Platelet-Rich Plasma Applications for Achilles Tendon Repair: A Bridge between Biology and Surgery.

Achilles tendon ruptures are very common tendon ruptures and their incidence is increasing in modern society, resulting in work incapacity and months off sport, which generate a need for accelerated and successful therapeutic repair strategy. Platelet-rich plasma (PRP) is emerging as adjuvant human blood-derived constructs to assist Achilles tendon rupture treatment. However, myriad PRP preparation methods in conjunction with poor standardization in the modalities of their applications impinge on the consistent effectiveness of clinical and structural outcomes regarding their therapeutic efficacy. The purpose of this review is to provide some light on the application of PRP for Achilles tendon ruptures. PRP has many characteristics that make it an attractive treatment. Elements such as the inclusion of leukocytes and erythrocytes within PRP, the absence of activation and activation ex vivo or in vivo, the modality of application, and the adjustment of PRP pH can influence the biology of the applied product and result in misleading therapeutic conclusions. The weakest points in demonstrating their consistent effectiveness are primarily the result of myriad PRP preparation methods and the poor standardization of modalities for their application. Selecting the right biological scaffold and applying it correctly to restitutio ad integrum of ruptured Achilles tendons remains a daunting and complex task.

Technical guide and tips on the all-arthroscopic Latarjet procedure.

Shoulder dislocation and subsequent anterior instability is a common problem in young athletes. The arthroscopic Bankart repair was originally described by Morgan et al. in 1987. The procedure has benefited from many technical advancements over the past 25 years and currently remains the most commonly utilized procedure in the treatment of anterior glenohumeral instability without glenoid bone loss. Capsulolabral repair alone may not be sufficient for treatment of patients with poor capsular tissue quality and significant bony defects. In the presence of chronic anterior glenoid bony defects, a bony reconstruction should be considered. The treatment of anterior shoulder instability with transfer of the coracoid and attached conjoint tendon such as the Latarjet procedure has provided reliable results. The arthroscopic Latarjet procedure was described in 2007 by the senior author, who has now performed the procedure over 450 times. The initial surgical technique has evolved considerably since its introduction, and this article presents a comprehensive update on this demanding but well-defined procedure. This article reviews technical tips to help the surgeon perform the surgery more smoothly, navigate through challenging situations, and avoid potential complications. Level of evidence V.

Meniscal allograft transplantation. Part 2: systematic review of transplant timing, outcomes, return to competition, associated procedures, and prevention of osteoarthritis.

PURPOSE: To provide a systematic review of the literature regarding five topics in meniscal allograft transplantation (MAT): optimal timing for transplantation, outcomes, return to competition, associated procedures, and prevention of osteoarthritis. METHODS: A systematic literature search was conducted using the PubMed (MEDLINE), ScienceDirect, and EBSCO-CINAHL databases. Articles were classified only in one topic, but information contained could be reported into other topics. Information was classified according to type of study (animal, in vitro human, and in vivo human) and level of evidence (for in vivo human studies). Specific inclusion criteria were determined for the outcomes and prevention of osteoarthritis topics. RESULTS: Twenty-four studies were finally included: two optimal timing, seven outcomes, three return to competitive sport, 16 MAT and associated procedures, and 5 MAT and prevention of osteoarthritis (some studies were categorized in more than one topic). These studies corresponded to 2 animal studies and 31 in vivo human studies (1 level II, 1 level III, and 29 level IV). CONCLUSIONS: The principal conclusions were as follows: (a) there is no evidence to support that MAT has to be performed at the same time or immediately after meniscectomy to prevent development of postmeniscectomy syndrome; (b) MAT successfully improves symptoms, function, and quality of life at 7-to-14 years of follow-up (level IV evidence); (c) the overall failure rate (need for knee arthroplasty) is 10-29% at long-term follow-up; (d) MAT allows return to same level of competition in 75-85% of patients at short- to mid-term follow-up (only three studies level IV evidence with small sample size); (e) associated cartilage procedures or anterior cruciate ligament reconstruction to MAT does not worsen the results; (f) MAT may prevent progression of cartilage damaged at long-term follow-up, but may not prevent degeneration in previously healthy cartilage. LEVEL OF EVIDENCE: Systematic review of level II-IV studies, Level IV.

Meniscal allograft transplantation. Part 1: systematic review of graft biology, graft shrinkage, graft extrusion, graft sizing, and graft fixation.

