Global cerebral ischemia in adult female rats interrupts estrous cyclicity and induces lasting changes in hypothalamic-pituitary-gonadal axis signaling peptides.

Persistent post-ischemic alterations to the hypothalamic-pituitary-adrenal (HPA) axis occur following global cerebral ischemia (GCI) in rodents. However, similar effects on hypothalamic-pituitary-gonadal (HPG) axis activation remain to be determined. Therefore, this study evaluated the effects of GCI in adult female rats (via four-vessel occlusion) on the regularity of the estrous cycle for 24-days post ischemia. A second objective aimed to assess persistent alterations of HPG axis activation through determination of the expression of estrogen receptor alpha (ERα), kisspeptin (Kiss1), and gonadotropin-inhibitory hormone (GnIH/RFamide-related peptide; RFRP3) in the medial preoptic area (POA), arcuate nucleus (ARC), dorsomedial nucleus (DMH) of the hypothalamus, and CA1 of the hippocampus 25 days post ischemia. Expression of glucocorticoid receptors (GR) in the paraventricular nucleus of the hypothalamus (PVN) and CA1 served as a proxy of altered HPA axis activation. Our findings demonstrated interruption of the estrous cycle in 87.5 % of ischemic rats, marked by persistent diestrus, lasting on average 11.86 days. Moreover, compared to sham-operated controls, ischemic female rats showed reduced Kiss1 expression in the hypothalamic ARC and POA, concomitant with elevated ERα in the ARC and increased GnIH in the DMH and CA1. Reduced GR expression in the CA1 was associated with increased GR-immunoreactivity in the PVN, indicative of lasting dysregulation of HPA axis activation. Together, these findings demonstrate GCI disruption of female rats' estrous cycle over multiple days, with a lasting impact on HPG axis regulators within the reproductive axis.

A Randomized Trial of Autologous Chondrocyte Implantation Versus Alternative Forms of Surgical Cartilage Management in Patients With a Failed Primary Treatment for Chondral or Osteochondral Defects in the Knee.

BACKGROUND: There are limited randomized controlled trials with long-term outcomes comparing autologous chondrocyte implantation (ACI) versus alternative forms of surgical cartilage management within the knee. PURPOSE: To determine at 5 years after surgery whether ACI was superior to alternative forms of cartilage management in patients after a failed previous treatment for chondral or osteochondral defects in the knee. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In total, 390 participants were randomly assigned to receive either ACI or alternative management. Patients aged 18 to 55 years with one or two symptomatic cartilage defects who had failed 1 previous therapeutic surgical procedure in excess of 6 months prior were included. Dual primary outcome measures were used: (1) patient-completed Lysholm knee score and (2) time from surgery to cessation of treatment benefit. Secondary outcome measures included International Knee Documentation Committee and Cincinnati Knee Rating System scores, as well as number of serious adverse events. Analysis was performed on an intention-to-treat basis. RESULTS: Lysholm scores were improved by 1 year in both groups (15.4 points [95% CI, 11.9 to 18.8] and 15.2 points [95% CI, 11.6 to 18.9]) for ACI and alternative, with this improvement sustained over the duration of the trial. However, no evidence of a difference was found between the groups at 5 years (2.9 points; 95% CI, -1.8 to 7.5; P = .46). Approximately half of the participants (55%; 95% CI, 47% to 64% with ACI) were still experiencing benefit at 5 years, with time to cessation of treatment benefit similar in both groups (hazard ratio, 0.97; 95% CI, 0.72 to 1.32; P > .99). There was a differential effect on Lysholm scores in patients without previous marrow stimulation compared with those with marrow stimulation (P = .03; 6.4 points in favor of ACI; 95% CI, -0.4 to 13.1). More participants experienced a serious adverse event with ACI (P = .02). CONCLUSION: Over 5 years, there was no evidence of a difference in Lysholm scores between ACI and alternative management in patients who had previously failed treatment. Previous marrow stimulation had a detrimental effect on the outcome of ACI. REGISTRATION: International Standard Randomised Controlled Trial Number: 48911177.

Immunoreactive distribution of gonadotropin-inhibitory hormone precursor, RFRP, in a temperate bat species (Eptesicus fuscus).

