Autologous Matrix-Induced Chondrogenesis (AMIC) and AMIC Enhanced by Autologous Concentrated Bone Marrow Aspirate (BMAC) Allow for Stable Clinical and Functional Improvements at up to 9 Years Follow-Up: Results from a Randomized Controlled Study.

The aims of the study were to evaluate long-term outcomes after autologous matrix-induced chondrogenesis (AMIC) in the treatment of focal chondral lesions and to assess the possible improvements given by the combination of this technique with bone marrow aspirate concentrate (BMAC). Twenty-four patients (age range 18⁻55 years) affected by focal knee chondral lesions were treated with standard AMIC or AMIC enhanced by BMAC (AMIC+). Pain (Visual Analogue Scale (VAS)) and functional scores (Lysholm, International Knee Documentation Committee (IKDC), Tegner, Knee injury and Osteoarthritis Outcome Score (KOOS)) were collected pre-operatively and then at 6, 12, 24, 60, and 100 months after treatment. Magnetic resonance imaging (MRI) evaluation was performed pre-operatively and at 6, 12, and 24 months follow-ups. Patients treated with AMIC+ showed higher Lysholm scores (p = 0.015) and lower VAS (p = 0.011) in comparison with patients in the standard AMIC group at the 12 months follow-up. Both treatments allowed for functional and pain improvements with respect to pre-operative levels lasting up to 100 months. MRI revealed consistent cartilage repair at 24 months in both groups. This study shows that AMIC and AMIC+ are effective treatments for focal chondral lesions with beneficial effect lasting up to 9 years. AMIC+ allows for faster recovery from injury, and is thus more indicated for patients requiring a prompt return to activity. Level of evidence: II, randomized controlled trial in an explorative cohort.

Italian consensus statement for the use of allografts in ACL reconstructive surgery.

PURPOSE: Graft choice for primary anterior cruciate ligament reconstruction (ACL-R) is debated, with considerable controversy and variability among surgeons. Autograft tendons are actually the most used grafts for primary surgery; however, allografts have been used in greater frequency for both primary and revision ACL surgery over the past decade. Given the great debate on the use of allografts in ACL-R, the "Allografts for Anterior Cruciate Ligament Reconstruction" consensus statement was developed among orthopedic surgeons and members of SIGASCOT (Società Italiana del Ginocchio, Artroscopia, Sport, Cartilagine, Tecnologie Ortopediche), with extensive experience in ACL-R, to investigate their habits in the use of allograft in different clinical situations. The results of this consensus statement will serve as benchmark information for future research and will help surgeons to facilitate the clinical decision making. METHODS: In March 2017, a formal consensus process was developed using a modified Delphi technique method, involving a steering group (9 participants), a rating group (28 participants) and a peer-review group (31 participants). Nine statements were generated and then debated during a SIGASCOT consensus meeting. A manuscript has been then developed to report methodology and results of the consensus process and finally approved by all steering group members. RESULTS: A different level of consensus has been reached among the topics selected. Strong agreement has been reported in considering harvesting, treatment and conservation methods relevant for clinical results, and in considering biological integration longer in allograft compared to autograft. Relative agreement has been reported in using allograft as the first-line graft for revision ACL-R, in considering biological integration a crucial aspect for rehabilitation protocol set-up, and in recommending a delayed return to sport when using allograft. Relative disagreement has been reported in using allograft as the first-line graft for primary ACL-R in patients over 50, and in not considering clinical results of allograft superior to autograft. Strong disagreement has been reported in using allograft as the first-line graft for primary ACL-R and for skeletally immature patients. CONCLUSIONS: Results of this consensus do not represent a guideline for surgeons, but could be used as starting point for an international discussion on use of allografts in ACL-R. LEVEL OF EVIDENCE: IV, consensus of experts.

Combined chronic anterior cruciate ligament and posterior cruciate ligament reconstruction: functional and clinical results.

PURPOSE: Multiligamentous injury to the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) is an uncommon but debilitating event. Patients with combined ligament injuries typically complain of painful, debilitating knee instability that restricts their sports and daily activities. The purpose of this retrospective study was to evaluate functional and clinical outcomes of patients with chronic ACL and PCL deficiency who underwent simultaneous single-stage arthroscopic reconstruction of the central pivot. METHODS: Medical records of 20 consecutive patients with chronic ACL and PCL deficiency who underwent simultaneous single-stage arthroscopic reconstruction of the central pivot were retrospectively reviewed. All patients had received either an allograft (group A) or a semitendinosus-gracilis graft for ACL repair and a bone-patellar tibial-bone graft for PCL repair (group B). Functional outcomes, after the initial follow-up period at 24-month FU, were assessed with concentric isokinetic knee extensor-flexor testing at 60 and 180°/s. The secondary aim was to compare long-term clinical recovery by the administration of the IKDC (International Knee Document Committee) Knee Ligament Evaluation Form, the Lysholm Knee Scoring Scale and the Cincinnati Knee Rating Scale. RESULTS: The mean per cent quadriceps strength deficit in the operated as compared to the healthy knee was 13.5 % in group A and 15 % in group B (angular velocity 60°/s) and 13.5 % in group A and 9.4 % in group B (angular velocity 180°/s). The mean per cent flexor strength deficit in the operated as compared to the healthy knee was 10.4 % in group A and 12.3 % in group B (angular velocity 60°/s) and 12.2 % in group A and 9 % in group B (angular velocity of 180°/s). The flexor-quadriceps ratio was 49.4 % in group A and 48.8 % in group B in the healthy knee and 53.2 % in group A and 53.8 % in group B in the operated knee (angular velocity 60°/s) and 63.9 % in group A and 60.7 % in group B in the healthy knee and 65 % in group A and 64.9 % in group B in the operated knee (angular velocity 180°/s). Lysholm outcome was 93.9 ± 3.9 in group A and 89.1 ± 7.6 in group B (n.s). Cincinnati score was 89.6 ± 7.3 in group A and 91.0 ± 6.9 in group B (p = 0.791). IKDC results were group A in six patients (60 %), group B in three patients (30 %) and group C in one patient (10 %) in the allograft group and group A in seven patients (70 %) and group B in three patients (30 %) for autologous group. CONCLUSIONS: The results of this study suggest that one-stage arthroscopic bicruciate ligament reconstruction can restore good knee joint function. Surgical treatment should be followed by a comprehensive rehabilitation programme with specific goals, objectives and strategies, including pain management and assessment of progress in recovery of joint function and perception of knee stability. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Reducing muscle injuries and reinjuries in one italian professional male soccer team.

