Postoperative Management for Articular Cartilage Surgery in the Knee.

The postoperative rehabilitation team plays a crucial role in optimizing outcomes after articular cartilage surgery. A comprehensive approach to postoperative physical therapy that considers the type of surgery, location in the knee, concurrent procedures, and patient-specific factors is imperative. While postoperative rehabilitation protocols should be specific to the patient and type of surgery performed and include phased rehabilitation goals and activities, the key principles for postoperative rehabilitation apply across the spectrum of articular cartilage surgeries and patients. These key principles consist of preoperative assessments that include physical, mental, and behavioral components critical to recovery; education and counseling with respect to expectations and compliance; and careful monitoring and adjustments throughout the rehabilitation period based on consistent communication among rehabilitation, surgical, and imaging teams to ensure strict patient compliance with restrictions, activities, and timelines to optimize functional outcomes after surgery.

Tratamento de queimaduras de segundo grau profundo em abdômen, coxas e genitália: uso da pele de tilápia como um xenoenxerto / Treatment of deep second-degree burns on the abdomen, thighs, and genitalia: use of tilapia skin as a xenograft

A pele de tilápia possui microbiota não infecciosa e estrutura morfológica semelhante à pele humana. Estudos clínicos fase II, ainda não publicados, mostraram resultados promissores na sua utilização para tratamento de queimaduras. Nos protocolos destes estudos, pacientes com lesões em áreas de dobras de pele, como genitais e região inguinal, foram excluídos, pois achava-se que o biomaterial não aderiria apropriadamente, resultando em um grau de cicatrização inferior. Relato de caso de paciente do sexo feminino, 18 anos, sem comorbidades, com queimaduras de segundo grau profundo em abdômen, região inguinal, parte da genitália e metade superior de ambas as coxas, envolvendo 13,5% da área total da superfície corporal. A pele de tilápia foi aplicada nas lesões levando a uma reepitelização completa com 16 dias de tratamento. Não foram observados efeitos colaterais. A pele de tilápia traz, portanto, a promessa de um produto inovador, de fácil aplicação e alta disponibilidade, que pode se tornar a primeira pele animal nacionalmente estudada e registrada pela Agência Nacional de Vigilância Sanitária, para uso no tratamento de queimaduras. Este relato de caso contribui para reduzir as limitações em relação às áreas anatômicas apropriadas para a aplicação da pele de tilápia, uma vez que, mesmo com a necessidade de reposição de pele, foram obtidos bons resultados com aplicação na genitália e região inguinal.

Tilapia skin has a non-infectious microbiota and a morphological structure similar to human skin. Phase II clinical studies, not yet published, have shown promising results in their use for the treatment of burns. In the protocols of these studies, patients with lesions in areas of skin folds, such as genitals and inguinal regions, were excluded, as it was thought that the biomaterial would not adhere properly, resulting in a lower degree of healing. Case report of a female patient, 18 years old, without comorbidities, with deep second-degree burns in the abdomen, inguinal region, part of the genitalia and upper half of both thighs, involving 13.5% of the total body surface area. Tilapia skin was applied to the lesions leading to a complete re-epithelialization with 16 days of treatment. No side effects were observed. Tilapia skin, therefore, brings the promise of an innovative product, easy to apply, and highly available, which can become the first animal skin nationally studied and registered by the Agência Nacional de Vigilância Sanitária, for use in the treatment of burns. This case report contributes to reduce the limitations concerning the anatomical areas appropriate for the application of tilapia skin, since, even with the need for skin replacement, good results were obtained with application to the genitalia and inguinal region.

Implications for Early Postoperative Care After Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction: A Technical Note.

