Meniscal Transplant surgery or Optimised Rehabilitation full randomised trial (MeTeOR2): a study protocol.

INTRODUCTION: Pain and disability after meniscectomy can be a substantial lifelong problem. There are few treatment options, especially for young people. Non-surgical management (rehabilitation) is an option but increasingly surgeons are performing meniscal allograft transplants (MATs) for these individuals. However, this is still an uncommon procedure, and availability and usage of MAT vary widely both in the UK and internationally. It is not known which treatment option is the most effective and cost-effective. METHODS AND ANALYSIS: The Meniscal Transplant surgery or Optimised Rehabilitation trial is an international, multicentre, randomised controlled trial. The aim is to compare the clinical and cost effectiveness of MAT versus an optimised package of individualised, progressive, rehabilitation that we have called personalised knee therapy (PKT).Participants will be recruited from sites across the UK, Australia, Canada and Belgium. The planned 144 participants provide at least 90% power to detect a 10-point difference in the Knee injury and Osteoarthritis Outcome Score (KOOS4) at 24-months post randomisation (primary outcome). A prospectively planned economic evaluation will be conducted from a healthcare system and personal social services perspective. Secondary outcome data including health utility, occupational status, sports participation, mental well-being, further treatment, and adverse events will be collected at 3, 6, 12, 18, and 24 months. Analysis will be on an intention-to-treat basis and reported in-line with the Consolidated Standards of Reporting Trials statement. ETHICS AND DISSEMINATION: The trial was approved by the London-Bloomsbury Research Ethics Committee on 19 August 2022 (22/LO/0327) and Northern Sydney Local Health District Human Research Ethics Committee, NSW, Australia on the 13 March 2023 (2022/ETH01890).Trial results will be disseminated via peer-reviewed publications, presentations at international conferences, in lay summaries and using social media as appropriate.This protocol adheres to the recommended Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist. TRIAL REGISTRATION NUMBER: ISRCTN87336549.

Preoperative glycaemic control, number of pain locations, structural knee damage, self-reported central sensitisation, satisfaction and personal control are predictive of 1-year postoperative pain, and change in pain from pre- to 1-year posttotal knee arthroplasty.

PURPOSE: The aim of this study was to identify preoperative predictors for 1-year posttotal knee arthroplasty (TKA) pain and pre- to post-TKA pain difference in knee osteoarthritis (KOA) patients. METHODS: From March 2018 to July 2023, this prospective longitudinal cohort study enrolled KOA patients awaiting TKA from four hospitals in Belgium and the Netherlands. Different biopsychosocial predictors were assessed preoperatively by questionnaires and physical examinations (input variables). The Knee injury and Osteoarthritis Outcome Score (KOOS) subscale pain was used to measure pain intensity. The absolute KOOS subscale pain score 1-year post-TKA and the difference score (ΔKOOS = 1-year postoperative - preoperative) were used as primary outcome measures (output variables). Two multivariable linear regression analyses were performed. RESULTS: Two hundred and twenty-three participants were included after multiple imputation. Worse absolute KOOS subscale pain scores 1-year post-TKA and negative or closer to zero ΔKOOS subscale pain scores were predicted by self-reported central sensitisation, lower KOA grade and preoperative satisfaction, and higher glycated haemoglobin, number of pain locations and personal control (adjusted R2 = 0.25). Additional predictors of negative or closer to zero ΔKOOS subscale pain scores were being self-employed, higher preoperative pain and function (adjusted R2 = 0.37). CONCLUSION: This study reports different biopsychosocial predictors for both outcomes that have filtered out other potential predictors and provide value for future studies on developing risk assessment tools for the prediction of chronic TKA pain. PROTOCOL REGISTRATION: The protocol is registered at clinicaltrials.gov (NCT05380648) on 13 May 2022. LEVEL OF EVIDENCE: Level II.

No clinical outcome difference between varus phenotypes after medial opening-wedge high tibial osteotomy at 2 years follow-up.

