS: Uniform nationwide guidelines for post-ACI rehabilitation do not exist. A survey was conducted among the members of the clinical tissue regeneration study group concerning the current rehabilitation protocols and the members of the study group published recommendations for postoperative rehabilitation and treatment after ACI based on the results of this survey. RESULTS: There was agreement on fundamentals concerning a location-specific rehabilitation protocol (femoral condyle vs. patellofemoral joint). With regard to weight bearing and range of motion a variety of different protocols exist. Similar to this total agreement on the role of magnetic resonance imaging (MRI) for postsurgical care was found but again a great variety of different protocols exist. CONCLUSIONS: This manuscript summarizes the recommendations of the members of the German clinical tissue regeneration study group on postsurgical rehabilitation and MRI assessment after ACI (level IVb/EBM).

A systematic review of reporting of rehabilitation in articular-cartilage-repair studies of third-generation autologous chondrocyte implantation in the knee.

CONTEXT: Autologous chondrocyte implantation (ACI) is a tissue-engineered surgical technique initially developed for articular cartilage repair of isolated chondral lesions of the knee. Third-generation techniques (ACI3) are now available that deliver autologous cultured chondrocytes into the defect using cell scaffolds. The successful outcomes of these techniques have some dependency on presurgical and postsurgical patient rehabilitation. OBJECTIVES: To determine if the standard of reporting for rehabilitation has improved in ACI3 studies; previous reviews in this field recommended describing the detail of this rehabilitation and patient compliance as integral elements. EVIDENCE ACQUISITION: A computerized search was performed in March 2013. Criteria for inclusion were any studies that evaluated or described the process of ACI3 in the knee and subsequent rehabilitation. The modified Coleman Methodology Score (CMS) was used to rate the standard of reporting of rehabilitation and surgical procedures; review articles were also evaluated for quality using the Strength of Recommendation Taxonomy (SORT). Mean scores, odds ratios, 95% confidence intervals, and Mann-Whitney U statistics were calculated. EVIDENCE SYNTHESIS: An improvement in mean CMS was seen compared with previous reviews, but rehabilitation reporting scores were lower than their surgical equivalent; significant association was seen between studies with rehabilitator involvement and high scores in the individual CMS rehabilitation element. Predominant SORT scores of 2A indicated medium strength of recommendation. CONCLUSIONS: The CMS provides a general overview of methodological quality, but a more specialized tool to report on the quantitative and qualitative aspects of the rehabilitation process would help raise the standards. It is recommended that rehabilitation therapists be included as key members of research teams and be involved in the design, implementation, and reporting of future studies.

Patient-oriented and performance-based outcomes after knee autologous chondrocyte implantation: a timeline for the first year of recovery.

CONTEXT: It is well established that autologous chondrocyte implantation (ACI) can require extended recovery postoperatively; however, little information exists to provide clinicians and patients with a timeline for anticipated function during the first year after ACI. OBJECTIVE: To document the recovery of functional performance of activities of daily living after ACI. PATIENTS: ACI patients (n = 48, 29 male; 35.1 ± 8.0 y). INTERVENTION: All patients completed functional tests (weight-bearing squat, walk-across, sit-to-stand, step-up/over, and forward lunge) using the NeuroCom long force plate (Clackamas, OR) and completed patient-reported outcome measures (International Knee Documentation Committee Subjective Knee Evaluation Form, Lysholm, Western Ontario and McMaster Osteoarthritis Index [WOMAC], and 36-Item Short-Form Health Survey) preoperatively and 3, 6, and 12 mo postoperatively. MAIN OUTCOME MEASURES: A covariance pattern model was used to compare performance and self-reported outcome across time and provide a timeline for functional recovery after ACI. RESULTS: Participants demonstrated significant improvement in walk-across stride length from baseline (42.0% ± 8.9% height) at 6 (46.8% ± 8.1%) and 12 mo (46.6% ± 7.6%). Weight bearing on the involved limb during squatting at 30°, 60°, and 90° was significantly less at 3 mo than presurgery. Step-up/over time was significantly slower at 3 mo (1.67 ± 0.69 s) than at baseline (1.49 ± 0.33 s), 6 mo (1.51 ± 0.36 s), and 12 mo (1.40 ± 0.26 s). Step-up/over lift-up index was increased from baseline (41.0% ± 11.3% body weight [BW]) at 3 (45.0% ± 11.7% BW), 6 (47.0% ± 11.3% BW), and 12 mo (47.3% ± 11.6% BW). Forward-lunge time was decreased at 3 mo (1.51 ± 0.44 s) compared with baseline (1.39 ± 0.43 s), 6 mo (1.32 ± 0.05 s), and 12 mo (1.27 ± 0.06). Similarly, forward-lunge impact force was decreased at 3 mo (22.2% ± 1.4% BW) compared with baseline (25.4% ± 1.5% BW). The WOMAC demonstrated significant improvements at 3 mo. All patient-reported outcomes were improved from baseline at 6 and 12 mo postsurgery. CONCLUSIONS: Patients' perceptions of improvements may outpace physical changes in function. Decreased function for at least the first 3 mo after ACI should be anticipated, and improvement in performance of tasks requiring weight-bearing knee flexion, such as squatting, going down stairs, or lunging, may not occur for a year or more after surgery.

