Sex does not influence the long-term outcome of matrix-assisted autologous chondrocyte transplantation.

PURPOSE: Regenerative techniques for articular cartilage lesions demonstrated heterogeneous clinical results. Several factors may influence the outcome, with sex being one of the most debated. This study aimed at quantifying the long-term influence of sex on the clinical outcome obtained with a regenerative procedure for knee chondral lesions. METHODS: Matrix-assisted autologous chondrocyte transplantation (MACT) was used to treat 235 knees which were prospectively evaluated with the International Knee Documentation Committee (IKDC), EuroQol visual analogue scale, and Tegner scores at 14-year mean follow-up. A multilevel analysis was performed with the IKDC subjective scores standardised according to the age/sex category of each patient and/or the selection of a match-paired subgroup to compare homogeneous men and women patients. RESULTS: At 14 years, men and women showed a failure rate of 10.7% and 28.8%, respectively (p < 0.0005). An overall improvement was observed in both sexes. Women had more patellar lesions and men more condylar lesions (p = 0.001), and the latter also presented a higher preinjury activity level (p < 0.0005). Men had significantly higher IKDC subjective scores at all follow-ups (at 14 years: 77.2 ± 18.9 vs. 62.8 ± 23.1; p < 0.0005). However, the analysis of homogeneous match-paired populations of men and women, with standardised IKDC subjective scores, showed no differences between men and women (at 14 years: -1.6 ± 1.7 vs. -1.9 ± 1.6). CONCLUSION: Men and women treated with MACT for knee chondral lesions presented a significant improvement and stable long-term results. When both sexes are compared with homogeneous match-paired groups, they have similar results over time. However, women present more often unfavourable lesion patterns, which proved more challenging in terms of long-term outcome after MACT. LEVEL OF EVIDENCE: Level II.

Autologous chondrocyte implantation for the treatment of osteochondral lesions of the talus: What happens after 20 years?

BACKGROUND: The purpose of this study was to assess the long-term clinical efficacy of first-generation autologous chondrocyte implantation (ACI) technique for osteochondral lesions of the ankle joint. METHODS: Eleven patients with symptomatic OLTs underwent ACI from December 1997 to October 2002. A total of 9 patients (5 men, 4 women, age 25.2 ± 6.3) were evaluated at baseline and at 1, 3, 10 years, and at final follow-up of minimum 20 years with AOFAS ankle-hindfoot score, NRS for pain, and with the Tegner score. RESULTS: The AOFAS score improved significantly from the baseline value of 40.4 ± 19.8 to 82.7 ± 12.9 at the final follow-up (p < 0.0005). The NRS for pain improved significantly from 7.8 ± 0.7 at baseline to 4.8 ± 2.1 at the final follow-up (p < 0.0005). Moreover, the Tegner score underwent a modification from the pre-operative median value of 1 (range: 1-3) and from a pre-injury value of 5 (range: 3-7) to 3 (range: 2-4) at the final follow-up (p < 0.0005). CONCLUSIONS: ACI has proven to be an effective treatment option for patients suffering from OLTs, leading to a long-lasting clinical improvement even beyond 20 years of follow-up. LEVEL OF EVIDENCE: Level IV.

Hyaluronic scaffold transplantation with bone marrow concentrate for the treatment of osteochondral lesions of the talus: durable results up to a minimum of 10 years.

PURPOSE: The aim of this study was to evaluate the long-term clinical results of the transplantation of a hyaluronic acid membrane augmented with bone marrow aspirate concentrate (BMAC) in an one-step technique for the treatment of patients affected by osteochondral lesions of the talus (OLT). METHODS: A total of 101 patients (64 men, 37 women, age 32.9 ± 10.9) were evaluated for a minimum of 10 years of follow-up (151.5 ± 18.4 months) The mean lesion size was 2.2 ± 1.4 cm2, the lesion had a post-traumatic origin in 73 patients, 15 patients previously had an ankle fracture, 22 patients had ankle osteoarthritis. All patients were clinically evaluated at baseline and at 2, 5, and a minimum of 10 years after treatment using the AOFAS score, the NRS for pain, and the Tegner score. A survival analysis was performed to check the survival to failure up to the last follow-up. RESULTS: The AOFAS score significantly improved from baseline (59.6 ± 13.9) to the final follow-up (82.3 ± 14.2) (p < 0.0005). A significant reduction in the AOFAS score was found from 2 to 10 years (p < 0.0005). The NRS for pain changed from 7.0 ± 1.3 at baseline to 3.9 ± 2.7 at the final follow-up (p < 0.0005). A significant worsening was documented between 5 years and the final follow-up (p < 0.0005). The Tegner score improved from the preoperative value of 2.0 (range 1-7) to 3.0 (range 1-7) at the final follow-up (p < 0.0005), although it remained lower as compared to the preinjury level of 4.0 (range 1-9) (p < 0.0005). Better results were documented in male and younger patients with smaller lesions, without the previous surgery, and without the previous ankle fractures or osteoarthritis. At the final follow-up, 85 patients considered their general health status "satisfactory" and 84 patients reported feeling "better" than the preoperative condition. Five patients were considered failures and underwent prosthetic ankle replacement or repeated the same surgery. CONCLUSION: This one-step technique showed to be an effective procedure for the treatment of OLT, providing a low failure rate and offering durable clinical improvements up to a minimum of 10 years of follow-up. However, this technique demonstrated a small yet significant decrease over the years in terms of pain and function and poor results in terms of sports activity level. LEVEL OF EVIDENCE: Level IV.