PURPOSE: Clinical studies regarding medial open-wedge high tibial osteotomy (MOWHTO) often analyse a large group of mechanical varus knees rather than differentiating for its primary varus-inducing component. This study aims to compare the radiological and clinical outcomes of the most prevalent varus malalignment phenotypes using the coronal plane alignment of the knee (CPAK) classification. METHODS: MOWHTO cases with minimal 2-year clinical follow-up were retrospectively selected from a knee osteotomy database (2016-2020). Based on the medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA), subjects were allocated to the correct CPAK phenotype pre- and postoperatively. Clinical outcomes were the numeric rating scale (NRS), the knee injury and osteoarthritis outcome score (KOOS) and the therapeutic response rate (TRR) at 2-year follow-up. Inter-observer correlation coefficient (ICC) and unpaired student t test were performed for cross-phenotype comparison. RESULTS: One hundred thirty-five (135) subjects were found eligible (53.0 years old ±9.6 [19-77], 72% male, 53% left-sided). The most prevalent preoperative phenotype was CPAK 1 (n = 70 (52%)) and the postoperative phenotype was CPAK 6 (n = 66 (49%)). All CPAK phenotypes improved significantly relative to baseline but cross-phenotype comparison yielded no significant differences in clinical outcome. The TRR at 2 years was 67% for CPAK 1, 69% for CPAK 2 and 87% for CPAK 4. The TRR for CPAK 6 was 64% compared with 80% for CPAK 9, which was not significantly different. CONCLUSION: At 2-year follow-up, no clinically significant differences are observed between different CPAK phenotypes. Accurate MOWHTO corrections provide significant clinical improvement even in the femoral-driven varus knee and the constitutional varus knee dominated by intra-articular wear. The clinical indication for MOWHTO performance should not be reduced to the medial arthritic varus knee with underlying tibial varus alone. LEVEL OF EVIDENCE: Level IV, retrospective comparative study.

Most Publications Regarding Arthroscopic Treatment of Posterolateral Corner Injuries of the Knee Have a Low Level of Evidence and Provide Limited Information to Determine the Most Effective Treatment.

Purpose: To examine the Level of Evidence and overall quality of studies addressing arthroscopic posterolateral corner reconstructions of the knee. Methods: A search was performed using the PubMed/Medline, Web of Science, and Google Scholar databases for all studies investigating arthroscopic treatment of posterolateral corner injuries of the knee. Studies reporting outcomes or describing arthroscopic techniques for treatment of posterolateral corner injuries of the knee were the focus of this analysis. Clinical as well as biomechanical and cadaveric studies were included. Studies only investigating open techniques were excluded. Two independent reviewers determined the level of evidence for each included study using the criteria established by the Journal of Bone and Joint Surgery and scored each clinical study from 0 to 100 based on 10 criteria from the modified Coleman Methodology Score. Results: Twenty-four studies matched the inclusion criteria. There were 6 cadaveric technique descriptions, 6 clinical technique descriptions, 3 biomechanical studies, 4 technical repair descriptions, and 5 clinical outcome studies. Thirty-eight percent of all studies were of Level V evidence. Fifty percent of studies were of Level IV evidence, and 12% of studies were of Level III evidence. The mean modified Coleman Methodology Score for the clinical studies was 43 ± 11.4, which is regarded as poor, mainly due to the limited number of patients and the retrospective nature of the studies. Conclusions: Most studies addressing arthroscopic posterolateral corner reconstruction of the knee are of low level of evidence and provide limited information about the best treatment options. Clinical Relevance: The number of publications on arthroscopic posterolateral corner reconstruction techniques continues to rise. This systematic review evaluates the level of evidence of these studies.

Fresh Versus Frozen Meniscal Allograft Transplant: Revisit or Redundant? A Systematic Review.

BACKGROUND: Fresh-frozen allografts are the current standard in meniscal allograft transplant (MAT) surgery, due to their availability, ease of preservation, and affordability. However, fresh-frozen grafts are associated with several clinical challenges such as graft shrinkage and extrusion, among many others. PURPOSE: To present the current knowledge on the use of fresh meniscal allografts, presenting whether benefits associated with fresh grafts provide sufficient evidence to support their use in clinical practice. STUDY DESIGN: Systematic review; Level of evidence, 5. METHODS: A comprehensive search was conducted with keywords listed below. After an initial screening on title and abstract, full-text articles were assessed with the inclusion criteria. RESULTS: A total of 78 studies matched the inclusion criteria. Literature and preclinical studies indicated that fresh meniscal allografts are beneficial for maintaining mechanical properties, graft ultrastructure, and matrix metabolism due to the presence of viable cells. Therefore, fresh allografts may address common complications associated with fresh-frozen MAT. To overcome challenges associated with both fresh-frozen and fresh allografts, a group has studied treating fresh-frozen allografts with a cell-based injection therapy. CONCLUSION: Fresh meniscal allografts pose several challenges including limited availability, demanding preservation procedures, and high costs. Although the role of viable cells within meniscal allografts remains controversial, these cells may be vital for maintaining tissue properties.