The quadriceps tendon (QT) has become increasingly used by orthopaedic surgeons as an alternative autograft choice in anterior cruciate ligament reconstruction. As its use increases, athletic trainers and other rehabilitation clinicians will treat a greater number of patients with this autograft type. The recently developed, minimally invasive technique for harvest of the all-soft tissue autograft has many benefits, including versatility, decreased donor-site morbidity, and enhanced cosmesis. Early clinical trials revealed that the QT autograft resulted in decreased anterior knee pain and similar strength and functional outcomes to those of more common autograft types. From a rehabilitation perspective, many characteristics should be considered, such as the importance of early knee extension and quadriceps activation. Therefore, the purpose of this technical note is to expose athletic trainers to the QT autograft so that they may provide the best care for patients after anterior cruciate ligament reconstruction.

Short term clinical results of single bundle ACL reconstruction, with a quadruple autologous hamstring graft, modified transtibial versus anteriomedial portal approach for femoral tunnel

Anteriior cruciate ligament injuries are known to be the most common spots injuries, and ACL reconstruction is widely used because of the low success rate of convservative treatment. This study was aimed to compare the short-terma functional results of modifying transtibial and transportal technique for femoral tunnel drilling. This Retrospective comparative case control study included 76 patients with an isolated ACL tear, operated with ST tendon autograft ACL reconstruction by the same surgical tea. 36 patients operated with a modified transtibial approach and 40 patients with an antreomedial approach for femoral drilling. The results of the current study revealed that the mean age in the series was 26 years; the majority of patients were male, only 6 patient's asses again after two years of surgery, by instability tests and lysholm scores reveal no significant differences between two group regarding anterioposterior and rotatory instability, also comparable lysholm score results. The Study concluded that modified transtibial femoral drilling of the femoral tunnel in ACL reconstruction surgery is still useful and give comparable results as tranportal drilling (AU)

How Does Autologous Breast Reconstruction Impact Downtime?

BACKGROUND: Although autologous breast reconstruction is technically quite demanding, it offers the best outcomes in terms of durable results, patient perceptions, and postoperative pain. Many studies have focused on clinical outcomes and technical aspects of such procedures, but few have addressed the impact of various flaps on patient recovery times. This particular investigation entailed an assessment of commonly used flaps, examining the periods of time required to resume daily activities. METHODS: Multiple choice questionnaires were administered to 121 patients after recovery from autologous reconstruction to determine the times required in returning to specific physical activities. To analyze results, the analysis of variance F-test was applied, and odds ratios (ORs) were determined. RESULTS: Among the activities surveyed, recovery time was not always a function of free-flap surgery. Additional treatments and psychological effects also contributed. Adjuvant chemotherapy increased average downtime by 2 weeks, and postoperative irradiation prolonged recovery as much as 4 weeks. Patient downtime was unrelated to flap type, ranging from 2.9 to 21.3 weeks for various activities in question. Deep inferior epigastric perforator (DIEP) flaps yielded the highest OR and transverse upper gracilis (TUG) flaps the lowest. CONCLUSION: Compared with superior gluteal artery perforator and TUG flaps, the DIEP flap was confirmed as the gold standard in autologous breast reconstruction, conferring the shortest recovery times. All adjuvant therapies served to prolong patient recovery as well. Surgical issues, patient lifestyles, and donor-site availability are other important aspects of flap selection.

Is it feasible to conduct a randomised controlled trial of pretransplant exercise (prehabilitation) for patients with multiple myeloma awaiting autologous haematopoietic stem cell transplantation? Protocol for the PREeMPT study.