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.

Bone marrow aspirate concentrate and scaffold for osteochondral lesions of the talus in ankle osteoarthritis: satisfactory clinical outcome at 10 years.

PURPOSE: To evaluate at long-term follow-up patients undergoing a one-step procedure of debridement and BMAC seeded in situ onto a scaffold for the treatment of osteochondral lesions of the talus (OLT) in ankles affected by osteoarthritis (OA), documenting the duration of the clinical benefit and its efficacy in postponing end-stage procedures. METHODS: This series included 56 consecutive patients. Patients were evaluated preoperatively and up to a mean of 10 years of follow-up with the AOFAS score and the AOS scale, including pain and disability subscales. Furthermore, patients were asked to rate the satisfaction and failures were documented as well. RESULTS: The AOFAS score improved from 52.3 ± 14.3 to 73.5 ± 23.1 at 10 years (p < 0.0005); the AOS pain and disability subscales decreased from 70.9 ± 14.1 to 37.2 ± 32.7 and from 69.0 ± 14.8 to 34.2 ± 29.3, respectively (both p < 0.0005). The overall rate of satisfaction was 61.8 ± 41.2 and 68.6% of patients would undergo again the surgical procedure. A total of 17 failures was documented, for a failure rate of 33.3%. Older patients and those with more complex cases requiring previous or combined surgeries had lower outcomes, as well as those affected by grade 3 OA, who experienced a high failure rate of 71.4%. CONCLUSIONS: This one-step technique for the treatment of OLT in OA ankles showed to be safe and to provide a satisfactory outcome, even if patients with end stage OA presented a high revision rate at 10 years. Moreover, this procedure was effective over time, with overall good results maintained up to a long-term follow-up. However, older age, more complex cases requiring previous or combined surgeries, and advanced OA led to an overall worst outcome and a significantly higher failure rate.

Ankle joint re-balancing in the management of ankle fracture malunion using fibular lengthening: prospective clinical-radiological results at mid-term follow-up.

PURPOSE: An unsatisfactory reduction and internal fixation of an ankle fracture can result in an alteration of the anatomical axes and distribution of the load on the ankle, with consequent development of chronic pain and articular degeneration. The aim of this study is to evaluate the results of the articular re-balancing with realignment and lengthening of the fibula in case of malunited distal fibular fractures. METHODS: A review of prospectively collected data was performed for all patients with a diagnosis of malunion of the fibula and underwent ankle joint re-balancing with fibular lengthening. Twenty-three patients, with a mean age of 39.4 ± 13.1 years, have been evaluated using radiographic parameters, American Orthopaedic Foot and Ankle Surgeons ankle-hindfoot, Ankle Activity scale, and SF-36 score at six, 12, 24, and 36 months post-operatively. RESULTS: All cases treated showed at follow-up the osteotomy healed in good correction of the deformities. Clinical scores showed a clear improvement: final 36-month mean AOFAS was 74.0 ± 8.9 point, final 36-month mean HALASI score was 4.9 ± 0.9 points, 36-month follow-up SF-36 score showed an average score of 73.2 ± 10.7 points. Pre- and post-operative radiographic parameters have been registered and described. CONCLUSIONS: The ankle joint is a complex structure, and even minor changes of the structure of this joint can significantly compromise its functionality. Ankle joint re-balancing is an effective surgical procedure in case of fibular malunion. This procedure, in patients carefully selected, could procrastinate more disabling surgical procedure, as arthrodesis or prosthesis.

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.

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.

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.

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.

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.

Autologous Chondrocyte Implantation for Talar Osteochondral Lesions: Comparison Between 5-Year Follow-Up Magnetic Resonance Imaging Findings and 7-Year Follow-Up Clinical Results.