Anterior Cruciate Ligament Reconstruction Plus Lateral Extra-articular Tenodesis Has a Similar Return-to-Sport Rate to Anterior Cruciate Ligament Reconstruction Alone but a Lower Failure Rate.

PURPOSE: To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) would improve return-to-sport (RTS) rates in young, active patients who play high-risk sports. METHODS: This multicenter randomized controlled trial compared standard hamstring tendon ACLR with combined ACLR and LET using a strip of the iliotibial band (modified Lemaire technique). Patients aged 25 years or younger with an anterior cruciate ligament-deficient knee were included. Patients also had to meet 2 of the following criteria: (1) pivot-shift grade 2 or greater, (2) participation in a high-risk or pivoting sport, and (3) generalized ligamentous laxity. Time to return and level of RTS were determined via administration of a questionnaire at 24 months postoperatively. RESULTS: We randomized 618 patients in this study, 553 of whom played high-risk sports preoperatively. The proportion of patients who did not RTS was similar between the ACLR (11%) and ACLR-LET (14%) groups; however, the graft rupture rate was significantly different (11.2% in ACLR group vs 4.1% in ACLR-LET group, P = .004). The most cited reason for no RTS was lack of confidence and/or fear of reinjury. A stable knee was associated with nearly 2 times greater odds of returning to a high-level high-risk sport postoperatively (odds ratio, 1.92; 95% confidence interval, 1.11-3.35; P = .02). There were no significant differences in patient-reported functional outcomes or hop test results between groups (P > .05). Patients who returned to high-risk sports had better hamstring symmetry than those who did not RTS (P = .001). CONCLUSIONS: At 24 months postoperatively, patients who underwent ACLR plus LET had a similar RTS rate to those who underwent ACLR alone. Although the subgroup analysis did not show a statistically significant increase in RTS with the addition of LET, on returning, the addition of LET kept subjects playing longer by reducing graft failure rates. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

The position of the lateral tibial spine and the implications for high tibial osteotomy planning.

The lateral tibial spine (LTS) is frequently proposed as a correction target in high tibial osteotomy (HTO), although little is known about its exact radiographic position. This study primarily aims to define the position and variance of the LTS. Secondly, this study wants to investigate the relevance of the LTS position on the mechanical tibiofemoral angle (mTFA°) while planning and postoperatively landing the weight-bearing line (WBL) on this landmark. The LTS position was studied on preoperative full-leg standing radiographs (FLSR) and computed tomography (CT) scans in 70 cases. 3D models of the tibia were created in Mimics 23.0 and measurements were conducted in 3-matic 15.0 (Materialise, Leuven®). Next, 100 HTO cases were retrospectively planned with the WBL through the LTS according to Dugdale's method on FLSR. Finally, 55 postoperative FLSR which had the WBL on the LTS (±2%) were assessed for mTFA° outcome. Statistics were conducted in GraphPad 8.0. The LTS was located at 58.3%±1.9 [55-63%] in 2D and 57.3%±2.2 [53-63%] in 3D showing a high correlation (r=0.77 [0.65 to 0.85]). The planned mTFA on the LTS was 181.8°±0.3 (181.3°-182.5°). On postoperative FLSR, the mTFA was 182.2°±0.6 (180.9°-183.1°). The lateral tibial spine is located at 57-58% on the tibial plateau with a 10% maximal variation range. Good agreement was found between 2D and 3D imaging modalities while evaluating its position in the coronal plane. When aiming the WBL through the LTS during valgus-producing HTO, a consistent realignment of 181-183° mTFA can be expected when performing accurate surgery.

Identification of Metabolic Factors and Inflammatory Markers Predictive of Outcome after Total Knee Arthroplasty in Patients with Knee Osteoarthritis: A Systematic Review.

OBJECTIVE: To identify metabolic factors and inflammatory markers that are predictive of postoperative total knee arthroplasty (TKA) outcome. METHOD: A systematic search of the existing literature was performed using the electronic databases PubMed, Web of Science and Embase until the 1st of August 2022. Studies that evaluated the influence of metabolic or inflammatory markers (I) on postsurgical outcome (O) in end-stage knee osteoarthritis patients awaiting primary TKA (P) were included in this review. RESULTS: In total, 49 studies were included. Risk of bias of the included studies was low for one study, moderate for 10 studies and high for the remaining 38 studies. Conflicting evidence was found for the influence of body mass index, diabetes, cytokine levels and dyslipidaemia on pain, function, satisfaction and quality of life at more than six months after TKA. CONCLUSIONS: Several limitations such as not taking into account known confounding factors, the use of many different outcome measures and a widely varying follow-up period made it challenging to draw firm conclusions and clinical implications. Therefore large-scaled longitudinal studies assessing the predictive value of metabolic and inflammatory factors pre-surgery in addition to the already evidenced risk factors with follow-up of one year after TKA are warranted.