INTRODUCTION: While myeloma is an incurable malignancy, developments in disease management have led to increased life expectancy in recent years. Treatment typically involves stem-cell transplantation. Increased survival rates equate to more patients living with the burden of both the disease and its treatment for increasing number of years, rendering myeloma a long-term condition.Evidence exists to demonstrate the benefits of exercise for patients recovering from stem-cell transplantation, and prehabilitation-exercise before treatment-has been shown to be effective in other disease areas. To date there has been no research into prehabilitation in patients with myeloma awaiting transplantation treatment.Our objective is to determine whether it is feasible to conduct a randomised controlled trial into pretransplant exercise for patients with multiple myeloma who are awaiting autologous stem-cell transplantation. METHODS AND ANALYSIS: This mixed methods study identifies patients with diagnosis of multiple myeloma who have been assigned to the autologous transplantation list and invites them to participate in six weekly sessions of individualised, supervised exercise while awaiting transplantation.Quantitative data to determine feasibility targets include rates of recruitment, adherence and adverse events, and outcome measures including 6 min walking distance test and quality of life.Qualitative interviews are undertaken with a purposive sample of patients to capture their experiences of the study and the intervention. ETHICS AND DISSEMINATION: Ethics committee approval has been obtained. Dissemination will be through open-access publications and presentations and will seek to reach multiprofessional bases as well as patients and carer groups, addressing the widespread interest in this area of research. TRIAL REGISTRATION NUMBER: NCT03135925; Pre-results.

Curativos tópicos para áreas doadoras de enxertos de pele parcial: é possível estabelecer o mais adequado com base em uma revisão da literatura? / Split-thickness skin graft donor-site dressings: is it possible to establish the ideal dressing based on a literature review?

O objetivo deste estudo foi verificar, por meio de uma revisão da literatura, a possibilidade de se estabelecer, com base em evidências científicas, o curativo tópico mais adequado para a aplicação em áreas doadoras em enxertos de pele parcial. Foram analisados os mais relevantes estudos publicados originalmente nos últimos sete anos, em qualquer idioma, porém, que estivessem indexados às bases de dados US National Library of Medicine (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL) e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). As buscas foram realizadas por meio do uso de descritores associados ao tema e de critérios de inclusão e exclusão. A amostra final deste estudo foi composta por 25 publicações, sendo uma nacional e 24 internacionais. Com base nos achados, constatou-se que há uma lacuna na literatura acerca de estudos que visam analisar os diferentes tipos de curativos usados em áreas doadoras em enxertos de pele parcial. Por meio da revisão da literatura realizada, pode-se concluir que não é possível se estabelecer o curativo mais adequado para uso em áreas doadoras de enxertos de pele parcial, devido à falta de evidências científicas que possibilitem um achado conclusivo acerca do tema.

This study aimed to assess the possibility of establishing the most suitable split-thickness skin graft donor site dressings on the basis of scientific evidence gathered through a literature review. The most relevant studies originally published in any language in the last 7 years and indexed in the US National Library of Medicine (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), and Latin American and Caribbean Literature Health Sciences (LILACS) databases were evaluated. A literature survey was performed using keywords related to the theme and inclusion and exclusion criteria. The final sample comprised 25 publications, one domestic and 24 international. The results showed a gap in the literature with respect to studies that evaluated different split-thickness skin graft donor site dressings. The literature review revealed the impossibility of establishing the most effective split-thickness skin graft donor site dressing due to the lack of scientific evidence, thus preventing the formulation of a definite conclusion on this topic.

A Comparison of 2-Year Outcomes in Patients Undergoing Tibiofemoral or Patellofemoral Matrix-Induced Autologous Chondrocyte Implantation.

