Cell-based versus corticosteroid injections for knee pain in osteoarthritis: a randomized phase 3 trial.

Various types of cellular injection have become a popular and costly treatment option for patients with knee osteoarthritis despite a paucity of literature establishing relative efficacy to each other or corticosteroid injections. Here we aimed to identify the safety and efficacy of cell injections from autologous bone marrow aspirate concentrate, autologous adipose stromal vascular fraction and allogeneic human umbilical cord tissue-derived mesenchymal stromal cells, in comparison to corticosteroid injection (CSI). The study was a phase 2/3, four-arm parallel, multicenter, single-blind, randomized, controlled clinical trial with 480 patients with a diagnosis of knee osteoarthritis (Kellgren-Lawrence II-IV). Participants were randomized to the three different arms with a 3:1 distribution. Arm 1: autologous bone marrow aspirate concentrate (n = 120), CSI (n = 40); arm 2: umbilical cord tissue-derived mesenchymal stromal cells (n = 120), CSI (n = 40); arm 3: stromal vascular fraction (n = 120), CSI (n = 40). The co-primary endpoints were the visual analog scale pain score and Knee injury and Osteoarthritis Outcome Score pain score at 12 months versus baseline. Analyses of our primary endpoints, with 440 patients, revealed that at 1 year post injection, none of the three orthobiologic injections was superior to another, or to the CSI control. In addition, none of the four groups showed a significant change in magnetic resonance imaging osteoarthritis score compared to baseline. No procedure-related serious adverse events were reported during the study period. In summary, this study shows that at 1 year post injection, there was no superior orthobiologic as compared to CSI for knee osteoarthritis. ClinicalTrials.gov Identifier: NCT03818737.

Return-to-Sport Review for Current Cartilage Treatments.

The return to play outcome is an important measure for orthopaedic sports medicine treatments. This variable is especially important when discussing cartilage treatments because there are many different cartilage options available to athletes with articular injuries and this population is particularly interested in the ability to return to activities. Although many outcome variables are considered in any surgical procedure, the return-to-sport variable is focused on an active population and can be tailored to that patient's sport-specific goals. In this article, we will review some of the most recent and up-to-date articles describing return-to-sport outcomes for various knee cartilage treatments. This article will focus on the most common current knee cartilage treatments including microfracture, autologous chondrocyte implantation, osteochondral autograft transplant, and osteochondral allograft transplantation.

Anterior Cruciate Ligament Injuries in Professional Hockey Players.

BACKGROUND: Performance outcomes and return-to-play data have been reported after anterior cruciate ligament (ACL) injuries in professional football and basketball, but they have rarely been reported in professional hockey. HYPOTHESIS: The hypothesis was that performance after ACL reconstruction would be comparable to prior levels of play in a series of National Hockey League (NHL) players. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The NHL Injury Surveillance System (ISS) was utilized to identify all players with an ACL injury between 2006 and 2010. Medical staff members for all NHL teams were surveyed regarding these injuries. The medical staff completed a questionnaire for each injury, and statistics were analyzed using multiple analyses of variance to compare outcomes, performance, and the complication rate. A control group was identified and matched based on performance, career length before injury, age, height, and weight. RESULTS: There were 47 players identified by the NHL ISS. There were 3 goalies, 8 defensemen, and 36 wings or centers. The average age of these players was 27.69 years. The average length of time played after the injury was 2.8 years, which was less than that of the control group (4.4 years) (P = .004). The presence of a meniscal injury was associated with a decreased length of career compared with the control group (P = .012) and with patients with an isolated ACL injury (P = .002). For wings and centers, the number of games played decreased from 71.2 to 58.2 in the first full season after the injury (P = .05) and to 59.29 in the second season (P = .03). In the first season after the injury, for forwards and wings, assists and total points decreased from 20.3 and 35.2 to 13.8 (P = .005) and 25.9 (P = .018), respectively. In the second season after the injury, assists and goals decreased to 10.0 (P = .002) and 10.0 (P = .013), respectively. Compared with controls, the per-season averages of goals (P = .001), assists (P = .010), and total points (P = .004) decreased. Four players (8.5%) had subsequent failure of reconstruction, and there was a total reoperation rate of 20%. Five players (10.6%) did not return to play, and 4 (8.5%) were unable to return to play for a full season. CONCLUSION: Most players are able to return to play in the NHL after an ACL injury. However, career length and performance may be significantly decreased compared with controls. This may represent a more severe initial injury, and more focused return-to-play pathways may identify barriers to return to play.