High degree of consensus amongst an expert panel regarding focal resurfacing of chondral and osteochondral lesions of the femur with mini-implants.

INTRODUCTION: The rationale for the use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions is still under debate. The evidence supporting best practise guidelines is based on studies with low-level evidence. A consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence. The purpose of this article is to report the resulting consensus statements. METHODS: Twenty-five experts participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted via an online survey of two rounds, for initial agreement and comments on the proposed statements. An in-person meeting between the panellists was organised during the 2022 ESSKA congress to further discuss and debate each of the statements. A final agreement was made via a final online survey a few days later. The strength of consensus was characterised as: consensus, 51-74% agreement; strong consensus, 75-99% agreement; unanimous, 100% agreement. RESULTS: Statements were developed in the fields of patient assessment and indications, surgical considerations and postoperative care. Between the 25 statements that were discussed by this working group, 18 achieved unanimous, whilst 7 strong consensus. CONCLUSION: The consensus statements, derived from experts in the field, represent guidelines to assist clinicians in decision-making for the appropriate use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions. LEVEL OF EVIDENCE: Level V.

Impacted bone allograft personalised by a novel 3D printed customization kit produces high surgical accuracy in medial opening wedge high tibial osteotomy: a pilot study.

PURPOSE: Contemporary medial opening wedge high tibial osteotomy (MOWHTO) still seems to struggle with inconsistent accuracy outcomes. Our objective was to assess surgical accuracy and short-term clinical outcomes when using 3D planning and a patient-specific instrumentation (PSI) kit to prepare customized bone allografts. METHODS: Thirty subjects (age 48y ± 13) were included in a double-center prospective case series. A low-dose CT-scan was performed to generate 3D bone models, a MOWHTO was simulated, and PSI was designed and 3D printed based on the complementary negative of the planned osteotomy gap. Clinical outcome was assessed at two, four, 12 weeks and one year using NRS, KOOS, UCLA activity score, EQ-5D and anchor questions. A linear-mixed model approach was implemented for data analysis. RESULTS: Preoperative 3D values were 175.0° ± 2.2 mechanical tibiofemoral angle (mTFA), 85.0° ± 3.0 medial proximal tibial angle (MPTA), and 94.1° ± 3.4 medial posterior tibial slope (MPTS). Target planning ranged from slight varus to the lateral tibial spine (slight valgus). Postoperative 3D analysis showed an accuracy of 1.1° ± 0.7 ΔMPTA (p = 0.04) and 1.2° ± 1.2 ΔMPTS (p = 0.11). NRS decreased from baseline 6.1 ± 1.9 to 2.7 ± 1.9 at four weeks (p < 0.001) and 1.7 ± 1.9 at one year (p < 0.001). KOOS increased from 31.4 ± 17.6 to 50.6 ± 20.6 at 12 weeks (p < 0.001) and to 71.8 ± 15.6 at one year (p < 0.001). CONCLUSION: The study suggests that 3D printed instrumentation to personalize structural bone allograft is a viable alternative method in MOWHTO that has the benefit of optimizing surgical accuracy while providing early and consistent pain relief after surgery.

Mid-term outcomes of posterior capsular release for fixed flexed deformity after total knee arthroplasty.

Fixed flexion deformity also called flexion contracture is relatively rare, but a very demanding functional limitation that both surgeons and patients may have to deal with. The purpose of the present study was to evaluate the functional outcomes after posteromedial capsular release in case of fixed flexed deformity > 15 o . Between June 2011 and November 2018, 15 patients (6 males and 9 females) were treated with open posterior capsular release through medial approach for fixed flexion deformity of the knee > 15 o and prospectively followed with a minimum follow-up of 2 years. Primary outcome was knee extension measured with a manual goniometer and secondary outcome treatment related complications. All patients reported inability to walk and clinical semiology of pain and swelling. The mean age of the study population at surgery was 61.7 years with a mean BMI of 30.9 kg/m2. Complete data were recorded for all patients. Statistically significant improvement was found in clinical and functional assessment tools analyzed from baseline to the latest follow-up (p<0.05). More precisely, the mean postoperative fixed flexion deformity was decreased from 23.57 o to 2.86 o . No adverse effect or major complications were recorded during follow-up. Posterior open release via posteromedial was shown to be an efficient and safe salvage procedure to deal with persistent fixed flexion deformity of more than 15 o following TKA at two years follow-up. However, future studies with a higher number of participants and longer follow-up should be conducted to validate our data.