Autologous chondrocyte implantation (ACI) is an established surgical procedure that has provided satisfactory results. The aim of the present study was to correlate the clinical outcomes of a series of 20 patients treated by ACI at a 7-year follow-up examination with the magnetic resonance imaging (MRI) T2-mapping 5-year follow-up findings. We evaluated 20 patients using the American Orthopaedic Foot and Ankle Society (AOFAS) score preoperatively and the established follow-up protocol until 87.2 ± 14.5 months. MRI T2-mapping sequences were acquired at the 5-year follow-up examination. At the MRI examination (60 ± 12 months), the mean AOFAS score improved from 58.7 ± 15.7 to 83.9 ± 18.4. At the final follow-up examination at 87.2 ± 14.5 months, the AOFAS score was 90.9 ± 12.7 (p = .0005). Those patients who experienced an improvement between 5 and 7 years after surgery had a significant greater percentage of T2-map value of 35 to 45 ms (hyaline cartilage) compared with those patients who did not improve (p = .038). MRI T2 mapping was shown to be a valuable tool capable of predicting reproducible clinical outcomes after ACI even 7 years after surgery. The quality of the regenerated tissue and the degree of defect filling became statistically significant to the clinical results at the final follow-up examination.

Surgical treatment of stage II posterior tibialis tendon dysfunction: ten-year clinical and radiographic results.

INTRODUCTION: Grade II chronic tibialis posterior tendon dysfunction (PTTD) poses a reconstructive challenge to the orthopaedic surgeon. Aim of this retrospective study is to report the clinical and radiographical results of a case series of 63 patients (102 ft) affected by grade II PTTD who underwent tailored surgical treatment at 10-year mean follow-up. MATERIALS AND METHODS: Sixty-three patients (102 ft) were available for clinical and radiological evaluation and were retrospectively reviewed at a mean follow-up of 125.1 ± 14.9 months. Tibialis posterior (PTT) treatment was based on the pathological anatomy of the degenerated tendon. PTT repair was performed in 53 cases. Flexor digitorum longus transfer was performed in the remaining 49. Associated procedures were represented by medial displacement calcaneal osteotomy (MDCO) and lateral column lengthening (LCL) depending on the main clinical feature of the foot (hindfoot valgus and forefoot abduction, respectively). Patients' evaluation included AOFAS score and radiographic examination with measure of lateral talus-first metatarsal angle (LTFMA) and talo-navicular coverage angle (TNCA). RESULTS WE OBSERVED FOUR FAILURES: AOFAS hindfoot score was 89 ± 10 points at final follow-up. Eighty-six per cent of the patients declared to be satisfied or satisfied with minor reservations. An overall statistical significant decrease was observed in both LTFMA and TNCA values. A better TNCA correction was observed in case of associated LCL with respect to MDCO. DISCUSSION: Tailored PTT treatment associated with MDCO or LCL seems provide long-term pain relief and satisfactory function in the treatment of stage II posterior tibial tendon dysfunction.

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.

"One-step" bone marrow-derived cells transplantation and joint debridement for osteochondral lesions of the talus in ankle osteoarthritis: clinical and radiological outcomes at 36 months.

INTRODUCTION: Ankle osteoarthritis (OA) is a challenging pathology, often requiring surgical treatments. In young patients, joint sparing, biologic procedures would be desirable. Recently, a few reports have described the efficacy of bone marrow stem cells in OA. Considering the good outcomes of one-step bone marrow derived cells transplantation (BMDCT) for osteochondral lesions of the talus (OLT), we applied this procedure for OLT in concomitant ankle OA. MATERIALS AND METHODS: 56 patients, with a mean age of 35.6 years (range 16­50), who suffered from OLT and ankle OA, were treated using BMDCT. All patients were clinically checked using AOFAS score, in the pre-operative setting until the final follow-up of 36 months. Weight-bearing radiographs and MRI evaluation using Mocart score were performed, preoperatively and postoperatively. RESULTS: The whole clinical outcome had a remarkable improvement at 12 months, a further amelioration at 24 months and a lowering trend at 36 months (77.8 ± 18.3). Early OA had better outcomes. 16 patients required another treatment and they were considered failures. Clinical outcome significantly correlates with OA degree, BMI, associate procedures. Radiographs were in line with clinical results. MRI evaluation showed signs of osteochondral repair. CONCLUSIONS: BMDCT showed encouraging clinical and radiological outcomes at short-term follow-up. This procedure should be applied in young and selected patients, excluding severe ankle degeneration, where the results are critical. Longer follow-ups and larger case series are needed to confirm these results and if this treatment could be effective in postponing end-stage procedures. LEVEL OF EVIDENCE: IV.

