Low rate of return to pre-injury sport level in athletes after cartilage surgery: a 10-year follow-up study.

PURPOSE: Although articular surface is frequently damaged in athletes, results in terms of return to sport and level of activity after cartilage surgery remain rather unpredictable and poorly documented. The aim of this study is to evaluate the clinical outcome in terms of rate and level of return to sport in a group of competitive athletes who underwent matrix-assisted autologous chondrocyte transplantation (MACT), as well as the impact on their athletic career. METHODS: Thirty-one male patients (mean age 22.6 ± 6.3 years) p racticing sport at competitive level, affected by focal chondral/osteochondral lesions of the distal femur, were enrolled and treated with arthroscopic hyaluronan-based MACT. Patients were evaluated prospectively at 1-year intervals with the IKDC subjective, Tegner, and EuroQol VAS scores during their pre-operative visit and subsequent follow-ups for up to 10 years. Return to sport in terms of level, time and maintenance of the activity level was documented, together with surgical or clinical failures. RESULTS: A marked improvement in all scores was found: IKDC increased from 40.3 ± 13.4 to 81.7 ± 14.4 (p < 0.0005) at 12 months; a further improvement was observed at 2 years (89.5 ± 11.3; p = 0.008), then results were stable for up to 10 years (87.3 ± 13.6). The analysis of return to sport documented that 64.5% of patients were able to return at a competitive level, and 58.1% performed at the same pre-injury level, with activity rates decreasing over time. The rate of patients returning to competitive level was 84% in those without previous surgery (vs. 33% who had undergone previous surgery), 87% for those with traumatic lesions (vs. 33% and 50% for degenerative and OCD lesions, respectively), and 92.3% in younger patients (age < 20 years). Among these factors, multivariate analysis demonstrated that previous surgery was the single most influencing factor for returning to the same sport level (p = 0.010). CONCLUSIONS: These long-term results showed that chondrocyte-based regenerative approach has some limitations in terms of sport-related outcomes. The level of high functional knee restoration needed for such high-demanding activity level can be challenging to achieve, especially in patients with a more compromised joint homeostasis. Return to sport rate varies significantly according to specific patient and lesion characteristics and best results are obtained in young patients with traumatic lesions without previous surgery, which should be considered when treating athletes affected by cartilage lesions. LEVEL OF EVIDENCE: IV.

No evidence for combining cartilage treatment and knee osteotomy in osteoarthritic joints: a systematic literature review.

PURPOSE: To assess whether the combination of HTO and cartilage treatment produced an additional clinical benefit compared to HTO alone. The secondary aim was to identify if there was any difference among different cartilage procedures in terms of healing potential and clinical outcome. METHODS: A systematic review of the literature was performed on PubMed database by three independent observers according to the following inclusion criteria: clinical reports of any level of evidence, written in the English language, with no time limitation, about HTO associated with cartilage surgical and injective treatment, including surveys reporting clinical, radiological, or second-look outcomes at any follow-up time. RESULTS: The database search identified 1956 records: 21 studies were included for the final analysis, for a total of 1068 patients; 10 case series and 11 comparative studies. While overall good results were reported in the case series, the analysis of the comparative studies showed less uniform results. Among the eight studies investigating HTO with cartilage surgical procedures, improved tissue regeneration was found in 5/8 studies, whereas a clinical improvement was reported only in two studies. Three studies on HTO combination with injective treatment showed better tissue regeneration and clinical benefit. CONCLUSIONS: Literature presents low-quality studies, with only few heterogeneous comparative papers. While surgical treatments targeting only the cartilage layer did not achieve clinical improvements, injective treatments targeting the overall joint environment showed promising findings. This prompts further research towards the development of treatments able to improve knee osteotomies outcomes. However, until new evidence will prove otherwise, there is no indication for a combined cartilage treatment in routine clinical practice. LEVEL OF EVIDENCE: Level IV.

Sport and early osteoarthritis: the role of sport in aetiology, progression and treatment of knee osteoarthritis.

Sports activities are considered favourable for general health; nevertheless, a possible influence of sports practice on the development of early osteoarthritis (OA) is a cause for concern. A higher incidence of OA in knees and ankles of former high-impact sports players than in those of the normal population has been shown and it is still debatable whether the cause is either to be recognized generically in the higher number of injuries or in a joint overload. The possibility to address knee OA in its early phases may be strictly connected to the modification of specific extrinsic or intrinsic factors, related to the patient in order to save the joint from further disease progression; these include sport practice, equipment and load. Non-surgical therapies such as continuative muscles reinforce and training play a strong role in the care of athletes with early OA, particularly if professional. There is an overall agreement on the need of an early restoring of a proper meniscal, ligament and cartilage integrity in order to protect the knee and resume sports safely, whereas alignment is a point still strongly debatable especially for professional athletes. Remaining questions still to be answered are the risks of different sports in relation to one another, although an actual protective effect of low-impact sports, such as walking, swimming or cycling, has been recognized on the appearance or worsening of OA, the effect of continuing or ceasing to practice a sport on the natural history of early OA, and even following appropriate treatment is still unknown.