Gonadotropin-inhibitory hormone (GnIH, also known RFRP-3 in mammals) is an important regulator of the hypothalamic-pituitary-gonadal axis and downstream reproductive physiology. Substantial species differences exist in the localization of cell bodies producing RFRP-3 and patterns of fiber immunoreactivity in the brain, raising the question of functional differences. Many temperate bat species exhibit unusual annual reproductive patterns. Male bats upregulate spermatogenesis in late spring which is asynchronous with periods of mating in the fall, while females have the physiological capacity to delay their reproductive investment over winter via sperm storage or delayed ovulation/fertilization. Neuroendocrine mechanisms regulating reproductive timing in male and female bats are not well-studied. We provide the first description of RFRP-precursor peptide of GnIH -expression and localization in the brain of any bat using a widespread temperate species (Eptesicus fuscus, big brown bat) as a model. RFRP mRNA expression was detected in the hypothalamus, testes, and ovaries of big brown bats. Cellular RFRP-immunoreactivity was observed within the periventricular nuclei, dorsomedial nucleus of the hypothalamus, arcuate nucleus (Arc), and median eminence (ME). As in other vertebrates, RFRP fiber immunoreactivity was widespread, with the greatest density observed in the hypothalamus, preoptic area, Arc, ME, midbrain, and thalamic nuclei. Putative interactions between RFRP-ir fibers and gonadotropin-releasing hormone (GnRH) cell bodies were observed in 16% of GnRH-immunoreactive cells, suggesting direct regulation of GnRH via RFRP signaling. This characterization of RFRP distribution contributes to a deeper understanding of bat neuroendocrinology, which serves as foundation for manipulative approaches examining changes in reproductive neuropeptide signaling in response to environmental and physiological challenges within, and among, bat species.

Hypothalamic Overexpression of Neurosecretory Protein GL Leads to Obesity in Male C57BL/6J Mice.

INTRODUCTION: The mechanisms underlying obesity are not fully understood, necessitating the creation of novel animal models for the investigation of metabolic disorders. We have previously found that neurosecretory protein GL (NPGL), a newly identified hypothalamic neuropeptide, is involved in feeding behavior and fat accumulation in rats. However, the impact of NPGL on obesity remains unclear in any animal model. The present investigation sought to elucidate whether NPGL causes obesity in the obesity-prone mouse strain C57BL/6J. METHODS: We overexpressed the NPGL-precursor gene (Npgl) in the hypothalamus using adeno-associated virus in male C57BL/6J mice fed normal chow (NC) or a high-calorie diet (HCD). After 9 weeks of Npgl overexpression, we measured adipose tissues, muscle, and several organ masses in addition to food intake and body mass. To assess the effects of Npgl overexpression on peripheral tissues, we analyzed mRNA expression of lipid metabolism-related genes by quantitative RT-PCR. Whole body energy consumption was assessed using an O2/CO2 metabolism measurement before an apparent increase in body mass. RESULTS: Npgl overexpression increased food intake, body mass, adipose tissues and liver masses, and food efficiency under both NC and HCD, resulting in obesity observable within 8 weeks. Furthermore, we observed fat accumulation in adipose tissues and liver. Additionally, mRNA expression of lipid metabolism-related factors was increased in white adipose tissue and the liver after Npgl overexpression. Npgl overexpression inhibited energy expenditure during a dark period. CONCLUSION: Taken together, the present study suggests that NPGL can act as an obesogenic factor that acts within a short period of time in mice. As a result, this Npgl overexpression-induced obesity can be widely applied to study the etiology of obesity from genes to behavior.

Stem cell transplantation for the treatment of osteochondral defects of the knee: Operative technique for a single-stage transplantation procedure using bone marrow-derived mesenchymal stem cells.

BACKGROUND: Autologous chondrocyte implantation (ACI) is a NICE-approved technique to regenerate hyaline cartilage in chondral and osteochondral defects (OCDs). The drawbacks of ACI include that it requires a two-stage approach, involves a lengthy rehabilitation process and is expensive. Bone marrow harvest with mesenchymal stem cell transplantation using a single-stage procedure and an accelerated rehabilitation programme has been developed to overcome this. The aim of this paper is to describe the surgical technique for stem cell transplantation of the knee for OCDs with reference to case examples. METHODS: The surgical technique for stem cell transplantation of the knee for OCDs is described, with reference to three cases. Magnetic resonance imaging was performed at six months postoperatively. RESULTS: The surgical technique is described in this paper. The three patient cases described all improved clinically with reduced pain and improved function at a minimum of six months follow-up. CONCLUSIONS: Stem cell transplantation has the potential to produce favourable outcomes for patients with osteochondral defects of the knee. This single-stage approach and accelerated rehabilitation is associated with reduced financial costs. A long-term prospective study of this technique is currently underway at our institution and randomised controlled trials are planned to demonstrate the effectiveness over other techniques.