BACKGROUND: Matrix-induced autologous chondrocyte implantation (MACI) has demonstrated encouraging clinical results in the treatment of knee chondral defects. However, earlier studies suggested that chondrocyte implantation in the patellofemoral (PF) joint was less effective than in the tibiofemoral (TF) joint. PURPOSE: To compare the radiological and clinical outcomes of those undergoing MACI to either the femoral condyles or PF joint. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 194 patients were included in this analysis, including 127 undergoing MACI to the medial (n = 94) and lateral (n = 33) femoral condyle, as well as 67 to the patella (n = 35) or trochlea (n = 32). All patients were evaluated clinically (Knee injury and Osteoarthritis Outcome Score [KOOS], visual analog scale, Short Form-36) before surgery and at 3, 12, and 24 months after surgery, while magnetic resonance imaging (MRI) was undertaken at 3, 12, and 24 months, with the MOCART (magnetic resonance observation of cartilage repair tissue) scoring system employed to evaluate the quality and quantity of repair tissue, as well as an MRI composite score. Patient satisfaction was evaluated. RESULTS: No significant group differences ( P > .05) were seen in demographics, defect size, prior injury, or surgical history, while the majority of clinical scores were similar preoperatively. All clinical scores significantly improved over time ( P < .05), with a significant group effect observed for KOOS activities of daily living ( P = .008), quality of life ( P = .008), and sport ( P = .017), reflecting better postoperative scores in the TF group. While the PF group had significantly lower values at baseline for the KOOS activities of daily living and quality of life subscales, it actually displayed a similar net improvement over time compared with the TF group. At 24 months, 93.7% (n = 119) and 91.0% (n = 61) of patients were satisfied with the ability of MACI to relieve their knee pain, 74.0% (n = 94) and 65.7% (n = 44) with their ability to participate in sport, and 90.5% (n = 115) and 83.6% (n = 56) satisfied overall, in the TF and PF groups, respectively. MRI evaluation via the MOCART score revealed a significant time effect ( P < .05) for the MRI composite score and graft infill over the 24-month period. While subchondral lamina scored significantly better ( P = .002) in the TF group, subchondral bone scored significantly worse ( P < .001). At 24 months, the overall MRI composite score was classified as good/excellent in 98 TF patients (77%) and 54 PF patients (81%). CONCLUSION: MACI in the PF joint with concurrent correction of PF maltracking if required leads to similar clinical and radiological outcomes compared with MACI on the femoral condyles.

A randomized controlled trial demonstrating sustained benefit of Autologous Matrix-Induced Chondrogenesis over microfracture at five years.

PURPOSE: Autologous Matrix-Induced Chondrogenesis (AMIC®) utilizing a type I/III collagen membrane was compared with microfracture (MFx) alone in focal cartilage lesions of the knee at one, two and five years. METHODS: Forty-seven patients (aged 37 ± 10 years, mean defect size 3.6 ± 1.6 cm2) were randomized and treated either with MFx, with sutured or glued AMIC® in a prospective multicentre clinical trial. RESULTS: After improvement for the first two years in all subgroups, a progressive and significant score degradation was observed in the MFx group, while all functional parameters remained stable for least five years in the AMIC® groups. At two and five years, MRI defect filling was more complete in the AMIC® groups. No treatment-related adverse events were reported. CONCLUSIONS: AMIC® is an effective cartilage repair procedure in the knee resulting in stable clinical results significantly better than the MFx group at five years.

Role of the autologous mesenchymal stem cells compared with platelet rich plasma on cicatrization of cutaneous wounds in diabetic mice / Papel das células-tronco mesenquimais autólogas em comparação com plasma rico em plaquetas na cicatrização de feridas cutâneas em camundongos diabéticos

Chronic cutaneous lesions affect 15% of diabetic human patients and represent a risk 15 to 46 times larger of limb amputations compared to people with normal glycemia. It is assumed that half of these amputations could be prevented by early treatment of wounds, for example, with proper cell therapy. Objectives: In this study, the action of the autologous transplant of mesenchymal stem-cells (MSC) was evaluated compared to the treatment with autologous platelet rich plasma (PRP) in the cicatrization of cutaneous lesions induced in diabetic mice. These animals were previously treated with streptozootocin to induce diabetes mellitus and round wounds of 1.5cm in diameter were created in the posterior region. Diameters of the wounds and healing time were evaluated during 30 days and the results were submitted to variance analysis and Tukey's test average. It was noticed that the animals treated with MSC presented a more accelerated cicatrization of the cutaneous lesion than the animals treated with PRP. However, the treatment with PRP presented better results than just the daily asepsis of the lesions with saline or covering them with semi-permeable bandage. Besides, the use of semi-permeable bandage kept the cutaneous lesions of diabetic mice did not interfere negatively with cicatrization, proved to be harmless to use, but kept the cutaneous lesions more hydrated than the ones exposed to the environment.(AU)