Measuring physical activity and sports participation after autologous cartilage implantation: a systematic review.

CONTEXT: The assessment of physical activity and return to sport and exercise activities is an important component in the overall evaluation of outcome after autologous cartilage implantation (ACI). OBJECTIVE: To identify the patient-report instruments that are commonly used in the evaluation of physical activity and return to sport after ACI and provide a critical analysis of these instruments from a rehabilitative perspective. EVIDENCE ACQUISITION: A computerized search was performed in January 2013 and repeated in March 2013. Criteria for inclusion required that studies (1) be written in English and published between 1994 and 2013; (2) be clinical studies where knee ACI cartilage repair was the primary treatment, or comparison studies between ACI and other techniques or between different ACI generations; (3) report postoperative physical activity and sport participation outcomes results, and (4) have evidence level of I-III. EVIDENCE SYNTHESIS: Twenty-six studies fulfilled the inclusion criteria. Three physical activity scales were identified: the Tegner Activity Scale, Modified Baecke Questionnaire, and Activity Rating Scale. Five knee-specific instruments were identified: the Lysholm Knee Function Scale, International Knee Documentation Committee Score Subjective Form, Knee Injury and Osteoarthritis Outcome Score, Modified Cincinnati Knee Score, and Stanmore-Bentley Functional Score. CONCLUSIONS: Considerable heterogeneity exists in the reporting of physical activity and sports participation after ACI. Current instruments do not fulfill the rehabilitative needs in the evaluation of physical activity and sports participation.

The progression of isokinetic knee strength after matrix-induced autologous chondrocyte implantation: implications for rehabilitation and return to activity.

CONTEXT: Matrix-induced autologous chondrocyte implantation (MACI) is an established technique for the repair of knee chondral defects. Despite the reported clinical improvement in knee pain and symptoms, little is known on the recovery of knee strength and its return to an appropriate level compared with the unaffected limb. OBJECTIVE: To investigate the progression of isokinetic knee strength and limb symmetry after MACI. DESIGN: Prospective cohort. SETTING: Private functional rehabilitation facility. PATIENTS: 58 patients treated with MACI for full-thickness cartilage defects to the femoral condyles. INTERVENTION: MACI and a standardized rehabilitation protocol. MAIN OUTCOME MEASURES: Preoperatively and at 1, 2, and 5 y postsurgery, patients underwent a 3-repetition-maximum straight-leg raise test, as well as assessment of isokinetic knee-flexor and -extensor torque and hamstring:quadriceps (H:Q) ratios. Correlation analysis investigated the association between strength and pain, demographics, defect, and surgery characteristics. Linear-regression analysis estimated differences in strength measures between the operated and nonoperated limbs, as well as Limb Symmetry Indexes (LSI) over time. RESULTS: Peak knee-extension torque improved significantly over time for both limbs but was significantly lower on the operated limb preoperatively and at 1, 2, and 5 y. Mean LSIs of 77.0%, 83.0%, and 86.5% were observed at 1, 2, and 5 y, respectively, while 53.4-72.4% of patients demonstrated an LSI < or = 90% across the postoperative timeline. Peak knee-flexion torque was significantly lower on the operated limb preoperatively and at 1 year. H:Q ratios were significantly higher on the operated limb at all time points. CONCLUSIONS: While peak knee-flexion and hip-flexor strength were within normal limits, the majority of patients in this study still demonstrated an LSI for peak knee-extensor strength < or = 90%, even at 5 y. It is unknown how this prolonged knee-extensor deficit may affect long-term graft outcome and risk of reinjury after return to activity.