Prophylaxis for preventing venous thromboembolism in knee arthroscopy and soft tissue reconstruction: consensus statements from an international panel of experts.

PURPOSE: There is a lack of consensus regarding need for Venous Thrombo Embolism (VTE) prophylaxis following arthroscopic knee surgery and open soft tissue knee reconstruction. Clear cut guidelines like ones for trauma surgery and arthroplasty do not exist and the published literature is limited to case reports with a few society guidelines. Given this lack of consensus, we conducted a modified Delphi questionnaire of international experts to provide recommendations on this topic. METHODS: The consensus statements were generated using an anonymised 3 round modified Delphi questionnaire, sent to an international panel of 38 knee surgeons, with an 80% agreement being set as the limit for consensus. The responses were analysed using descriptive statistics with measures like mode, median and box plots. Feedback was provided to all panelists based on responses from the previous rounds to help generate the consensus. RESULTS: Six consensus statements were generated after the three rounds of Delphi. Patient factors, prolonged surgery duration and family history of thrombogenic events emerged as the main points to be taken into consideration for prophylaxis. CONCLUSION: It was established through this study, that there exists a select group of patients undergoing arthroscopic surgery that justify the usage of VTE prophylaxis. The expert responses to most of the questions in different scenarios favoured usage of VTE prophylaxis based on patient factors like advanced age, past history of VTE, smoking, oral contraceptive use etc. LEVEL OF EVIDENCE: Level V.

Human meniscus allograft augmentation by allogeneic mesenchymal stromal/stem cell injections.

Meniscus allograft transplantations (MATs) represent established surgical procedures with proven outcomes. Yet, storage as frozen specimens and limited cellular repopulation may impair graft viability. This proof-of-concept study tests the feasibility of injecting allogeneic mesenchymal stromal/stem cells (MSCs) in meniscus allograft tissue. We investigated the injectable cell quantity, survival rate, migration, and proliferation ability of MSCs up to 28 days of incubation. In this controlled laboratory study, seven fresh-frozen human allografts were injected with human allogeneic MSCs. Cells were labeled and histological characteristics were microscopically imaged up to 28 days. Mock-injected menisci were included as negative controls in each experiment. Toluidine blue staining demonstrated that a 100-µl volume can be injected while retracting and rotating the inserted needle. Immediately after injection, labeled MSCs were distributed throughout the injection channel and eventually migrated into the surrounding tissues. Histological assessment revealed that MSCs cluster in disc-like shapes, parallel to the intrinsic lamination of the meniscus and around the vascular network. Quantification showed that more than 60% of cells were present in horizontally injected grafts and more than 30% were observed in vertically injected samples. On Day 14, cells adopted a spindle-shaped morphology and exhibited proliferative and migratory behaviors. On Day 28, live/dead ratio assessment revealed an approximately 80% cell survival. The study demonstrated the feasibility of injecting doses of MSCs (>0.1 million) in meniscus allograft tissue with active cell proliferation, migration, and robust cell survival.

Nonoperative and Operative Bone and Cartilage Regeneration and Orthopaedic Biologics of the Hip: An Orthoregeneration Network (ON) Foundation Hip Review.