Lesões cutâneas crônicas afetam 15% dos pacientes diabéticos e humanos representam um risco 15 a 46 vezes maior de amputações de membros em comparação com as pessoas com a glicemia normal. Supõe-se que a metade destas amputações poderia ser evitada por meio do tratamento precoce das feridas cutâneas com, por exemplo, uma adequada terapia celular. Objetivos: Neste estudo, a ação do transplante autólogo de células estaminais mesenquimais (MSC) foi avaliada em comparação com o tratamento com plasma rico em plaquetas autólogo (PRP) na cicatrização de lesões cutâneas induzidas em camundongos diabéticos. Estes animais foram previamente tratados com estreptozotocina para induzir diabetes mellitus e feridas redondas de 1,5 cm de diâmetro foram criadas na região posterior. Os diâmetros dos ferimentos e tempo de cicatrização foram avaliados durante 30 dias e os resultados foram submetidos à análise de variância e média pelo teste de Tukey. Verificou-se que os animais tratados com MSC apresentam uma cicatrização mais acelerada da lesão cutânea que do que os animais tratados com PRP. No entanto, o tratamento com PRP apresentou melhores resultados do que apenas a assepsia das lesões diariamente com solução salina ou cobrindo-os com atadura semi-permeável. Além disso, a utilização de atadura semi-permeável mantidas as lesões cutâneas de camundongos diabéticos não interfere negativamente com a cicatrização, provou ser inofensiva para usar, mas manteve as lesões cutâneas hidratadas mais do que os expostos ao meio ambiente.(AU)

Autologous Chondrocyte Implantation: Past, Present, and Future.

Focal cartilage defects of the knee are relatively common and may increase the risk of developing osteoarthritis. Autologous chondrocyte implantation (ACI) aims to restore the integrity of isolated cartilage lesions through the induction of hyaline-like cartilage formation. Although ACI has traditionally been used as a second-line treatment, recent evidence suggests that ACI should be considered as a first-line treatment option in certain patients. Recent controlled trials also suggest that there are improved clinical outcomes among those patients who undergo ACI over the mid-term and long-term compared with those treated with microfracture or osteochondral autograft/mosaicplasty, regardless of lesion size. Recent literature also indicates that arthroscopic, second-generation and third-generation techniques are associated with better outcomes and fewer complications than first-generation ACI. In summary, ACI is an effective tool for cartilage restoration that may be more efficacious and durable than other cartilage restoration techniques for appropriate candidates.

Autologous osteochondral transplantation for osteochondral lesions of the talus in an athletic population.

PURPOSE: To assess clinical outcomes and return to sport in an athletic population treated with autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus. METHODS: A total of 36 patients were included in this retrospective study including 21 professional athletes and 15 amateur athletes who participated in regular moderate- or high-impact athletic activity. All patients underwent autologous osteochondral transplantation of the talus under the care of a single surgeon. At a mean follow-up of 5.9 years, patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. All patients also received pre-operative MRI with the follow-up MRI performed at 1 year and underwent assessment of return to athletic activity. RESULTS: The overall AOFAS score improved from 65.5 (SD ± 11.1) to 89.4 (SD ± 14.4) (p = 0.01). At a final follow-up, 90% of professional athletes (19 of 21) were still competing in athletic activity or still able to participate in unrestricted activity. Of the recreational athletes, 87% (13 of 15) had full return to pre-injury activity levels, while two (13%) returned to activity with restrictions or reduced intensity. MRI showed cystic change in 33% of patients post-operatively; however, this did not appear to affect outcomes (n.s.). Donor site symptoms were seen in 11% of the cohort at final follow-up, despite high function at donor knee. CONCLUSION: The results of our study indicate that AOT procedure is able to achieve good outcomes in an athletic population at a midterm follow-up. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Relationship between quadriceps strength and patellofemoral joint chondral lesions after anterior cruciate ligament reconstruction.