Percutaneous autologous concentrated bone marrow grafting in the treatment for nonunion.

The purpose of this study was to evaluate the clinical and radiographic treatment effects of percutaneous autologous concentrated bone marrow grafting in nonunion cases and to evaluate the effectiveness of this grafting procedure. We enrolled 17 cases those had atrophic changes due to continuous nonunion for over 9 months after injury and had undergone low-intensity pulsed ultrasound treatment for more than 3 months. The site of nonunion was the femur in 10 cases, the tibia in 5 cases, the humerus in 1 case, and the ulna in 1 case. They underwent percutaneous autologous concentrated bone marrow grafting and continued low-intensity pulsed ultrasound stimulation treatment after grafting. Patients were evaluated using the visual analogue scale for pain at immediately before the procedure, 3, 6, and 12 months after grafting. Plain radiographs of the affected site were taken and evaluated about the healing of the nonunion site at each clinical evaluation. As quantitative assessment, CT scans were undertaken before the procedure and 6 months after grafting. The visual analogue scale pain score was reduced consistently after grafting in all patients. About the healing at the nonunion site, 11 and 13 cases of bone union were observed at 6 and 12 months after grafting. The mean volume of callus formation based on CT images was 4,147 (262-27,392) mm3 total between grafting and 6 months. Percutaneous autologous concentrated bone marrow grafting is an effective procedure for the treatment of patients with nonunion.

Postoperative Management for Articular Cartilage Surgery in the Knee.

The postoperative rehabilitation team plays a crucial role in optimizing outcomes after articular cartilage surgery. A comprehensive approach to postoperative physical therapy that considers the type of surgery, location in the knee, concurrent procedures, and patient-specific factors is imperative. While postoperative rehabilitation protocols should be specific to the patient and type of surgery performed and include phased rehabilitation goals and activities, the key principles for postoperative rehabilitation apply across the spectrum of articular cartilage surgeries and patients. These key principles consist of preoperative assessments that include physical, mental, and behavioral components critical to recovery; education and counseling with respect to expectations and compliance; and careful monitoring and adjustments throughout the rehabilitation period based on consistent communication among rehabilitation, surgical, and imaging teams to ensure strict patient compliance with restrictions, activities, and timelines to optimize functional outcomes after surgery.

Delayed recovery after autologous peripheral hematopoietic cell transplantation: potential effect of a high number of total nucleated cells in the graft.

BACKGROUND: Some patients demonstrate delayed recoveries after autologous hematopoietic stem cell transplantation despite infusion of an adequate number of CD34+ cells/kg and clinically stable status. Factors considered being possible predictors of this outcome in this context were explored. STUDY DESIGN AND METHODS: A total of 246 patients were evaluated in terms of engraftment. Delayed recovery was defined by white blood cell recovery time exceeding mean+1 SEM. Clinical factors and graft characteristics were examined. Comparisons between patients with normal or delayed engraftment were made. Proinflammatory cytokines and proteolytic enzyme quantification and CXCR4+ and CD44+ cell enumeration were performed on peripheral hematopoietic stem cells (PHSC) product samples of patients with delayed engraftment and patients with usual engraftment time. RESULTS: Sixteen patients, who received at least 3 × 10(6) CD34+ cells/kg without known clinical factors likely to affect engraftment, demonstrated a delayed recovery time of over 20 days. Some graft variables were found to be significantly increased in these patients by univariate analysis. One variable was the total number of nucleated cells cryopreserved and infused. Among the nucleated cells, the absolute number of granulocytes before and after cryopreservation also differed significantly between the two groups. A multivariate analysis showed that the main predictive factor for delayed recovery was the number of nucleated cells in the graft (p=0.0044). The influence of contaminating cells might be related to the release of elastase, matrix metalloproteinase-9, interleukin (IL)-1ß, and IL-6 involved in stem cell homing. CONCLUSION: Therefore, the numeration of total nucleated cells and granulocytes should be considered as a possible quality control variable of PHSCs submitted for cryopreservation.