Current solutions for the treatment of chronic articular cartilage defects in the knee.

Chondral and osteochondral defects in the knee are common and may lead to degenerative joint disease if treated inappropriately.Conventional treatments such as microfracture often result in fibrocartilage formation and are associated with inferior results. Additionally, microfracture is generally unsuitable for the treatment of defects larger than 2-4 cm2.The osteochondral autograft transfer system (OATS) has been shown to produce superior clinical outcomes to microfracture but is technically difficult and may be associated with donor-site morbidity. Osteochondral allograft use is limited by graft availability and failure of cartilage incorporation is an issue.Autologous chondrocyte implantation (ACI) has been shown to result in repair with hyaline-like cartilage but involves a two-stage procedure and is relatively expensive.Rehabilitation after ACI takes 12 months, which is inconvenient and not feasible for athletic patients.Newer methods to regenerate cartilage include autologous stem cell transplantation, which may be performed as a single-stage procedure, can have a shorter rehabilitation period and is less expensive than ACI. Longer-term studies of these methods are needed. Cite this article: EFORT Open Rev 2020;5:156-163. DOI: 10.1302/2058-5241.5.190031.

Sex steroids influence organizational but not functional decidualization of feline endometrial cells in a 3D culture system†.

Successful implantation requires complex signaling between the uterine endometrium and the blastocyst. Prior to the blastocyst reaching the uterus, the endometrium is remodeled by sex steroids and other signals to render the endometrium receptive. In vitro models have facilitated major advances in our understanding of endometrium preparation and endometrial-blastocyst communication in mice and humans, but these systems have not been widely adapted for use in other models which might generate a deeper understanding of these processes. The objective of our study was to use a recently developed, three-dimensional culture system to identify specific roles of female sex steroids in remodeling the organization and function of feline endometrial cells. We treated endometrial cells with physiologically relevant concentrations of estradiol and progesterone, either in isolation or in combination, for 1 week. We then examined size and density of three-dimensional structures, and quantified expression of candidate genes known to vary in response to sex steroid treatments and that have functional relevance to the decidualization process. Combined sex steroid treatments recapitulated organizational patterns seen in vivo; however, sex steroid manipulations did not induce expected changes to expression of decidualization-related genes. Our results demonstrate that sex steroids may not be sufficient for complete decidualization and preparation of the feline endometrium, thereby highlighting key areas of opportunity for further study and suggesting some unique functions of felid uterine tissues.

Pregnancy stage determines the effect of chronic stress on ovarian progesterone synthesis.

Although stress-induced glucocorticoid release is thought to be a primary driver by which maternal stress negatively impacts pregnancy outcomes, the downstream neuroendocrine targets mediating these adverse outcomes are less well understood. We hypothesized that stress-induced glucocorticoid secretion inhibits pituitary hormone secretion, resulting in decreased ovarian progesterone synthesis. Using a chronic restraint model of stress in mice, we quantified steroid hormone production, pituitary hormones, and expression of ovarian genes that support progesterone production at both early ( day 5) and midpregnancy ( day 10). Females subjected to daily restraint had elevated baseline glucocorticoids during both early and midpregnancy; however, lower circulating progesterone was observed only during early pregnancy. Lower progesterone production was associated with lower expression of steroidogenic enzymes in the ovary of restrained females during early pregnancy. There were no stress-related changes to luteinizing hormone (LH) or prolactin (PRL). By midpregnancy, circulating LH decreased regardless of treatment, and this was associated with downregulation of ovarian steroidogenic gene expression. Our results are consistent with a role for LH in maintaining steroidogenic enzyme expression in the ovary, but neither circulating PRL nor LH were associated with the stress-induced inhibition of ovarian progesterone production during early pregnancy. We conclude that chronic stress impacts endocrine networks differently in pregnant and nonpregnant mammals. These findings underscore the need for further studies exploring dynamic changes in endocrine networks participating in pregnancy initiation and progression to elucidate the physiological mechanisms that connect stress exposure to adverse pregnancy outcomes.

Low glucose availability stimulates progesterone production by mouse ovaries in vitro.