BACKGROUND: The incidence rate of muscle injuries and re-injuries in professional elite soccer players actually is very high and may interfere with the fate of a championship. PURPOSE: To investigate the effect of a two-tiered injury prevention programme on first injury and re-injury incidence in top level male soccer players. Study design. CASE SERIES STUDY: Muscle injuries and re-injuries sustained by a group of 36 soccer player of an italian elite soccer team have been collected during 2010-2011 season. These data have been compared with those collected during the previous season in the same elite soccer team. RESULTS: A total of 64 injuries occurred, 36 (56%) of which during practice and 28 (44%) during matches. Muscle injuries accounted for 31.3% of the total (n=20), 70% (n=14) of which occurred during practice and 30% (n=6) during matches. Hamstring were the muscles most often injured (n=11) In all, 3 re-injuries occurred (15% of muscle injuries). No early re-injuries occurred. The incidence was 2.5 injuries/1000 hours and the burden was 37 days absence/1000 hours. CONCLUSIONS: Through the implementation of a group and personalized injury prevention program, we were able to reduce the total number of muscle injuries and days absent because of injury, in a team of elite soccer players, as compared to the previous season. Specifically, muscle injuries accounted for 31% of all injuries, as compared to 59% of all injuries sustained by the team during the previous season. The number of injuries/1000 hours of exposure was reduced by half (from 5.6 to 2.5) and the days absent/1000 hours fell from 106 to 37.

Distal realignment and patellar autologous chondrocyte implantation: mid-term results in a selected population.

The aim of this prospective observational study was to assess the 3-year clinical outcome of distal realignment and membrane-seeded autologous chondrocyte implantation (MACI) in selected patients with patellofemoral malalignment and large, isolated, patellar cartilage lesions. Twelve patients (14 knees; 6 females, 6 males; mean age 31 years) with Fulkerson type II patellofemoral malalignment (lateralized and tilted patella) and Outerbridge grade III-IV isolated patellar cartilage lesions were treated. All had tibial tuberosity and trochlear sulcus >20 mm on a preoperative CT scan and a cartilage defect >3 cm2. Patients with Outerbridge grade III-IV trochlear cartilage lesions, those with rheumatic, infective or neoplastic conditions, or ligament instability, diabetes or obesity and those aged >40 years were excluded. Follow-up was at 36 months. Patients were enrolled after diagnostic arthroscopy. Cartilage was harvested and sent for culture. After a mean period of 30 days (range 25-40) patients underwent transfer of the tibial tuberosity according to Fulkerson associated with a MACI procedure. Clinical assessment was performed with the Kujala, Lysholm, Tegner and Modified Cincinnati scores. The Patient Satisfaction Survey was administered at 36 months. Consistently improved knee function and activity levels were reflected by significantly increased Kujala, Lysholm, Tegner and Modified Cincinnati scores at 36 months. The significant clinical improvement support the value of associating distal realignment and autologous chondrocyte implantation in treating large, isolated, patellar cartilage lesions associated with patellofemoral malalignment.

Revision anterior cruciate ligament reconstruction: causes of failure, surgical technique, and clinical results.

BACKGROUND: Revision of an anterior cruciate ligament reconstruction is a complicated and delicate clinical procedure whose results, theoretically, are less satisfactory than those of the first operation. HYPOTHESIS: The outcome of a revised anterior cruciate ligament surgery is comparable to primary anterior cruciate ligament reconstruction, with a rate of success around 70% to 80%. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 66 revisions of anterior cruciate ligament reconstructions were carried out from September 2000 to September 2004. Patients with concomitant instability and those with alterations in the weightbearing axis of the lower limbs were not included. Sixty patients were followed from 24 to 72 months: 50 clinically and 10 by a phone interview. Six patients were lost to follow-up due to changes of address. RESULTS: Lysholm scores were 57% excellent (95-100 points), 13% good (84-94 points), 22% fair (63-83 points), and 8% poor (<64 points). A total of 68% of patients had negative Lachman tests, 20% had positive tests with a hard end point, 10% had positive results, and 2% had very positive results. Stabilometric evaluation with the KT-1000 arthrometer at the maximum load showed that 56% of patients had <3 mm side-to-side difference, 34% had between 3 and 5 mm, and 10% had 6 to 10 mm. The International Knee Documentation Committee scores were 36% excellent (class A), 46% good (class B), and 18% fair (class C). The percentage of patients who resumed sport at the same level was 78%, compared with 58% after their primary reconstruction. CONCLUSION: The results of these anterior cruciate ligament reconstruction revision surgeries are close to those achieved by other series of primary reconstructions with a little less satisfactory results. We attribute the high success rate to the strict application of the same technique and the confinement of revision to motivated patients. It should be noted, however, that follow-up is only at the midterm stage (mean, 41.9 months).