Donor site wound protein synthesis correlates with length of acute hospitalization in severely burned children.

Autografting of burn wounds results in generation of donor site wounds. Here we measured donor site wound protein fractional synthesis rate (FSR) in a burn pediatric population and showed that FSR increases over time postsurgery and correlates with the length of hospital stay (LOS) normalized for total body surface area (TBSA) burn size. 3.9 +/- 1.1 days after the grafting surgery patients participated in a metabolic study consisting of continuous infusion of l-[ring-(2)H(5)]-phenylalanine and donor site wound punch biopsies. Donor site wound protein FSR was 10.4 +/- 7.5%/day. Wound FSR demonstrated linear correlation with the time postsurgery (p<0.05). Multiple regression analysis showed that LOS/TBSA correlated with donor site wound protein FSR and time postsurgery (p<0.001) and the following equation describes the relationship: estimated LOS/TBSA=(FSR-12.95-1.414 x postsurgery day)/(-17.8). This equation predicted that FSR corrected for the postsurgery day when the metabolic study was conducted accounted for 67% of the variability (r(2)=0.673) in the LOS/TBSA. Donor site wound protein FSR correlated to LOS/TBSA of burn patients admitted to the intensive care unit. Measurement of protein deposition in regenerating donor site wound using stable isotope technique provides a quantitative measure of wound healing.

Implications for Early Postoperative Care After Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction: A Technical Note.

The quadriceps tendon (QT) has become increasingly used by orthopaedic surgeons as an alternative autograft choice in anterior cruciate ligament reconstruction. As its use increases, athletic trainers and other rehabilitation clinicians will treat a greater number of patients with this autograft type. The recently developed, minimally invasive technique for harvest of the all-soft tissue autograft has many benefits, including versatility, decreased donor-site morbidity, and enhanced cosmesis. Early clinical trials revealed that the QT autograft resulted in decreased anterior knee pain and similar strength and functional outcomes to those of more common autograft types. From a rehabilitation perspective, many characteristics should be considered, such as the importance of early knee extension and quadriceps activation. Therefore, the purpose of this technical note is to expose athletic trainers to the QT autograft so that they may provide the best care for patients after anterior cruciate ligament reconstruction.

Fresh cortical autograft versus fresh cortical allograft effects on experimental bone healing in rabbits: radiological, histopathological and biomechanical evaluation.

Bone grafting is used to enhance healing in osteotomies, arthrodesis, and multifragmentary fractures and to replace bony loss resulting from neoplasia or cysts. They are source of osteoprogenitor cells and induce bone formation and provide mechanical support for vascular and bone ingrowth. Autografts are used commonly but quantity of harvested bone is limit. This study was designed to evaluate fresh cortical autograft and allograft effects on bone healing process. Twenty male White New Zealand rabbits were used in this study. In autograft group the defect was filled by fresh autogenous cortical graft, in allograft group the defect was filled by a segment of fresh allogenous cortical bone which was harvested at the time of surgery during the creation of radius bone defect. Then all surface soft tissue, such as muscle attachments, were removed from the harvested bone and changed between rabbits as a fresh allogenous cortical bone graft and was fixed by cercelage wire. Radiological, histopathological and biomechanical evaluations were performed blindly and results scored and analyzed statistically. Statistical tests did not support significant differences between two groups at the 14th and 56th postoperative day radiographically (P > 0.05). There was a significant difference radiologically for the 28th and the 42nd postoperative (P < 0.05). Autograft was superior to allograft at the 28th and 42nd postoperative day in radiological evaluation (P < 0.03). Histopathological and biomechanical evaluation revealed no significant differences between two groups.

Traditional vs accelerated approaches to post-operative rehabilitation following matrix-induced autologous chondrocyte implantation (MACI): comparison of clinical, biomechanical and radiographic outcomes.