Value and limitations of transesophageal echocardiographic monitoring during percutaneous balloon mitral valvotomy.

To determine the utility of transesophageal echocardiographic monitoring during percutaneous balloon mitral valvotomy, we analyzed data from 40 consecutive patients who had been randomly assigned to undergo balloon mitral valvotomy under transesophageal echocardiographic guidance or without echo. All procedures were carried out under general anaesthesia. The completion rate (100% vs 73%), the procedure time (108 +/- 28 min vs 65 +/- 18 min), the X-ray exposure time (62 +/- 13 vs 33 +/- 12 min), resulted significantly (P less than 0.001) more favorable in the echo-monitored patients. Moreover, a lower rate of major complications (cardiac tamponade, large residual atrial shunting, and severe mitral regurgitation) was noted in the echo-monitored patients. The achieved final area of the mitral valve did not differ significantly between the two groups. From an evaluation of results as a whole, 96% of the echo-monitored procedures were successful, whereas only 40% of the procedures conducted without echocardiographic control achieved a satisfactory final result in absence of major complications. We conclude that transesophageal echocardiography is a safe, effective, and valuable tool to monitor each step of balloon mitral valvotomy in order to shorten the time of the procedure, and to improve the results of this complex interventional catheterization technique.

[Pre- and postoperative ECG-VCG study of the correction of atrioventricular septal defects]. / Estudio ECG-VCG pre y postoperatorio de la corrección del defecto del septum atrio-ventricular.

In order to determine the possible implication of the right bundle branch block (RBBB) in the superior axis deviation of patients (pt) affected with AV septal (Canal) defect, we studied the preoperative and postsurgical ECG of 50 patients who underwent radical correction of the malformation complex. 36 pt had the complete form and 14 a partial form. In 14 of them it was also possible to perform a VCG before and after surgery. The amplitude of S1, R' in a VR and V1 modified significantly (p less than 0.0001), the AQRS showed a clockwise displacement of 19 degrees (p less than 0.002). The terminal forces in the VCG frontal plane changed significantly 62 degrees (p less than 0.0001). Nevertheless the D.I. in a VL and V6 made no difference. Postoperative ECG patterns of pt with partial or complete forms did not differ substantially. Results allowed us to conclude that the major determinant of the AV septal defect ECG pattern is the posterior (inlet) deficiency of the interventricular septum. Surgical correction of the right ventricle overload leads to a clockwise AQRS displacement in the frontal plane. The conduction asynchronism through the left branch showed no modifications.

Outcome of 290 patients with aortic dissection. A 12-year multicentre experience.

Retrospective data regarding 290 patients suffering from spontaneous aortic dissection between January 1976 and June 1987 are reported. Dissection was always documented by retrograde aortography and data were collected from 11 catheterization laboratories operating in North-East Italy. The results show that over a 12-year period there was an increase in cases, an increase in the number of operations and a decline in operative mortality. Multivariate discriminant analysis demonstrated that acute myocardial infarction, persistent shock and persistent central neurologic deficit were significant independent predictors of operative mortality in type A patients. Only persistent shock was significantly related to higher operative mortality in type B patients. Late deaths occurred in 14/118 operated patients, and were mostly secondary (directly or indirectly) to aortic dissection. Discharged patients underwent frequent medical checks and chronically received drugs to control hypertension and reduce inotropism. Most of them (73.7%) were asymptomatic: careful post-operative medical assistance is necessary to guarantee the long-term success of surgical treatment.

[Short- and mid-term results of percutaneous aortic valvuloplasty for calcific aortic stenosis in elderly patients]. / Risultati a breve e medio termine della valvuloplastica aortica percutanea nel trattamento della stenosi aortica calcifica dell'anziano.

In order to evaluate the short and mid-term results of percutaneous aortic balloon valvuloplasty, 40 consecutive elderly patients with symptomatic severe calcific aortic stenosis, underwent the procedure consecutively, with follow-up by clinical evaluation and Doppler echocardiography. Over a mean follow-up period of 11.2 months there were 5 deaths, and 12 patients underwent subsequent aortic valve replacement. Doppler echocardiography revealed an increase in aortic valve area from 0.62 +/- 0.20 cm2 to 0.91 +/- 0.23 cm2 after the procedure, but there was a significant trend toward restenosis by 12 months follow-up in 23 of 32 patients (72%). Restenosis was accompanied by symptomatic deterioration in 18 of 23 patients (78%). Although balloon valvuloplasty may often improve haemodynamics and relieve symptoms, these benefits seem to be short-lived in most cases. Restenosis has a high rate of occurrence. Aortic balloon valvuloplasty should be reserved for truly inoperable cases and for haemodynamically-unstable patients, who may later undergo surgery.