Steroid production by the ovary is primarily stimulated by gonadotropins but can also be affected by biological cues that provide information about energy status and environmental stress. To further understand which metabolic cues the ovary can respond to, we exposed gonadotropin-stimulated mouse ovaries in vitro to glucose metabolism inhibitors and measured steroid accumulation in media. Gonadotropin-stimulated ovaries exposed to 2-deoxy-d-glucose increased progesterone production and steroidogenic acute regulatory protein mRNA levels. However, oocytes and granulosa cells in antral follicles do not independently mediate this response because targeted treatment of these cell types with a different inhibitor of glucose metabolism (bromopyruvic acid) did not affect progesterone production. Elevated progesterone production is consistent with the homeostatic role of progesterone in glucose regulation in mammals. It also may regulate follicle growth and/or atresia within the ovary. These results suggest that ovaries can regulate glucose homeostasis in addition to their primary role in reproductive activity.

RFamide-related peptide-3 (RFRP-3) suppresses sexual maturation in a eusocial mammal.

Neuroendocrine mechanisms underlying social inhibition of puberty are not well understood. Here, we use a model exhibiting the most profound case of pubertal suppression among mammals to explore a role for RFamide-related peptide-3 [RFRP-3; mammalian ortholog to gonadotropin-inhibitory hormone (GnIH)] in neuroendocrine control of reproductive development. Naked mole rats (NMRs) live in sizable colonies where breeding is monopolized by two to four dominant animals, and no other members exhibit signs of puberty throughout their lives unless they are removed from the colony. Because of its inhibitory action on the reproductive axis in other vertebrates, we investigated the role of RFRP-3 in social reproductive suppression in NMRs. We report that RFRP-3 immunofluorescence expression patterns and RFRP-3/GnRH cross-talk are largely conserved in the NMR brain, with the exception of the unique presence of RFRP-3 cell bodies in the arcuate nucleus (Arc). Immunofluorescence comparisons revealed that central expression of RFRP-3 is altered by reproductive status, with RFRP-3 immunoreactivity enhanced in the paraventricular nucleus, dorsomedial nucleus, and Arc of reproductively quiescent NMRs. We further observed that exogenous RFRP-3 suppresses gonadal steroidogenesis and mating behavior in NMRs given the opportunity to undergo puberty. Together, our findings establish a role for RFRP-3 in preserving reproductive immaturity, and challenge the view that stimulatory peptides are the ultimate gatekeepers of puberty.

Inhibitory action of gonadotropin-inhibitory hormone on the signaling pathways induced by kisspeptin and vasoactive intestinal polypeptide in GnRH neuronal cell line, GT1-7.

Gonadotropin-inhibitory hormone (GnIH) acts as a negative regulator of reproduction by acting on gonadotropes and gonadotropin-releasing hormone (GnRH) neurons. Despite its functional significance, the molecular mechanism of GnIH action in the target cells has not been fully elucidated. To expand our previous study on GnIH actions in gonadotropes, we investigated the potential signal transduction pathway that conveys the inhibitory action of GnIH in GnRH neurons by using the GnRH neuronal cell line, GT1-7. We examined whether GnIH inhibits the action of kisspeptin and vasoactive intestinal polypeptide (VIP), positive regulators of GnRH neurons. Although GnIH significantly suppressed the stimulatory effect of kisspeptin on GnRH release in hypothalamic culture, GnIH had no inhibitory effect on kisspeptin stimulation of serum response element and nuclear factor of activated T-cell response element activities and ERK phosphorylation, indicating that GnIH may not directly inhibit kisspeptin signaling in GnRH neurons. On the contrary, GnIH effectively eliminated the stimulatory effect of VIP on p38 and ERK phosphorylation, c-Fos mRNA expression, and GnRH release. The use of pharmacological modulators strongly demonstrated the specific inhibitory action of GnIH on the adenylate cyclase/cAMP/protein kinase A pathway, suggesting a common inhibitory mechanism of GnIH action in GnRH neurons and gonadotropes.-Son, Y. L., Ubuka, T., Soga, T., Yamamoto, K., Bentley, G. E., Tsutsui, K. Inhibitory action of gonadotropin-inhibitory hormone on the signaling pathways induced by kisspeptin and vasoactive intestinal polypeptide in GnRH neuronal cell line, GT1-7.

Neural and neuroendocrine processing of a non-photic cue in an opportunistically breeding songbird.

