Free Hand Drilling Technique to Enhance Central Position of Tunnels in Arthroscopic Acromioclavicular Joint Fixation Using TightRope System.

Acromioclavicular joint (ACJ) dislocations represent one of the most common lesions in the shoulder. Arthroscopic reduction and ACJ fixation with the button system is one of the most used techniques for displaced and unstable dislocations. Difficulties with placing the tunnels in the central and correct position of the clavicular and coracoid can occur with the use of a guide, which can result in fractures, eccentric tunnel position, cortical rupture, prolongation of surgical times with its complications as bleeding, tissue infiltration, difficult visualization, and increased risk of infection. Prior free hand central tunnel placement in the clavicle with a 3.2 mm drill helps to keep in place the pin guide over the superior cortical of coracoid with reduction of guide movement to enhance the correct position of tunnel in the coracoid process avoiding bone complications.

Anterior Tibial Tendon Side-to-Side Tenorrhaphy after Posterior Tibial Tendon Transfer: A Technique to Improve Reliability in Drop Foot after Common Peroneal Nerve Injury.

Common peroneal nerve injury is present in 40% of knee dislocations, and foot drop is the principal complication. Posterior tibial tendon transfer is a viable solution to replace the function of the anterior tibial tendon (ATT) in the mid-foot. Several techniques for posterior tibial tendon transfer exist today, with variable results reported. However, adding augmentation with side-to-side tenorrhaphy of ATT to the transferred posterior tibial tendon (PTT) enhances anterior tissue balance and load sharing stress between native ATT enthesis and PTT tenodesis, allowing early rehabilitation and improving functional outcomes. Side-to-side tenorrhaphy is performed after PTT tenodesis in the lateral cuneiform to improve reliability in foot drop. This technique allows shorter immobilization time (from 6 to 2 weeks), earlier rehabilitation, sooner weight-bearing, and decreased risk of arthrofibrosis, scar formation, and muscle atrophy.

Arthroscopic Matrix-Assisted Autologous Chondrocyte Transplantation Versus Microfracture: A 6-Year Follow-up of a Prospective Randomized Trial.

BACKGROUND: Few randomized controlled trials with a midterm follow-up have compared matrix-assisted autologous chondrocyte transplantation (MACT) with microfracture (MFx) for knee cartilage lesions. PURPOSE: To compare the structural, clinical, and safety outcomes at midterm follow-up of MACT versus MFx for treating symptomatic knee cartilage lesions. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 48 patients aged between 18 and 50 years, with 1- to 4-cm2 International Cartilage Repair Society (ICRS) grade III to IV knee chondral lesions, were randomized in a 1:1 ratio to the MACT and MFx treatment groups. A sequential prospective evaluation was performed using magnetic resonance imaging (MRI) T2 mapping, the MOCART (magnetic resonance observation of cartilage repair tissue) score, second-look arthroscopic surgery, patient-reported outcome measures, the responder rate (based on achieving the minimal clinically important difference for the Knee injury and Osteoarthritis Outcome Score [KOOS] pain and KOOS Sport/Recreation), adverse events, and treatment failure (defined as a reoperation because of symptoms caused by the primary defect and the detachment or absence of >50% of the repaired tissue during revision surgery). RESULTS: Overall, 35 patients (18 MACT and 17 MFx) with a mean chondral lesion size of 1.8 ± 0.8 cm2 (range, 1-4 cm2) were followed up to a mean of 6 years postoperatively (range, 4-9 years). MACT demonstrated significantly better structural outcomes than MFx at 1 to 6 years postoperatively. At final follow-up, the MRI T2 mapping values of the repaired tissue were 37.7 ± 8.5 ms for MACT versus 46.4 ± 8.5 ms for MFx (P = .003), while the MOCART scores were 59.4 ± 17.3 and 42.4 ± 16.3, respectively (P = .006). More than 50% defect filling was seen in 95% of patients at 2 years and 82% at 6 years in the MACT group and in 67% at 2 years and 53% at 6 years in the MFx group. The second-look ICRS scores at 1 year were 10.7 ± 1.3 for MACT and 9.0 ± 1.8 for MFx (P = .001). Both groups showed significant clinical improvements at 6 years postoperatively compared with their preoperative status. Significant differences favoring the MACT group were observed at 2 years on the KOOS Activities of Daily Living (P = .043), at 4 years on all KOOS subscales (except Symptoms; P < .05) and the Tegner scale (P = .008), and at 6 years on the Tegner scale (P = .010). The responder rates at 6 years were 53% and 77% for MFx and MACT, respectively. There were no reported treatment failures after MACT; the failure rate was 8.3% in the MFx group. Neither group had serious adverse events related to treatment. CONCLUSION: Patients who underwent MACT had better structural outcomes than those who underwent MFx at 1 to 6 years postoperatively. Both groups of patients showed significant clinical improvements at final follow-up compared with their preoperative status. MACT showed superiority at 4 years for the majority of the KOOS subscales and for the Tegner scale at 4 to 6 years. The MACT group also had a higher responder rate and lower failure rate at final follow-up. REGISTRATION: NCT01947374 (ClinicalTrials.gov identifier).

