Articular cartilage regeneration with autologous peripheral blood progenitor cells and hyaluronic acid after arthroscopic subchondral drilling: a report of 5 cases with histology.

PURPOSE: The purpose of this study was to evaluate the quality of articular cartilage regeneration after arthroscopic subchondral drilling followed by postoperative intraarticular injections of autologous peripheral blood progenitor cells (PBPCs) in combination with hyaluronic acid (HA). METHODS: Five patients underwent second-look arthroscopy with chondral core biopsy. These 5 patients are part of a larger pilot study in which 180 patients with International Cartilage Repair Society grade III and IV lesions of the knee joint underwent arthroscopic subchondral drilling followed by postoperative intra-articular injections. Continuous passive motion was used on the operated knee 2 hours per day for 4 weeks. Partial weight bearing was observed for the first 6 to 8 weeks. Autologous PBPCs were harvested 1 week after surgery. One week after surgery, 8 mL of the harvested PBPCs in combination with 2 mL of HA was injected intra-articularly into the operated knee. The remaining PBPCs were divided into vials and cryopreserved. A total of 5 weekly intra-articular injections were given. RESULTS: Second-look arthroscopy confirmed articular cartilage regeneration, and histologic sections showed features of hyaline cartilage. Apart from the minimal discomfort of PBPC harvesting and localized pain associated with the intra-articular injections, there were no other notable adverse reactions. CONCLUSIONS: Articular hyaline cartilage regeneration is possible with arthroscopic subchondral drilling followed by postoperative intraarticular injections of autologous PBPCs in combination with HA. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Comparison of anatomic versus nonanatomic placement of femoral tunnels in Achilles double-bundle posterior cruciate ligament reconstruction.

PURPOSE: In this study, we compared femoral tunnel pairs that differ by group in a double-bundle Achilles tendon allograft posterior cruciate ligament (PCL) reconstruction. METHODS: Group 1 patients had femoral tunnels drilled nearly within the footprint area most proximal and most distal to the axis of the femur. Group 2 patients had femoral tunnels drilled eccentrically within the footprint along an axis nearly perpendicular to the axis of the femur. Patient assessments were made subjectively with preoperative and postoperative assessments of Lysholm rating scale, posterior drawer test, and dial test. Objective assessments used range of motion and quadriceps circumference. Group 1 contained 7 patients with a mean age of 32 years (range, 20 to 46 years). Group 2 contained 10 patients with a mean age of 32 years (range, 20 to 46 years). RESULTS: Group 2 patients had significantly less posterior laxity than group 1 patients. Postoperatively, 6 patients in group 1 (86%) had a positive posterior drawer test compared with 3 in group 2 (30%). Rotational laxity was identified by dial test results postoperatively in 3 patients in group 1 (43%) compared with 0% in group 2. Extension deficit occurred in 2 patients in group 1 (29%) and 1 patient in group 2 (10%). Flexion deficit occurred more than twice as frequently in group 1 (71% [5 patients]) than in group 2 (30% [3 patients]). There were no statistically significant differences for other comparisons. CONCLUSIONS: The clinical outcomes support the group 2 method with femoral tunnel placement at the anterior-most and posterior-most portions of the femoral PCL insertion. The group 2 procedure described in this study incorporates advanced principles for successful outcomes with Achilles double-bundle PCL reconstruction. LEVEL OF EVIDENCE: Level III, case-control study.

Allograft tissue in ACL reconstruction.

Musculoskeletal allografts are an essential component for the surgical management of orthopedic injuries. Allografts are most frequently used in the knee for anterior cruciate ligament (ACL) deficiency and less frequently for other ligament lesions, meniscal transplant, and osteochondral repair. Clinical ACL outcomes have continued to improve as techniques and instrumentation have developed. Allografts are routinely used for ACL reconstructions and although some may argue against them, others feel that not using allografts is a disservice to their patients. The increase in demand for a larger and safer supply of allografts is directly related to the growth in the number of allografts being used. Allografts are safe, reliable, and when all factors are considered, is an excellent ligament replacement solution surgeons should consider for their ACL patients.

Anterior cruciate ligament reconstruction graft harvesting: pitfalls and tips.

Surgical treatment for anterior cruciate ligament deficiency has relied predominantly on reconstruction with autografts. Grafts taken from patients' own central third of their patellar tendon, bone-patellar tendon bone, or one or more of the hamstring tendons, semitendinosus, and gracilis, constitute the majority of grafts used for these purposes. Although there is no single graft option that clearly outperforms another, an abundance of articles replete with complications associated with harvest and use are available from peer-reviewed journals. It is these complications and their prevention that will be addressed in the following chapter. The idea in mind is that the reader might adopt these techniques to improve their patient outcomes by minimizing, or eliminating, the ongoing problems that such complications produce.

Incidences of frostbite in arthroscopic knee surgery postoperative cryotherapy rehabilitation.

A retrospective study of 4 cases of frostbite was undertaken to examine causes and to identify related contributory behaviors and circumstances. These patients underwent various surgical interventions before the onset of frostbite during similar postoperative care regimens. Surgical procedures included some of the following in each patient: lateral retinacular release, vastus medialis oblique muscle advancement, partial medial meniscectomy, chondromalacia patella, trochlea, medial and lateral femoral condyle debridement, lateral retinaculum release, and excision of medial plica. The mechanism of onset, development, and sites of frostbite were uniform in all patients. In every case, the sites were located in the area on top of the patella including some adjacent regions depending on the size of each injury. Frostbite locations were correlated with the part of the cryotherapy cold cuff device located on top of the patellar region. This cuff portion was originally designed to accommodate surgical trauma induced during autogenous bone-tendon-bone graft harvest in anterior cruciate ligament reconstruction surgery. Locating cryotherapy over this region assisted in minimizing pain and effusion for patients subsequent to distal patella bone plug harvest trauma. However, the requirement for use of the pad in the patella area for patients not undergoing anterior cruciate ligament reconstruction with autograft was found to be unnecessary and was the primary cause of frostbite in the cases presented here.

Posterolateral corner reconstruction.

One should suspect a compromise of the lateral structures when presented with a posterior cruciate ligament (PCL) injury, especially if grade III laxity is present. In our experience, if a combined injury to the PCL and posterolateral corner is diagnosed, a combined PCL and posterolateral reconstruction is needed to restore stability. This article describes a posterolateral reconstruction procedure. This procedure, when used in combination with an intra-articular PCL reconstruction, restores rotary and posterior knee stability. This procedure uses allograft tissue and interference screw fixation, although autograft tissue may be used.