BACKGROUND: The incidence of the patellofemoral joint chondral lesions after anterior cruciate ligament reconstruction (ACLR) is disturbingly high. Few studies have assessed the factors affecting patellofemoral joint chondral lesions postoperatively. HYPOTHESIS: The recovery of quadriceps strength after ACLR could be associated with patellofemoral joint cartilage damage. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 88 patients who underwent arthroscopic anatomic double-bundle ACLR with hamstring autografts received second-look arthroscopy at the time of metal staple removal at an average of 24.1 months (range, 12-51 months) postoperatively. All patients underwent standardized isokinetic strength testing for bilateral quadriceps and hamstrings 1 to 2 days before second-look arthroscopy. The patients were divided into 2 groups: Patients in group 1 had a ≥20% deficit on the peak torque measures for quadriceps compared with that of the contralateral knee, whereas those in group 2 had a <20% deficit on peak torque. Cartilage status at the patellofemoral joint and tibiofemoral joint were evaluated by second-look arthroscopy and the Outerbridge classification. Other assessments included the International Knee Documentation Committee (IKDC) score, Tegner and Lysholm scores, side-to-side difference on KT-2000 arthrometer, and range of motion. RESULTS: There were 42 patients included in group 1 and 46 patients in group 2. The mean postoperative quadriceps peak torque of the involved knee compared with the contralateral knee was 70% (range, 57%-80%) in group 1 and 95% (range, 81%-116%) in group 2. For all patients, a significant worsening was seen in the patellar and trochlear cartilage (P = .030 and <.001, respectively) but not at the medial or lateral tibiofemoral joint after ACLR. A significant worsening in the status of both patellar and trochlear cartilage was seen after ACLR in group 1 (P = .013 and =.011, respectively) and of trochlear cartilage in group 2 (P = .006). Significantly fewer severe chondral lesions of the patella were found in group 2 than in group 1 (proportion of patients whose cartilage grade worsened: 26% vs 48%, P < .05; difference in cartilage grade: 0.09 vs 0.62, P < .05). There was no significant difference for trochlear chondral worsening between the 2 groups. No significant differences were detected between the 2 groups in terms of hamstring strength; Lysholm, Tegner, and IKDC scores; KT-2000 arthrometer anterior laxity; or range of motion. CONCLUSION: Greater than 80% recovery of quadriceps strength after ACLR is associated with less severe patellar cartilage damage at short-term follow-up.

Autologous proliferative therapies in recalcitrant lateral epicondylitis.

OBJECTIVE: This study investigates the clinical effects of autologous conditioned plasma (ACP) injections and low-level laser application as therapy options for chronic lateral epicondylitis. DESIGN: A total of 52 patients with chronic lateral epicondylitis were evaluated in this study; 26 of these patients received three ACP injections and the control group, with 26 patients, received 12 laser applications, with standardized physical therapy for all patients afterward. Control examinations took place before treatment, after 2 and 6 mos, and in the 1 yr final follow-up. The control examination included the visual analog scale for pain and Disabilities of the Arm, Shoulder and Hand outcome measure scores. RESULTS: The analysis at final follow-up after 1 yr showed that both treatment options resulted in successful therapy outcome for the patients. In total, 63.5 % were successfully treated. Successful treatment was defined as more than 30% improvement in the visual analog score and more than 10.2 points in the Disabilities of the Arm, Shoulder and Hand score. Both groups showed a significant improvement in time response. CONCLUSIONS: This study demonstrates the beneficial effects of autologous proliferative therapies in the treatment of lateral epicondylitis. The data show that laser application and ACP therapy lead to a clinical improvement in epicondylopathia. Especially the new treatment with ACP can be highlighted as an alternative and as an easy-to-apply therapy option for clinical practice.