Hamstring graft tibial insertion preservation versus detachment in anterior cruciate ligament reconstruction: a prospective randomized comparative study.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction with hamstring graft (HG) is a commonly performed procedure. Despite the type of reconstruction chosen, the detached HG undergoes a remodeling process known as ligamentization. In order to shorten the ligamentization process, the maintenance of HG tibial insertion, aimed to spare the tendons vascular supply, has been postulated. The aim of this paper is to report the results of a prospective randomized study comparing clinical and MRI results between two different ACL reconstructive procedures with and without HG tibial insertion preservation. METHODS: Forty patients (mean age 27.5 ± 9.5 years) were enrolled and randomly divided into two groups. The study group underwent an ACL reconstruction using a distally inserted HG, while the control group underwent a technique encompassing HG tibial detachment. Subjective and objective IKDC score was administered preoperatively and at 3-, 6-, 12- and 24-month follow-up. Graft morphology was assessed through MRI evaluation performed at 6-month follow-up. RESULTS: Clinical results were excellent in both groups. Regarding MRI results, a better intra-articular graft morphology was observed in the study group (Tau = 0.313, p = 0.024). No differences in graft integration were noticed. CONCLUSION: The main finding of this preliminary study is that preservation of the hamstring tibial insertion seems to enhance graft ligamentization with improved morphology of the intra-articular portion of the graft compared to a detachment of the hamstring tendons from the tibial side. Further well-designed studies with higher number of patients as well as more serial MRI evaluations are required to validate these preliminary findings.

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.

Pulsed electromagnetic fields combined with a collagenous scaffold and bone marrow concentrate enhance osteochondral regeneration: an in vivo study.

BACKGROUND: The study aimed to evaluate the combined effect of Pulsed Electromagnetic Field (PEMF) biophysical stimulation and bone marrow concentrate (BMC) in osteochondral defect healing in comparison to the treatment with scaffold alone. METHODS: An osteochondral lesion of both knees was performed in ten rabbits. One was treated with a collagen scaffold alone and the other with scaffold seeded with BMC. Half of the animals were stimulated by PEMFs (75 Hz, 1.5 mT, 4 h/day) and at 40 d, macroscopic, histological and histomorphometric analyses were performed to evaluate osteochondral defect regeneration. RESULTS: Regarding cartilage, the addition of BMC to the scaffold improved cell parameters and the PEMF stimulation improved both cell and matrix parameters compared with scaffold alone. The combination of BMC and PEMFs further improved osteochondral regeneration: there was an improvement in macroscopic, cartilage cellularity and matrix parameters and a reduction in the percentage of cartilage under the tidemark. Epiphyseal bone healing improved in all the osteochondral defects regardless of treatment, although PEMFs alone did not significantly improve the reconstruction of subchondral bone in comparison to treatment with scaffold alone. CONCLUSIONS: Results show that BMC and PEMFs might have a separate effect on osteochondral regeneration, but it seems that they have a greater effect when used together. Biophysical stimulation is a non-invasive therapy, free from side effects and should be started soon after BMC transplantation to increase the quality of the regenerated tissue. However, because this is the first explorative study on the combination of a biological and a biophysical treatment for osteochondral regeneration, future preclinical and clinical research should be focused on this topic to explore mechanisms of action and the correct clinical translation.

Regenerative treatment in osteochondral lesions of the talus: autologous chondrocyte implantation versus one-step bone marrow derived cells transplantation.

PURPOSE: Osteochondral lesions of the talus (OLT) usually require surgical treatment. Regenerative techniques for hyaline cartilage restoration, like autologous chondrocytes implantation (ACI) or bone marrow derived cells transplantation (BMDCT), should be preferred. The aim of this work is comparing two clusters with OLT, treated with ACI or BMDCT. METHODS: Eighty patients were treated with regenerative techniques, 40 with ACI and 40 with BMDCT. The two groups were homogenous regarding age, lesion size and depth, previous surgeries, etiology of the lesion, subchondral bone graft, final follow-up and pre-operative AOFAS score. The two procedures were performed arthroscopically. The scaffold was a hyaluronic acid membrane in all the cases, loaded with previously cultured chondrocytes (ACI) or with bone marrow concentrated cells, harvested in the same surgical session (BMDCT). All the patients were clinically and radiologically evaluated, using MRI Mocart score and T2 mapping sequence. RESULTS: Clinical results were similar in both groups at 48 months. No statistically significant influence was reported after evaluation of all the pre-operative parameters. The rate of return to sport activity showed slightly better results for BMDCT than ACI. MRI Mocart score was similar in both groups. MRI T2 mapping evaluation highlighted a higher presence of hyaline like values in the BMDCT group, and lower incidence of fibrocartilage as well. CONCLUSIONS: To date, ACI and BMDCT showed to be effective regenerative techniques for the treatment of OLT. BMDCT could be preferred over ACI for the single step procedure, patients' discomfort and lower costs.