Arthroscopic Treatment of Patellar and Trochlear Cartilage Lesions with Matrix Encapsulated Chondrocyte Implantation versus Microfracture: Quantitative Assessment with MRI T2-Mapping and MOCART at 4-Year Follow-up.

METHODS: Seventeen patients aged 18 to 55 years with symptomatic full-thickness cartilage lesions on either patella or trochlea were treated with matrix autologous chondrocyte implantation (MACI) or microfracture (MF). Both procedures combined with unloading/realigning techniques. Clinical assessment and T2-mapping were evaluated at 48-months. RESULTS: Clinically results from pre-op to 48-months improved significantly in MACI and MF for Lysholm (p = 0.001, p = 0.001), IKDC-S (p = 0.001, p = 0.002), KOOS-P (p = 0.000, p = 0.002), KOOS-DLA (p = 0.002, p = 0.003), KOOS-Sports/Rec (p = 0.000, p = 0.004), KOOS-QoL (p = 0.000, p = 0.003), KOOS-symptoms (p = 0.001, p = 0.020), and Kujala (p = 0.000, p = 0.01), respectively. Tegner was significant between baseline and 48 months only for MACI (p < 0.008) compared with MF (p = 0.25). No significant difference was observed between groups for any score at 3, 12, 24, and 48-months (p > 0.05). T2-mapping values improved significantly over time in MACI compared with MF at 24 months (39.35 vs. 50.44, p = 0.007) and 48 months (36.54 vs. 48.37, p = 0.005). When comparing control values to MACI at 12-m (p = 0.714), 24-m (p = 0.175), and 48-m (p = 0.097), no significant difference was found. MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) score comparison gave no statistical difference between groups. CONCLUSIONS: Clinically both techniques improved significantly over time. However, quantitative assessment showed that only newly formed tissue with MACI technique improves significantly since 12-months and maintains stable values compared with native cartilage until 48-month follow-up. MF results were never comparable to those native values. Level of evidence II.

Arthroscopic Matrix-Encapsulated Autologous Chondrocyte Implantation: A Pilot Multicenter Investigation in Latin America.

Objective. To evaluate minimum biosecurity parameters (MBP) for arthroscopic matrix-encapsulated autologous chondrocyte implantation (AMECI) based on patients' clinical outcomes, magnetic resonance imaging (MRI) T2-mapping, Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score, and International Cartilage Repair Society (ICRS) second-look arthroscopic evaluation, laying the basis for a future multicenter study. Design. Pilot clinical study. We analyzed the logistics to perform AMECI to treat focal chondral lesions in different hospitals following strict biosecurity parameters related to tissue and construct transportation, chondrocyte isolation, and cell expansion. Patient progress was analyzed with patient-reported outcome measures, MRI T2-mapping, MOCART, and ICRS arthroscopic second-look evaluation. Results. Thirty-five lesions in 30 patients treated in 7 different hospitals were evaluated. Cell viability before implantation was >90%. Cell viability in construct remnants was 87% ± 11% at 24 hours, 75% ± 17.1% at 48 hours, and 60% ± 8% at 72 hours after implantation. Mean final follow-up was 37 months (12-72 months). Patients showed statistically significant improvement in all clinical scores and MOCART evaluations. MRI T2-mapping evaluation showed significant decrease in relaxation time from 61.2 ± 14.3 to 42.9 ± 7.2 ms (P < 0.05). Arthroscopic second-look evaluation showed grade II "near normal" tissue in 83% of patients. Two treatment failures were documented. Conclusions. It was feasible to perform AMECI in 7 different institutions in a large metropolitan area following our biosecurity measures without any implant-related complication. Treated patients showed improvement in clinical, MRI T2-mapping, and MOCART scores, as well as a low failure rate and a favorable ICRS arthroscopic evaluation at a mid-term follow-up. Level of Evidence. 2b.