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and, optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electromagnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the hip, including osteonecrosis (aseptic necrosis) involving bone marrow, bone, and cartilage, and chondral injuries involving articular cartilage, synovium, and bone marrow. Promising and established treatment modalities for osteonecrosis include nonweightbearing; pharmacological treatments including low molecular-weight heparin, prostacyclin, statins, bisphosphonates, and denosumab, a receptor activator of nuclear factor-kB ligand inhibitor; extracorporeal shock wave therapy; pulsed electromagnetic fields; core decompression surgery; cellular therapies including bone marrow aspirate comprising mesenchymal stromal cells (MSCs aka mesenchymal stem cells) and bone marrow autologous concentrate, with or without expanded or cultured cells, and possible addition of bone morphogenetic protein-2, vascular endothelial growth factor, and basic fibroblast growth factor; and arterial perfusion of MSCs that may be combined with addition of carriers or scaffolds including autologous MSCs cultured with beta-tricalcium phosphate ceramics associated with a free vascularized fibula. Promising and established treatment modalities for chondral lesions include autologous platelet-rich plasma; hyaluronic acid; MSCs (in expanded or nonexpanded form) derived from bone marrow or other sources such as fat, placenta, umbilical cord blood, synovial membrane, and cartilage; microfracture or microfracture augmented with membrane containing MSCs, collagen, HA, or synthetic polymer; mosaicplasty; 1-stage autologous cartilage translation (ACT) or 2-stage ACT using 3-dimensional spheroids; and autologous cartilage grafting; chondral flap repair, or flap fixation with fibrin glue. Hip pain is catastrophic in young patients, and promising therapies offer an alternative to premature arthroplasty. This may address both physical and psychological components of pain; the goal is to avoid or postpone an artificial joint. LEVEL OF EVIDENCE: Level V, expert opinion.

Does practice of meniscus surgery change over time? A report of the 2021 'THE MENISCUS' Webinar.

PURPOSE: The aim of this paper was to report the results presented in the session "Does practice of meniscus surgery change over time?" of the 2021 MENISCUS webinar held online on January 30th 2021. METHOD: During the 2021 MENISCUS webinar, an evaluation of meniscus surgery practices was performed by analyzing: (1) The presentation of the results of a survey conducted among ESSKA members and assessing their current practices in the field of meniscus surgery, (2) Four reports by national experts analyzing the trends in Arthroscopic Partial Meniscectomy (APM) and meniscus repair procedures in their respective countries (France, Belgium, Germany and Japan). RESULTS: (1) ESSKA Survey: Among the 461 respondents, 75% of surgeons claimed to perform more meniscus repairs and 85% less APM than 5 years ago. In ACL-associated meniscus injuries, a majority of surgeons (60%) indicated to perform a meniscal resection in less than 25% of cases. 25% declared to perform meniscus repair in ACL-associated meniscus injuries in less than 25% of cases and 37% in more than 50% of cases. Half of the respondents repair medial or lateral root tears in less than 25% of cases. Less than 20% of respondents were not familiar with the ESSKA consensus. (2) National trends: In France, between 2005 and 2017, the APM rate decreased by 21.4%, while the repair rate increased by 320%. In Belgium, between 2007 and 2017, the APM rate decreased by 28.6%. In Germany, between 2010 and 2017 the number of APM decreased by 30%, while the number of repair procedures increased by 55%. Finally, in Japan, between 2011 and 2016, the APM ratio (APM/meniscus procedures) decreased by 16% from 91 to 75% while the repair ratio increased from 9 to 25%. CONCLUSION: The 2021 ESSKA members' survey as well as statistics from 4 specifically examined countries (Belgium, France, Germany and Japan) suggest there has been a significant shift over the last years in the surgical management of meniscal lesions towards less APM and more conservative treatments.

Aragonite-Based Scaffold for the Treatment of Joint Surface Lesions in Mild to Moderate Osteoarthritic Knees: Results of a 2-Year Multicenter Prospective Study.

BACKGROUND: Osteoarthritis (OA) is considered a contraindication to most cartilage repair techniques. Several regenerative approaches have been attempted with the aim of delaying or preventing joint replacement, with controversial results. Currently, there is a paucity of data on the use of single-step techniques, such as cell-free biomimetic scaffolds, for the treatment of joint surface lesions (JSLs) in OA knees. PURPOSE: To present the 2-year follow-up clinical and radiological outcomes after implantation of a novel, cell-free aragonite-based scaffold for the treatment of JSLs in patients with mild to moderate knee OA in a multicenter prospective study. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 86 patients, 60 male and 26 female, with a mean age of 37.4 ± 10.0 years, mild to moderate knee OA, and a mean defect size of 3.0 ± 1.7 cm2, were recruited at 8 medical centers according to the following criteria: radiographic mild to moderate knee OA (Kellgren-Lawrence grade 2 or 3); up to 3 treatable chondral/osteochondral defects (International Cartilage Repair Society grades 3 and 4) on the femoral condyles or trochlea; a total defect size ≤7 cm2; and no concurrent knee instability, severe axial malalignment, or systemic arthropathy. All patients were evaluated at baseline and at 6, 12, 18, and 24 months after implantation using the Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) subjective score. Additionally, magnetic resonance imaging (MRI) was performed to assess the amount of cartilage defect filling at the repaired site. RESULTS: Significant improvement on all KOOS subscales was recorded from baseline (Pain: 49.6 ± 13.1; Activities of Daily Living [ADL]: 56.1 ± 18.4; Sport: 22.8 ± 18.8; Quality of Life [QoL]: 23.5 ± 16.5; Symptoms: 55.4 ± 19.9) to the 24 months' follow-up (Pain: 79.5 ± 21.1 [P < .001]; ADL: 84.1 ± 21.4 [P < .001]; Sport: 60.8 ± 31.9 [P < .001]; QoL: 54.9 ± 30.4 [P < .001]; Symptoms: 77.7 ± 21.2 [P < .001]). The IKDC subjective score showed a similar trend and improved from 37.8 ± 14.7 at baseline to 65.8 ± 23.5 at 24 months (P < .001). MRI showed a significant increase in defect filling over time: up to 78.7% ± 25.3% of surface coverage after 24 months. Treatment failure requiring revision surgery occurred in 8 patients (9.3%). CONCLUSION: The use of an aragonite-based osteochondral scaffold in patients with JSLs and mild to moderate knee OA provided significant clinical improvement at the 24-month follow-up, as reported by the patients. These findings were associated with good cartilage defect filling, as observed on MRI.