PURPOSE: To provide a systematic review of the literature regarding five topics in meniscal allograft transplantation: graft biology, shrinkage, extrusion, sizing, and fixation. METHODS: A systematic literature search was conducted using the PubMed (MEDLINE), ScienceDirect, and EBSCO-CINAHL databases. Articles were classified only in one topic, but information contained could be reported into other topics. Information was classified according to type of study (animal, in vitro human, and in vivo human) and level of evidence (for in vivo human studies). RESULTS: Sixty-two studies were finally included: 30 biology, 3 graft shrinkage, 11 graft extrusion, 17 graft size, and 6 graft fixation (some studies were categorized in more than one topic). These studies corresponded to 22 animal studies, 22 in vitro human studies, and 23 in vivo human studies (7 level II, 10 level III, and 6 level IV). CONCLUSIONS: The principal conclusions were as follows: (a) Donor cells decrease after MAT and grafts are repopulated with host cells form synovium; (b) graft preservation alters collagen network (deep freezing) and causes cell apoptosis with loss of viable cells (cryopreservation); (c) graft shrinkage occurs mainly in lyophilized and gamma-irradiated grafts (less with cryopreservation); (d) graft extrusion is common but has no clinical/functional implications; (e) overall, MRI is not superior to plain radiograph for graft sizing; (f) graft width size matching is more important than length size matching; (g) height appears to be the most important factor influencing meniscal size; (h) bone fixation better restores contact mechanics than suture fixation, but there are no differences for pullout strength or functional results; and (i) suture fixation has more risk of graft extrusion compared to bone fixation. LEVEL OF EVIDENCE: Systematic review of level II-IV studies, Level IV.

Acromioclavicular Fracture-Dislocation Fixation Technique With Cerclages and Osteosutures: The "Invisible" Repair.

Surgical treatment usually is indicated for the management of acromioclavicular fracture-dislocations. These are unstable injuries and have shown a high rate of nonunion when managed conservatively. However, surgical strategies often require a second surgery for hardware removal. We describe an arthroscopic-assisted technique to repair the acromioclavicular fracture-dislocation without implants, using a double cerclage and osteosutures. This technique does not require specific instrumentation, avoids clavicle/coracoid drilling, and minimizes secondary irritation related to hardware. This can be used in different anatomic locations and can theoretically reduce the chances of symptomatic hardware, reoperation rates, and iatrogenic fractures.

Percutaneous Lateral Collateral Ligament Release for Arthroscopic Procedures of the Knee: The "Lateral Pie-Crusting".

Arthroscopy of the knee is among the most frequent procedures worldwide in orthopaedic surgery. To avoid iatrogenic cartilage injury, adequate visualization and working space are mandatory to perform complex procedures. Narrow femorotibial joint space is often encountered, and it is challenging to obtain consistent satisfactory results. Medial collateral ligament release is safe and reliable for facilitating medial joint widening. Current clinical studies support lateral collateral ligament (LCL) healing capacity in isolated injuries. This article describes a simple, safe, and reproducible technique of LCL release through a multiple-puncture method to facilitate lateral compartment visualization and instrumentation, the so-called lateral pie-crusting.

Particulated Autologous Chondral-Platelet-Rich Plasma Matrix Implantation (PACI) for Treatment of Full-Thickness Cartilage Osteochondral Defects.

Articular hyaline cartilage injuries can occur as a result of either traumatic of progressive degeneration. When the articular cartilage in a joint is damaged, it can cause joint pain and dysfunction, predisposing patients for the development of early-onset osteoarthritis. There are many restoration procedures available to treat these injuries, such as bone marrow-stimulation techniques, osteoarticular auto/allograft transplants, and autologous chondrocyte implantation. Each of these techniques has its own limitations, which led researchers to explore new regenerative and repair techniques to produce normal hyaline cartilage. The purpose of this Technical Note is to describe in detail the particulated autologous chondral-platelet-rich plasma matrix implantation (PACI) technique that could be used as a single-stage cartilage restoration procedure for treatment of full-thickness cartilage and osteochondral defects.

The transtibial versus the anteromedial portal technique in the arthroscopic bone-patellar tendon-bone anterior cruciate ligament reconstruction.