First Clinical Application of Polyurethane Meniscal Scaffolds with Mesenchymal Stem Cells and Assessment of Cartilage Quality with T2 Mapping at 12 Months.

BACKGROUND: Complex meniscal lesions often require meniscectomy with favorable results in the short term but a high risk of early osteoarthritis subsequently. Partial meniscectomy treated with meniscal substitutes may delay articular cartilage degeneration. PURPOSE: To evaluate the status of articular cartilage by T2 mapping after meniscal substitution with polyurethane scaffolds enriched with mesenchymal stem cells (MSC) and comparison with acellular scaffolds at 12 months. METHODS: Seventeen patients (18-50 years) with past meniscectomies were enrolled in 2 groups: (1) acellular polyurethane scaffold (APS) or (2) polyurethane scaffold enriched with MSC (MPS). Patients in the MPS group received filgrastim to stimulate MSC production, and CD90+ cells were obtained and cultured in the polyurethane scaffold. The scaffolds were implanted arthroscopically into partial meniscus defects. Concomitant injuries (articular cartilage lesions or cartilage lesions) were treated during the same procedure. Changes in the quality of articular cartilage were evaluated with T2 mapping in femur and tibia at 12 months. RESULTS: In tibial T2 mapping, values for the MPS group increased slightly at 9 months but returned to initial values at 12 months (P > 0.05). In the APS group, a clear decrease from 3 months to 12 months was observed (P > 0.05). This difference tended to be significantly lower in the APS group compared with the MPS group at the final time point (P = 0.18). In the femur, a slight increase in the MPS group (47.8 ± 3.4) compared with the APS group (45.3 ± 4.9) was observed (P > 0.05). CONCLUSION: Meniscal substitution with polyurethane scaffold maintains normal T2 mapping values in adjacent cartilage at 12 months. The addition of MSC did not show any advantage in the protection of articular cartilage over acellular scaffolds (P > 0.05).

Anatomic Considerations in Hamstring Tendon Harvesting for Ligament Reconstruction.

Hamstring tendon autograft remains a popular graft choice for anterior cruciate ligament reconstruction. Although the technique of hamstring autograft harvest is relatively straightforward, it is critical to pay attention to several technical steps to avoid iatrogenic anatomic or neurovascular damage as well as to reduce the risk of premature amputation of the graft when using a tendon stripper. We describe a technique of hamstring autograft harvesting using only 2 anatomic references that makes it a simple and reproducible technique for surgeons, especially those in training.

Resultados en la reconstrucción del ligamento cruzado anterior con el injerto rotuliano hueso-tendon-hueso. Seguimiento a dos años / Results of reconstruction of anterior cruciate ligament by bone tendon bone patellar grafting. A two year follow up

Se desarrolló el presente trabajo con el objetivo de evaluar los resultados, a dos años de la reconstrucción del ligamento cruzado anterior (LCA) con el injerto rotuliano hueso-tendón-hueso. El presente estudio incluyó a 37 pacientes con lesión del LCA que se sometieron a reconstrucción con técnica artroscópica utilizando injerto autólogo del tendón patelar, hueso-tendón-hueso. Se les realizó una evaluación pre y postoperatoria clínica, radiográfica y funcional de acuerdo a las escalas de valoración de Lysholm y del IKDC. Se observó mejoría funcional en 36 de los pacientes estudiados retornando a sus actividades previas a la lesión, la inestabilidad disminuyó en todos los pacientes al menos 1 grado y en algunos ésta desapareció. Como complicaciones 3 pacientes refirieron dolor en la zona donadora del injerto y 2 más presentaron intolerancia al material por lo que se retiraron los tornillos sin afectar el resultado final. Se concluye que se obtuvo un 94.5 por ciento de resultados excelentes y buenos, proporcionando adecuada estabilidad, excelente función de la rodilla y con mínimos o nulos cambios radiográficos postoperatorios.