Feasibility and 3D Planning of a Novel Patient-Specific Instrumentation Technique in Medial Opening-Wedge High Tibial Osteotomy.

A novel approach for opening-wedge high tibial osteotomy (OWHTO) with patient-specific instrumentation (PSI) was evaluated for its safety, feasibility, and accuracy. Next, the mechanical medial proximal tibial angle (mMPTA) was assessed as a potential planning angle by investigating the relation with the mechanical femorotibial angle (mFTA). Ten OWHTO cases were 3D planned using the mMPTA and operated with a customized 3D-printed wedge and cast which resembled the intended osteotomy opening. Patients were closely monitored for intraoperative and postoperative complications up to 1 year after surgery. Radiological assessment was conducted on full leg standing radiographs and supine lower limb computed tomography-scans preoperatively and 3 months after surgery. No intraoperative complications or logistical issues during PSI processing were observed. Absolute accuracy outcomes showed a correction error of 1.3° ± 1.1 mMPTA and 0.9° ± 0.6 mFTA with all osteotomies falling in (-2°; + 2°) mFTA around the target. The mMPTA and mFTA were found to have a strong correlation in both 3D (r = 0.842, p = 0.002) and 2D (r = 0.766, p = 0.01) imaging for effective correction. The study confirmed the development of a safe and feasible PSI technique in OWHTO with excellent accuracy outcomes. The strong correlation between the mMPTA and mFTA indicated that soft tissue changes after OWHTO are of minor significance to the final alignment in ligament-stable patients. Finally, the mMPTA was found to be a reliable planning angle in 3D software for obtaining the intended lower limb realignment and its use can therefore be recommended in modern OWHTO planning.

Autologous protein solution as selective treatment for advanced patellofemoral osteoarthritis in the middle-aged female patient: 54% response rate at 1 year follow-up.

PURPOSE: The study wanted to investigate the benefit, durability and safety of autologous protein solution (APS) injection(s) in a middle-aged female-only cohort suffering predominantly from patellofemoral osteoarthritis. METHODS: Fifty females (aged 50.4 ± 6.5) with mainly moderate-severe (86%) patellofemoral cartilage wear (PFCW) were treated with a unilateral intra-articular APS injection. The KOOS, NRS, Kujala, UCLA and EQ-5D were assessed at baseline and 1, 3, 6, and 12 months post-injection. Therapeutic response rate (TRR) was based on KOOS pain improvement > 10 points. Absolute improvement for, respectively, therapy responders and non-responders was determined. Second APS injection was administered if improvement was deemed insufficient by the patient after 3 months. RESULTS: The TRR remained stable averaging to 53.7% at final follow-up with subjects improving overall from 40.3 ± 18.7 to 57.3 ± 24.8 points on KOOS pain (p = 0.0002) and from 48.4 ± 13.0 to 56.3 ± 18.1 points on Kujala (p = 0.0203) at 12 months. Significant improvement was observed for the other KOOS subscales and NRS at each follow-up. In absolute values, APS responders improved with 30.5 ± 11.4 points on KOOS pain at 12 months. In contrast, non-responders deteriorated with 5.9 ± 8.9 points relative to baseline. A second APS injection was administered in 28 subjects. Patients with definite synovitis improved more on KOOS symptoms (p = 0.017) and KOOS ADL (p = 0.037) at 12 months compared to non-synovitis subjects. Mild-moderate arthralgia (46%) and effusion (29%) were commonly observed during the first month post-injection. CONCLUSION: This study evidenced a 54% response rate at 12 months to a single or second APS injection in a middle-aged female population with advanced patellofemoral cartilage wear. Moderate temporary flares can be expected without affecting clinical outcomes. Second APS injection has low efficacy in initially poor responding patients after 3 months. Major synovitis on baseline MRI appeared to be a beneficial prognosticator for pain relief and functional improvement after APS. LEVEL OF EVIDENCE: IV.