The transtibial (TT) drilling of the femoral tunnel in the bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction was found to place the tunnel non-anatomically. The use of the anteromedial portal (AMP) for the femoral drilling would provide the surgeon with more freedom to anatomically place the tunnel in the real femoral ACL footprint. The purpose of this study was to compare the clinical outcomes of BPTB ACL reconstruction using the AMP or the TT technique for the femoral tunnel drilling. A Medline search was not able to identify any study directly comparing the clinical outcomes of the AMP and the TT techniques. The literature search identified experimental and quasi-experimental studies published from 1966 to March 2009 where at least one group underwent arthroscopic autologous BPTB ACL reconstructions using either the AMP or the TT technique for the femoral tunnel drilling. Overall IKDC, Lysholm score, activity level, range of motion, single-leg hoop test, Lachman test, Pivot shift sign test, KT-1000 arthrometer measurements, and radiographic assessments were indirectly compared between the two groups (AMP versus TT). Twenty-one studies, involving a total of 859 patients (257 in the AMP and 602 in the TT group), were included in this analysis. The AMP group demonstrated significantly earlier return to run and significantly greater range of motion, Lachman test values, and KT-1000 arthrometer measurements in the 1-2-year follow-up, although no differences were found for both the 3-5 and the 6-10-year follow-ups for any of these parameters. In contrast, the TT group demonstrated significantly higher activity level for the 3-5 and 6-10-year follow-up. The use of the AMP elicited greater knee stability and range of motion values, and earlier return to run compared to the TT technique. These results may indicate a potential benefit of the AMP over the TT technique. However, as the benefits of the AMP were not obtained in the mid and long-term follow-ups, overall there is no definitive evidence at this point to conclude that one technique is superior to the other. Randomized controlled trials directly comparing the use of both techniques with long-term follow-ups will help clarify which one, if any, provides best clinical outcomes.

Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: a blinded cross-sectional study at two- to five-year follow-up.

Drilling of the femoral tunnel with the transtibial (TT) technique is widely used in bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction. Recent studies suggest higher knee stability with the use of the anteromedial portal (AMP). The purpose of this study was to compare functional and clinical outcomes of BPTB ACL reconstruction using the TT or the AMP technique for drilling the femoral tunnel. All ACL reconstructions between January 2003 and April 2006 were approached for eligibility. Forty-seven patients met inclusion criteria (21 TT group and 26 AMP group). Blinded assessments of IKDC score, knee stability and range of motion, one-leg hop test, mid-quadriceps circumference, VAS for satisfaction with surgery, Lysholm and Tegner scores, and SF-12 questionnaire were obtained for both groups. Data on preoperative and postoperative surgical timing were retrospectively reviewed through the charts. The AMP group demonstrated a significantly lower recovery time from surgery to walking without crutches (p < 0.01), to return to normal life (p < 0.03), to return jogging (p < 0.03), to return training (p < 0.03), and to return to play (p < 0.03). Knee stability values measured with KT-1000, Lachman test, pivot-shift sign, and objective IKDC score assessments were significantly better for the AMP compared to TT group (p < 0.002, p < 0.03, p < 0.02, p < 0.015, respectively). No differences were found for VAS for satisfaction with surgery, Lysholm, Tegner, and SF-12 between both groups. The use of the AMP technique significantly improved the anterior-posterior and rotational knee stability, IKDC scores, and recovery time from surgery compared to the TT technique.

One-Stage Osteochondral Fracture Repair Technique With Knotless Anchors and Interconnected Crossing Suture Sliding Loops for the Knee.

Osteochondral fractures of the knee represent a challenging entity to manage since there are many different surgical techniques for cartilage repair or other salvage procedures. In terms of cartilage repair, several hardware devices can be used, and many of them could imply a second-stage surgery for hardware removal. The purpose of this article is to describe in detail a one-stage osteochondral fracture repair technique with knotless anchors and interconnected crossing suture sliding loops for the knee. This technique is a one-stage open or arthroscopic procedure with an unlimited number of loops configurations with no particular need for a second surgery for hardware removal, no knot damage, and without the use of bone tunnels. It can be used in different cartilage anatomic locations, such as femoral condyles, trochlea, patella, or other joints.

All-Arthroscopic Meniscal Allograft Transplantation Technique with Bone Plugs and Preloaded Sutures.

The meniscus is an essential structure for the knee functioning and survival. Meniscectomy is the most common surgical procedure in orthopaedic surgery. Following total or subtotal meniscectomy, meniscal allograft transplantation (MAT) should be considered in symptomatic active young patients. Several MAT techniques have been described in the literature as an attempt to restore normal knee kinematics and potentially decrease the risk of developing knee osteoarthritis. The purpose of this article is to describe in detail an efficient and reproducible all-arthroscopic MAT technique with bone plugs and preloaded sutures.

A novel autologous-made matrix using hyaline cartilage chips and platelet-rich growth factors for the treatment of full-thickness cartilage or osteochondral defects: Preliminary results.