OBJECTIVE: To determine the effectiveness of 'accelerated' compared to 'traditional' post-operative load bearing rehabilitation protocols following matrix-induced autologous chondrocyte implantation (MACI). METHOD: A randomized controlled study design was used to investigate clinical, biomechanical and radiographic assessment at 3 months post-surgery in 62 patients following MACI to the medial or lateral femoral condyle. Both rehabilitation interventions sought to protect the implant for an initial period, then incrementally increase load bearing. Under the 'accelerated' protocol, patients reached full weight bearing at 8 weeks post-surgery, compared to 11 weeks for the 'traditional' group. RESULTS: Patients in the 'accelerated' group achieved greater 6 min walk distances and daily activity levels as measured by accelerometry (P<0.05) compared to the 'traditional' group. Furthermore, the 'accelerated' group reported significantly better improvement in knee pain at 12 weeks as indicated by the Knee Injury and Osteoarthritis Outcome Score (P<0.05), and regardless of the rehabilitation protocol employed, no patient suffered any adverse effect to the implant as assessed by magnetic resonance imaging at 3 months. Comparison of each rehabilitation group with an unaffected control group revealed a significant difference in peak knee adduction and flexion moments for the traditional group (P<0.05). However, there was no difference for accelerated patients (P>0.05), which may demonstrate a faster return to knee loading patterns typically observed in unaffected subjects. CONCLUSION: The 'accelerated' load bearing approach that reduced the length of time spent ambulating on crutches resulted in reduced knee pain, improved function, no graft complications and may speed up the recovery of normal gait function. Patient follow-up to at least 24 months would be required to observe longer-term graft outcomes.

Is it feasible to conduct a randomised controlled trial of pretransplant exercise (prehabilitation) for patients with multiple myeloma awaiting autologous haematopoietic stem cell transplantation? Protocol for the PREeMPT study.

INTRODUCTION: While myeloma is an incurable malignancy, developments in disease management have led to increased life expectancy in recent years. Treatment typically involves stem-cell transplantation. Increased survival rates equate to more patients living with the burden of both the disease and its treatment for increasing number of years, rendering myeloma a long-term condition.Evidence exists to demonstrate the benefits of exercise for patients recovering from stem-cell transplantation, and prehabilitation-exercise before treatment-has been shown to be effective in other disease areas. To date there has been no research into prehabilitation in patients with myeloma awaiting transplantation treatment.Our objective is to determine whether it is feasible to conduct a randomised controlled trial into pretransplant exercise for patients with multiple myeloma who are awaiting autologous stem-cell transplantation. METHODS AND ANALYSIS: This mixed methods study identifies patients with diagnosis of multiple myeloma who have been assigned to the autologous transplantation list and invites them to participate in six weekly sessions of individualised, supervised exercise while awaiting transplantation.Quantitative data to determine feasibility targets include rates of recruitment, adherence and adverse events, and outcome measures including 6 min walking distance test and quality of life.Qualitative interviews are undertaken with a purposive sample of patients to capture their experiences of the study and the intervention. ETHICS AND DISSEMINATION: Ethics committee approval has been obtained. Dissemination will be through open-access publications and presentations and will seek to reach multiprofessional bases as well as patients and carer groups, addressing the widespread interest in this area of research. TRIAL REGISTRATION NUMBER: NCT03135925; Pre-results.

A Comparison of 2-Year Outcomes in Patients Undergoing Tibiofemoral or Patellofemoral Matrix-Induced Autologous Chondrocyte Implantation.