Recent studies of the onset of breeding in long-day photoperiodic breeders have focused on the roles of type 2 and 3 iodothyronine deiodinases (DIO2 and DIO3) in the conversion of thyroxine (T4) to triiodothyronine (T3) and subsequent activation of the reproductive axis. It has been hypothesized that an increase in DIO2 and a reciprocal decrease in DIO3 causes the release of gonadotropin-releasing hormone (GnRH) from the hypothalamus, setting off a reproductive cascade, and that this DIO mechanism for GnRH release is conserved across vertebrate taxa. We sought to test whether social cues that are known to stimulate reproductive behaviors can activate the DIO system to initiate reproduction in a non-photoperiodic bird, the zebra finch (Taeniopygia guttata). Isolation of males and subsequent presentation of females did not increase DIO2 or GnRH expression in the hypothalamus, nor did it decrease gonadotropin-inhibitory hormone (GnIH) or DIO3. Males receiving a female stimulus showed significantly higher mRNA expression and immunoreactive cell count of the immediate-early gene early growth response protein 1 (EGR-1) than isolated males, indicating hypothalamic activation in response to a female. Cells immunoreactive for EGR-1 were not co-localized with those immunoreactive for GnRH. Reproductive behaviors (singing, copulation attempts and overall activity) were significantly higher in males receiving a female stimulus. This study presents a social effect on behavior and EGR-1 expression in the hypothalamus of males in response to females, but more research is needed to determine whether the DIO2 system and the GnRH system are responsive to social stimulation in this species.

Outcome of combined autologous chondrocyte implantation and anterior cruciate ligament reconstruction.

BACKGROUND: Instability of the knee joint, after anterior cruciate ligament (ACL) injury, is contraindication to osteochondral defect repair. This prospective study is to investigate the role of combined autologous chondrocyte implantation (ACI) with ACL reconstruction. MATERIALS AND METHODS: Three independent groups of patients with previous ACL injuries undergoing ACI were identified and prospectively followed up. The first group had ACI in combination with ACL reconstruction (combined group); the 2(nd) group consisted of individuals who had an ACI procedure having had a previously successful ACL reconstruction (ACL first group); and the third group included patients who had an ACI procedure to a clinically stable knee with documented nonreconstructed ACL disruption (No ACL group). Their outcomes were assessed using the modified cincinnati rating system, the Bentley functional (BF) rating system (BF) and a visual analog scale (VAS). RESULTS: At a mean followup of 64.24 months for the ACL first group, 63 months for combined group and 78.33 months for the No ACL group; 60% of ACL first patients, 72.73% of combined group and 83.33% of the No ACL group felt their outcome was better following surgery. There was no significant difference demonstrated in BF and VAS between the combined and ACL first groups. Results revealed a significant affect of osteochondral defect size on outcome measures. CONCLUSION: The study confirms that ACI in combination with ACL reconstruction is a viable option with similar outcomes as those patients who have had the procedures staged.

Food, stress, and circulating testosterone: Cue integration by the testes, not the brain, in male zebra finches (Taeniopygia guttata).

Food abundance is closely associated with reproductive readiness in vertebrates. Food scarcity can activate the hypothalamo-pituitary-adrenal axis, decrease sex steroid secretion, and dampen reproductive behavior. However, the mechanisms underlying these transient effects are unclear. Gonadotropin inhibitory hormone (GnIH), a neuropeptide present in the brain and gonads, is also influenced by glucocorticoids and fasting in some species. We investigated whether fasting stress activated the GnIH system in zebra finches (Taeniopygia guttata), with the potential for downstream effects on reproductive physiology and behavior. We fasted or fed males ad libitum for 10h. Fasting increased corticosterone and decreased testosterone in circulation. To assess whether the decrease in testosterone was mediated by changes in the hypothalamus and/or the gonads, we (1) quantified GnRH- and GnIH-positive neurons in the hypothalamus, (2) assessed hypothalamic gene expression for GnRH and GnIH, and (3) examined gene expression for proteins involved in testosterone synthesis in fasted and control birds. No measure of hypothalamic neuropeptides was related to treatment or circulating steroids. However, birds with higher corticosterone had higher testicular GnIH expression and lower testosterone. StAR and LHR expression were lower in the testes of fasted birds than controls. Thus, the decrease in testosterone was not likely mediated by hypothalamic GnIH, but rather by direct actions of fasting and/or corticosterone on the testes, indicating that the testes can integrate and respond to cues of stress directly. Such local inhibition of testosterone synthesis may allow for rapid and reversible changes in physiology and behavior when conditions are inappropriate for breeding.