Complex Osteochondral Lesions of the Talus Treated With a Novel Bi-Phasic Aragonite-based Implant.

To present initial results of a novel, bi-phasic, porous, biodegrade, and cell-free aragonite-based scaffold for treating complex osteochondral lesions of the talus (OLT). Four subjects (2 males and 2 females; 34-61 years old) were operated on their ankles due to chronic and deep OLT-Hepple grades 4 or 5 (1.8-2.2 cm2). Three subjects had OLT on the medial central trochlea, and 1 had a combined medial and lateral lesions. OLT were exposed through medial malleolus osteotomy, with an additional lateral arthrotomy in the combined lesions. Bi-phasic porous osteochondral scaffolds (single implant or 2 implants) were implanted in a press-fit manner using a designated surgical toolset. Treatment outcome was followed clinically (Foot and Ankle Outcome Score, EQ-5D 3L, Tegner activity scale) and by medical imaging (radiographs, magnetic resonance imaging) from 18 to 32 months. All Foot and Ankle Outcome Score values increased from preoperative to final follow-up values (Symptoms 62 to 71, Pain 53 to 84, ADL 60 to 89, Sport 19 to 65, and QoL 18 to 47). EQ-5D 3L increased from 0.59 to 0.76, and Tegner activity values increased from 1.5 to 3. Kellgren-Lawrence ankle radiographic scores remained stable (2 to 2). Postoperative MR evaluation demonstrated cartilage defect fill of 75% to 100% respect to the native cartilage in 3 subjects (4 OLTs), while 1 lesion was filled 25% to 50%. No graft related serious adverse events or graft failures were reported. The use of a bi-phasic osteochondral biodegradable aragonite-based scaffold in the treatment of complex OLT during the reported period presented positive and promising clinical and radiologic outcome, without serious adverse events or graft failures.

Patient-specific metal implants for focal chondral and osteochondral lesions in the knee; excellent clinical results at 2 years.

PURPOSE: Surgical treatment options for the management of focal chondral and osteochondral lesions in the knee include biological solutions and focal metal implants. A treatment gap exists for patients with lesions not suitable for arthroplasty or biologic repair or who have failed prior cartilage repair surgery. This study reports on the early clinical and functional outcomes in patients undergoing treatment with an individualised mini-metal implant for an isolated focal chondral defect in the knee. METHODS: Open-label, multicentre, non-randomised, non-comparative retrospective observational analysis of prospectively collected clinical data in a consecutive series of 80 patients undergoing knee reconstruction with the Episealer® implant. Knee injury and Osteoarthritis Outcome Score (KOOS) and VAS scores, were recorded preoperatively and at 3 months, 1 year, and 2 years postoperatively. RESULTS: Seventy-five patients were evaluated at a minimum 24 months following implantation. Two patients had undergone revision (2.5%), 1 declined participation, and 2 had not completed the full data requirements, leaving 75 of the 80 with complete data for analysis. All 5 KOOS domain mean scores were significantly improved at 1 and 2 years (p < 0.001-0.002). Mean preoperative aggregated KOOS4 of 35 (95% CI 33.5-37.5) improved to 57 (95% CI 54.5-60.2) and 59 (95% CI 55.7-61.6) at 12 and 24 months respectively (p < 0.05). Mean VAS score improved from 63 (95% CI 56.0-68.1) preoperatively to 32 (95% CI 24.4-38.3) at 24 months. The improvement exceeded the minimal clinically important difference (MCID) and this improvement was maintained over time. Location of defect and history of previous cartilage repair did not significantly affect the outcome (p > 0.05). CONCLUSION: The study suggests that at 2 years, Episealer® implants are safe with a low failure rate of 2.5% and result in clinically significant improvement. Individualised mini-metal implants with appropriate accurate guides for implantation appear to have a place in the management of focal femoral chondral and osteochondral defects in the knee. LEVEL OF EVIDENCE: IV.