Patient-specific instrumentation and return to activities after unicondylar knee arthroplasty.

In the past decade, there has been a major increase in the use of unicompartmental knee arthroplasty (UKA) as surgical techniques have been refined and patient selection has improved. UKAs now account for 8% to 10% of knee arthoplasty procedures. Recent studies have suggested excellent medium- and long-term results of UKA. Overall, results have shown 85% to 90% survivorship at 10 years, with 90% of patients reporting good to excellent subjective and objective outcomes. Recent studies suggest that unicompartmental arthroplasty allows a high percentage of patients to return to presurgical sport and activity participation.

The effect of a proximal tibial medial opening wedge osteotomy on posterolateral knee instability: a biomechanical study.

BACKGROUND: Increased stability of posterolateral corner knee injuries has been observed clinically after proximal tibial medial opening wedge osteotomies. HYPOTHESIS: Static varus and external rotatory stability will be significantly improved in a knee with a grade 3 posterolateral knee injury after a proximal tibial medial opening wedge osteotomy. STUDY DESIGN: Controlled laboratory study. METHODS: Biomechanical testing of 10 nonpaired, cadaveric knees was performed in the intact state, after transection of the posterolateral corner (fibular collateral ligament, popliteus tendon, and popliteofibular ligament), and after a 10-mm proximal tibial medial opening wedge osteotomy. Loading conditions consisted of 12 N.m varus moments and 6 N.m external rotation torques. Six degrees of freedom motion analysis was used to assess motion changes, and a buckle transducer was used to measure the force on the superficial medial collateral ligament during applied loads. RESULTS: After transection of the posterolateral corner structures, a significant increase in varus rotation was found to applied varus moments with a mean increased opening of 5.9 degrees to varus stress at 30 degrees and 5.8 degrees at 90 degrees of knee flexion. After proximal tibial medial opening wedge osteotomy, varus rotation was increased by a mean of 1.6 degrees at 30 degrees and 1.7 degrees at 90 degrees of knee flexion compared with the intact state. There was a significant decrease in varus rotation to a varus moment after osteotomy compared with the posterolateral sectioned state at both 30 degrees and 90 degrees . External rotation of the knee increased by 4.7 degrees at 30 degrees and 4.8 degrees at 90 degrees after posterolateral structure sectioning compared with the intact state. After the osteotomy, there was a significant decrease in external rotation compared with the posterolateral sectioned state, and there was no significant difference in external rotation compared with the intact state. There was a significant increase in force on the superficial medial collateral ligament after the osteotomy compared with both the intact and posterolateral corner cut state for both an applied varus moment and external rotation torque at both 30 degrees and 90 degrees . CONCLUSION: Our results demonstrate that a proximal tibial medial opening wedge osteotomy decreased varus and external rotation laxity for posterolateral corner-deficient knees. Concurrently, an increase in force was observed on the superficial medial collateral ligament compared with the native state. CLINICAL SIGNIFICANCE: The improved stability observed in some patients with grade 3 posterolateral knee injuries after a proximal tibial medial opening wedge osteotomy appears to at least in part be due to tightening of the superficial medial collateral ligament. The long-term consequences of the increased force on the superficial medial collateral ligament on the medial compartment, and whether it elongates with time, merit further investigation.