Seasonal control of gonadotropin-inhibitory hormone (GnIH) in birds and mammals.

Animals inhabiting temperate and boreal latitudes experience marked seasonal changes in the quality of their environments and maximize reproductive success by phasing breeding activities with the most favorable time of year. Whereas the specific mechanisms driving seasonal changes in reproductive function vary across species, converging lines of evidence suggest gonadotropin-inhibitory hormone (GnIH) serves as a key component of the neuroendocrine circuitry driving seasonal changes in reproduction and sexual motivation in some species. In addition to anticipating environmental change through transduction of photoperiodic information and modifying reproductive state accordingly, GnIH is also positioned to regulate acute changes in reproductive status should unpredictable conditions manifest throughout the year. The present overview summarizes the role of GnIH in avian and mammalian seasonal breeding while considering the similarities and disparities that have emerged from broad investigations across reproductively photoperiodic species.

Social cues regulate reciprocal switching of hypothalamic Dio2/Dio3 and the transition into final follicle maturation in European starlings (Sturnus vulgaris).

With final maturation of ovarian follicles, birds are committed to a major energetic investment: egg laying. Follicles develop in a 2-step process: 1) initial development of regressed follicles stimulated by long days and 2) yolk incorporation into hierarchical follicles, ovulation, and oviposition. We know little about how females transduce environmental cues into neuroendocrine signals regulating the second step. The present study measures gene expression in tissues within the hypothalamo-pituitary-gonadal axis. Females were housed in seminatural enclosures experiencing natural changes in photoperiod and environmental cues (eg, temperature, rainfall, etc), without males or with constant access to males (January to April). By April, females with males had begun to lay eggs, whereas those without males had not. In a second study, females without males for 3.5 months were then given access to males for 7 days. Restricting male access completely inhibited final follicle maturation, whereas 7-day male access stimulated full vitellogenesis and follicle maturation. Few gene expression changes were attributable to constant male access (January to March), but naïve females given 7-day male access had increased type 2 deiodinase (DIO2) and decreased DIO3 synthesis in the hypothalamus, potentially influencing local thyroid hormone metabolism, increased expression of LH receptor and aromatase in follicles and vitellogenin in liver. Our data suggest that initial follicle development may be more heavily influenced by photoperiod, but the second step (final maturation) is sensitive to other cues such as social interactions. This is the first demonstration of a social effect on the Dio2/Dio3 system, previously thought only responsive to photoperiod cues.

A prospective, multi-institutional study of pediatric all-terrain vehicle crashes.

BACKGROUND: Pediatric all-terrain vehicle (ATV) injuries have been increasing annually for more than a decade. The purpose of this study was to prospectively evaluate crash circumstances and clinical outcomes resulting from pediatric ATV crashes. METHODS: Three pediatric trauma centers prospectively collected data from patients during their hospitalization for injuries sustained in ATV crashes from July 2007 through June 2012. Patients completed a 35-item questionnaire describing the crash circumstances (ATV engine size, safety equipment use, and training/experience). Clinical data (injuries, surgical procedures, etc.) were collected for each patient. RESULTS: Eighty-four patients were enrolled, with a mean (SD) age of 13.0 (3.1) years, and were predominantly male (n = 55, 65%). Injuries were musculoskeletal (42%), central nervous system (39%), abdominal (20%), thoracic (16%), and genitourinary (4%). Multisystem injuries were prevalent (27%), and two patients died. Thirty-three patients (43%) required operative intervention. Most children were riding for recreation (96%) and ignored ATV manufacturers' recommendation that children younger than 16 years ride ATVs with smaller (≤90 cc) engines (71%). Dangerous riding practices were widespread: no helmet (70%), no adult supervision (56%), double riding (50%), riding on paved roads (23%), and nighttime riding (16%). Lack of helmet use was significantly associated with head injury (53% vs. 25%, p = 0.03). Rollover crashes were most common (44%), followed by collision with a stationary object (25%) or another vehicle (12%). Half (51%) of children said that they would ride an ATV again. CONCLUSION: These data demonstrate a relationship between dangerous ATV riding behaviors and severe injuries in children who crash. Children younger than 16 years should not operate ATVs, and legislation that effectively restricts ATV use in children is urgently needed. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Long-term results of autologous chondrocyte implantation in the knee for chronic chondral and osteochondral defects.