BACKGROUND: Matrix-induced autologous chondrocyte implantation (MACI) has demonstrated encouraging clinical results in the treatment of knee chondral defects. However, earlier studies suggested that chondrocyte implantation in the patellofemoral (PF) joint was less effective than in the tibiofemoral (TF) joint. PURPOSE: To compare the radiological and clinical outcomes of those undergoing MACI to either the femoral condyles or PF joint. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 194 patients were included in this analysis, including 127 undergoing MACI to the medial (n = 94) and lateral (n = 33) femoral condyle, as well as 67 to the patella (n = 35) or trochlea (n = 32). All patients were evaluated clinically (Knee injury and Osteoarthritis Outcome Score [KOOS], visual analog scale, Short Form-36) before surgery and at 3, 12, and 24 months after surgery, while magnetic resonance imaging (MRI) was undertaken at 3, 12, and 24 months, with the MOCART (magnetic resonance observation of cartilage repair tissue) scoring system employed to evaluate the quality and quantity of repair tissue, as well as an MRI composite score. Patient satisfaction was evaluated. RESULTS: No significant group differences ( P > .05) were seen in demographics, defect size, prior injury, or surgical history, while the majority of clinical scores were similar preoperatively. All clinical scores significantly improved over time ( P < .05), with a significant group effect observed for KOOS activities of daily living ( P = .008), quality of life ( P = .008), and sport ( P = .017), reflecting better postoperative scores in the TF group. While the PF group had significantly lower values at baseline for the KOOS activities of daily living and quality of life subscales, it actually displayed a similar net improvement over time compared with the TF group. At 24 months, 93.7% (n = 119) and 91.0% (n = 61) of patients were satisfied with the ability of MACI to relieve their knee pain, 74.0% (n = 94) and 65.7% (n = 44) with their ability to participate in sport, and 90.5% (n = 115) and 83.6% (n = 56) satisfied overall, in the TF and PF groups, respectively. MRI evaluation via the MOCART score revealed a significant time effect ( P < .05) for the MRI composite score and graft infill over the 24-month period. While subchondral lamina scored significantly better ( P = .002) in the TF group, subchondral bone scored significantly worse ( P < .001). At 24 months, the overall MRI composite score was classified as good/excellent in 98 TF patients (77%) and 54 PF patients (81%). CONCLUSION: MACI in the PF joint with concurrent correction of PF maltracking if required leads to similar clinical and radiological outcomes compared with MACI on the femoral condyles.

Autologous Chondrocyte Implantation: Past, Present, and Future.

Focal cartilage defects of the knee are relatively common and may increase the risk of developing osteoarthritis. Autologous chondrocyte implantation (ACI) aims to restore the integrity of isolated cartilage lesions through the induction of hyaline-like cartilage formation. Although ACI has traditionally been used as a second-line treatment, recent evidence suggests that ACI should be considered as a first-line treatment option in certain patients. Recent controlled trials also suggest that there are improved clinical outcomes among those patients who undergo ACI over the mid-term and long-term compared with those treated with microfracture or osteochondral autograft/mosaicplasty, regardless of lesion size. Recent literature also indicates that arthroscopic, second-generation and third-generation techniques are associated with better outcomes and fewer complications than first-generation ACI. In summary, ACI is an effective tool for cartilage restoration that may be more efficacious and durable than other cartilage restoration techniques for appropriate candidates.

Autologous proliferative therapies in recalcitrant lateral epicondylitis.

OBJECTIVE: This study investigates the clinical effects of autologous conditioned plasma (ACP) injections and low-level laser application as therapy options for chronic lateral epicondylitis. DESIGN: A total of 52 patients with chronic lateral epicondylitis were evaluated in this study; 26 of these patients received three ACP injections and the control group, with 26 patients, received 12 laser applications, with standardized physical therapy for all patients afterward. Control examinations took place before treatment, after 2 and 6 mos, and in the 1 yr final follow-up. The control examination included the visual analog scale for pain and Disabilities of the Arm, Shoulder and Hand outcome measure scores. RESULTS: The analysis at final follow-up after 1 yr showed that both treatment options resulted in successful therapy outcome for the patients. In total, 63.5 % were successfully treated. Successful treatment was defined as more than 30% improvement in the visual analog score and more than 10.2 points in the Disabilities of the Arm, Shoulder and Hand score. Both groups showed a significant improvement in time response. CONCLUSIONS: This study demonstrates the beneficial effects of autologous proliferative therapies in the treatment of lateral epicondylitis. The data show that laser application and ACP therapy lead to a clinical improvement in epicondylopathia. Especially the new treatment with ACP can be highlighted as an alternative and as an easy-to-apply therapy option for clinical practice.