PURPOSE: To report the clinical, functional, and magnetic resonance imaging (MRI)-based outcomes of a novel autologous-made matrix consisting of hyaline cartilage chips combined with mixed plasma poor rich in platelets clot and plasma rich in growth factors (PRGF) for the treatment of knee full-thickness cartilage or osteochondral defects. METHODS: Between July 2015 and January 2018, all patients with full-thickness cartilage or osteochondral defects undergoing this novel cartilage restoration surgical technique were approached for eligibility. Indications for this procedure included traumatic or atraumatic full-thickness knee cartilage defects or osteochondritis dissecans. Patients were included if they had no concomitant use of stem cells, previous ipsilateral cartilage repair procedure, or follow-up was less than 10 months. The outcomes included data on current symptoms, physical exam, patient-reported, and functional outcomes (visual analogue scale (VAS) for pain, Lysholm score, Tegner activity scale, International Knee Documentation Committee (IKDC) subjective form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Lequesne index, and short form-12 (SF-12)) and the magnetic resonance observation of cartilage repair tissue (MOCART) score. These outcomes were compared to preoperative values, except for the MOCART score. RESULTS: Fifteen patients were included in this preliminary study: mean (standard deviation (SD), range) follow-up 15.9 months (7.2, 10-32), age 26.8 years (12.1, 16-58), and body mass index 23.2 (2.1, 19.3-26.9). There were 14 men (93%) and 1 woman (7%). There was a statistically significant improvement between pre- and postoperative periods for VAS for pain (p = 0.003), Lysholm score (p = 0.002), IKDC subjective form (p = 0.003), WOMAC for pain (p = 0.005), WOMAC for stiffness (p = 0.01), WOMAC for function (p = 0.002), Lequesne Index (p = 0.002), and SF-12 physical component summary (p = 0.007). The postoperative mean (SD; range) MOCART score was 70 (12.4; 40-85). CONCLUSIONS: The use of this novel cartilage restoration surgical technique provides excellent clinical, functional, and MRI-based outcomes in young, active individuals with full-thickness cartilage or osteochondral defects. LEVEL OF EVIDENCE: Level IV-Therapeutic case series.

Circumferential-Surrounding ("Sandwich") Meniscal Repair: A Salvage Technique to Save the Meniscus.

Meniscal injuries are extremely common in the general and athletic populations. The management strategy has switched from meniscectomy to meniscal-preserving techniques. It is nowadays extensively accepted that surgeons have to do their best to repair the meniscus and try to preserve as much tissue as possible. However, in many cases the tissue quality is poor and the tear pattern is complex. In such scenarios, meniscal repair has a lower success rate. In the present surgical technique, an arthroscopic all-inside circumferential-surrounding meniscal repair technique is presented. Any meniscal tissue or the meniscal rim is first debrided to a bleeding bed. Then, an all-inside device is used to create vertical sutures from capsule to capsule surrounding the entire meniscus (circumferential-surrounding). Care should be taken not to tighten the suture too much to avoid cutting the meniscal tissue. This easy and effective repair technique "packs" the meniscal tear fragments altogether and allows the surgeon to save the meniscus when facing with irreparable, degenerative, complex meniscus tears.

Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors.

Soccer is the most commonly played sport in the world, with an estimated 265 million active soccer players by 2006. Inherent to this sport is the higher risk of injury to the anterior cruciate ligament (ACL) relative to other sports. ACL injury causes the most time lost from competition in soccer which has influenced a strong research focus to determine the risk factors for injury. This research emphasis has afforded a rapid influx of literature defining potential modifiable and non-modifiable risk factors that increase the risk of injury. The purpose of the current review is to sequence the most recent literature that reports potential mechanisms and risk factors for non-contact ACL injury in soccer players. Most ACL tears in soccer players are non-contact in nature. Common playing situations precluding a non-contact ACL injury include: change of direction or cutting maneuvers combined with deceleration, landing from a jump in or near full extension, and pivoting with knee near full extension and a planted foot. The most common non-contact ACL injury mechanism include a deceleration task with high knee internal extension torque (with or without perturbation) combined with dynamic valgus rotation with the body weight shifted over the injured leg and the plantar surface of the foot fixed flat on the playing surface. Potential extrinsic non-contact ACL injury risk factors include: dry weather and surface, and artificial surface instead of natural grass. Commonly purported intrinsic risk factors include: generalized and specific knee joint laxity, small and narrow intercondylar notch width (ratio of notch width to the diameter and cross sectional area of the ACL), pre-ovulatory phase of menstrual cycle in females not using oral contraceptives, decreased relative (to quadriceps) hamstring strength and recruitment, muscular fatigue by altering neuromuscular control, decreased "core" strength and proprioception, low trunk, hip, and knee flexion angles, and high dorsiflexion of the ankle when performing sport tasks, lateral trunk displacement and hip adduction combined with increased knee abduction moments (dynamic knee valgus), and increased hip internal rotation and tibial external rotation with or without foot pronation. The identified mechanisms and risk factors for non-contact ACL injuries have been mainly studied in female soccer players; thus, further research in male players is warranted. Non-contact ACL injuries in soccer players likely has a multi-factorial etiology. The identification of those athletes at increased risk may be a salient first step before designing and implementing specific pre-season and in-season training programs aimed to modify the identified risk factors and to decrease ACL injury rates. Current evidence indicates that this crucial step to prevent ACL injury is the only option to effectively prevent the sequelae of osteoarthritis associated with this traumatic injury.

Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 2: a review of prevention programs aimed to modify risk factors and to reduce injury rates.

Soccer is the most commonly played sport in the world, with an estimated 265 million active soccer players participating in the game as on 2006. Inherent to this sport is the higher risk of injury to the anterior cruciate ligament (ACL) relative to other sports. ACL injury causes a significant loss of time from competition in soccer, which has served as the strong impetus to conduct research that focuses to determine the risk factors for injury, and more importantly, to identify and teach techniques to reduce this injury in the sport. This research emphasis has afforded a rapid influx of literature aimed to report the effects of neuromuscular training on the risk factors and the incidence of non-contact ACL injury in high-risk soccer populations. The purpose of the current review is to sequence the most recent literature relating the effects of prevention programs that were developed to alter risk factors associated with non-contact ACL injuries and to reduce the rate of non-contact ACL injuries in soccer players. To date there is no standardized intervention program established for soccer to prevent non-contact ACL injuries. Multi-component programs show better results than single-component preventive programs to reduce the risk and incidence of non-contact ACL injuries in soccer players. Lower extremity plyometrics, dynamic balance and strength, stretching, body awareness and decision-making, and targeted core and trunk control appear to be successful training components to reduce non-contact ACL injury risk factors (decrease landing forces, decrease varus/valgus moments, and increase effective muscle activation) and prevent non-contact ACL injuries in soccer players, especially in female athletes. Pre-season injury prevention combined with an in-season maintenance program may be advocated to prevent injury. Compliance may in fact be the limiting factor to the overall success of ACL injury interventions targeted to soccer players regardless of gender. Thus, interventional research must also consider techniques to improve compliance especially at the elite levels which will likely influence trickle down effects to sub-elite levels. Future research is also needed for male soccer athletes to help determine the most effective intervention to reduce the non-contact ACL injury risk factors and to prevent non-contact ACL injuries.

Hamstring Braid Graft Technique for Anterior Cruciate Ligament Reconstruction.

Hamstring autograft is one of the most used grafts for anterior cruciate ligament (ACL) reconstruction, although there are several graft preparation techniques. It is extremely difficult to mimic the biomechanical properties of the native ACL; thus, it is important to achieve a proper graft configuration, diameter, and length. To avoid reruptures, an optimal and reproducible hamstring autograft is desired. Hamstring autograft has been traditionally devalued when compared with other options such as bone-patellar tendon-bone autograft. The purpose of this Technical Note is to describe in detail a hamstring braid graft configuration that could potentially overcome the past disadvantages of ACL reconstruction.

Posterosuperior osteochondritis of the calcaneus.

Osteochondritis of the posterosuperior area of the talocalcaneal surface is a relatively uncommon injury, and only 1 case has been described in the literature. We present a 37-year-old man who complained of pain in the tarsal canal area during walking and when standing up. The magnetic resonance imaging study showed an osteochondral signal in the posterosuperior medial area of the calcaneus on the talocalcaneal surface. The persistence of pain and lack of improvement with conservative treatment made arthroscopic debridement of the injury necessary. The arthroscopic procedure was performed through 2 medial portals, made under fluoroscopy, marked with needles, and dissected with mosquito clamps, and the affected surface could be fully visualized, showing a chondral lesion. Debridement of the osteonecrotic area was performed, and the Steadman technique was used on the injured bone surface. The patient was pain-free, and limited activity (i.e., standing up and walking without symptoms) was allowed. After 24 months, the patient remains asymptomatic with weight-bearing working activities and when standing. Arthroscopic curettage and scission of the injury have been shown to yield good or excellent outcomes in 75% to 80% of patients with regard to the talar surface.