BACKGROUND: Autologous chondrocyte implantation (ACI) has been shown to be effective in the midterm for the treatment of symptomatic articular cartilage lesions of the knee, but few long-term series have been published. The multioperated chronic articular cartilage defect remains a difficult condition to treat. PURPOSE: To examine the long-term clinical results of ACI for large chronic articular cartilage defects, many treated as salvage. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This is a prospective case series of 104 patients with a mean age of 30.2 years and a symptomatic lesion of the articular cartilage in the knee, who underwent ACI between 1998 and 2001. The mean duration of symptoms before surgery was 7.8 years. The mean number of previous surgical procedures on the cartilage defect, excluding arthroscopic debridement, was 1.3. The defects were large, with a mean size of 477.1 mm(2) (range, 120-2500 mm(2)). The modified Cincinnati, Stanmore/Bentley, and visual analog scale for pain scoring systems were used to assess pain and functional outcomes at a minimum 10 years (mean, 10.4 years; range, 10-12 years). RESULTS: Twenty-seven patients (26%) experienced graft failure at a mean of 5.7 years after ACI. Of the 73 patients who did not fail, 46 patients (63% of patients with a surviving graft) had an excellent result, 18 (25%) were good, 6 (8%) were fair, and 3 (4%) had a poor result. Of a total of 100 patients successfully followed up, 98 were satisfied with the ACI technique for their chronic knee pain and would undergo the procedure again. CONCLUSION: Autologous chondrocyte implantation can provide a long-term solution in more than 70% of young patients of a difficult-to-treat group with large chronic articular cartilage lesions, even in the salvage situation.

Autologous chondrocyte implantation in the knee: mid-term to long-term results.

BACKGROUND: From 1998 to 2008, 1000 skeletally mature patients underwent autologous chondrocyte implantation for an osteochondral defect of the knee. We evaluated the functional outcomes in 827 of 869 patients who had undergone autologous chondrocyte implantation with Chondron or periosteum (ACI-C/ACI-P) or matrix-assisted chondrocyte implantation (MACI) and attempted to identify factors that influenced outcome. METHODS: The age of the patient, the size and site of the osteochondral lesion, previous surgery, and the presence of early osteoarthritis were assessed for their influence on outcomes. Each factor was evaluated in a separate Cox proportional hazards model with use of hazard ratios (HRs), with 95% confidence intervals (CIs), describing the likelihood of failure for that particular factor. Outcomes were assessed with use of the modified Cincinnati score, visual analog scale pain score, and Stanmore functional score. RESULTS: The mean duration of follow-up was 6.2 years (range, two to twelve years). The mean age was thirty-four years (range, fourteen to fifty-six years), with 493 males and 334 females. The average size of the defect was 409 mm2 (range, 64 to 2075 mm2). Four hundred and twenty-one procedures (51%) were performed on the medial femoral condyle; 109 (13%), on the lateral femoral condyle; 200 (24%), on the patella; and fifty (6%), on the trochlea. Kaplan-Meier survival analysis revealed that the unadjusted graft survival rate was 78.2% at five years and 50.7% and ten years for the entire cohort. No difference was found between the survival rates of the ACI-C/ACI-P and MACI techniques (HR = 0.948, 95% CI = 0.738 to 1.219, p = 0.678). There was a significant postoperative improvement in the function and pain scores of all three outcome measures (p < 0.002). Survivorship in the group with a previous cartilage regenerative procedure was inferior to that in patients with a previously untreated lesion, with failure five times more likely in the former group (HR = 4.718, standard error [SE] = 0.742, 95% CI = 3.466 to 6.420, p < 0.001). Degenerative change in any compartment had a significant detrimental effect on survivorship, with survivorship worsening as the osteoarthritis grade increased (Grade 1: HR = 2.077, 95% CI = 1.299 to 3.322, p = 0.002; Grade 2: HR = 3.450, 95% CI = 2.646 to 4.498, p < 0.001; and Grade 3: HR = 3.820, 95% CI = 2.185 to 6.677, p < 0.001). CONCLUSIONS: Our study demonstrated an overall graft survival of 78% at five years and 51% beyond ten years following both autologous chondrocyte implantation techniques. Despite study limitations, our results demonstrate that autologous chondrocyte implantation for the treatment of osteochondral defects of the knee can achieve good results. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.