Utilização da hidroxiapatita em implantodontia - revisão de literatura / Use of hydroxyapatite in implantology - literature review

A disponibilidade óssea é importante na Implantodontia para proporcionar estabilidade primária e a manutenção dos tecidos peri-implantares necessários para a estética e osseointe- gração. Em algumas situações, os defeitos ósseos devem ser corrigidos antes da instalação dos implantes usando enxertos. Os clínicos buscam um material ideal de enxerto ósseo e o objetivo desta revisão de literatura foi avaliar os resultados obtidos após o uso da hidroxiapatita. A literatura consultada mostrou que o uso deste material favorece a neoformação óssea em defeitos críticos, o que justifica sua utilização em alvéolos após exodontia com paredes que não apresentem integridade; em defeitos ósseos periodontais, peri-implantares ou periapicais e em aumentos ósseos verticais na região de seio maxilar, de forma isolada ou em conjunto com outros biomateriais. Diante da diversidade de tipos de hidroxiapatita, o profissional deve selecionar aquele com propriedades que favoreçam sua reabsorção para diminuir a presença de partículas residuais.

In Implantology, bone availability is important to provide primary stability and maintenance of peri-implant soft and hard tissues necessary for aesthetics and osseointegration. In some situations, osseous defects must be corrected before implant placement using bone grafts. Professional search for an ideal bone grafting material and the aim of this literature review was to evaluate the results obtained by the use of hydroxyapatite. It has been shown that this material favors neo bone formation in critical defects, supporting its use in extraction sockets with non-intact bone structure, periapical, peri-implantar or periodontal osseous de¬fects and maxillary sinus grafting, alone or combined with other biomaterials. Because of the many types of hydroxyapatite, professionals shall select the one with proprieties that support its reabsorption, in order to have fewer residual particles.

A systematic review of reporting of rehabilitation in articular-cartilage-repair studies of third-generation autologous chondrocyte implantation in the knee.

CONTEXT: Autologous chondrocyte implantation (ACI) is a tissue-engineered surgical technique initially developed for articular cartilage repair of isolated chondral lesions of the knee. Third-generation techniques (ACI3) are now available that deliver autologous cultured chondrocytes into the defect using cell scaffolds. The successful outcomes of these techniques have some dependency on presurgical and postsurgical patient rehabilitation. OBJECTIVES: To determine if the standard of reporting for rehabilitation has improved in ACI3 studies; previous reviews in this field recommended describing the detail of this rehabilitation and patient compliance as integral elements. EVIDENCE ACQUISITION: A computerized search was performed in March 2013. Criteria for inclusion were any studies that evaluated or described the process of ACI3 in the knee and subsequent rehabilitation. The modified Coleman Methodology Score (CMS) was used to rate the standard of reporting of rehabilitation and surgical procedures; review articles were also evaluated for quality using the Strength of Recommendation Taxonomy (SORT). Mean scores, odds ratios, 95% confidence intervals, and Mann-Whitney U statistics were calculated. EVIDENCE SYNTHESIS: An improvement in mean CMS was seen compared with previous reviews, but rehabilitation reporting scores were lower than their surgical equivalent; significant association was seen between studies with rehabilitator involvement and high scores in the individual CMS rehabilitation element. Predominant SORT scores of 2A indicated medium strength of recommendation. CONCLUSIONS: The CMS provides a general overview of methodological quality, but a more specialized tool to report on the quantitative and qualitative aspects of the rehabilitation process would help raise the standards. It is recommended that rehabilitation therapists be included as key members of research teams and be involved in the design, implementation, and reporting of future studies.

The progression of isokinetic knee strength after matrix-induced autologous chondrocyte implantation: implications for rehabilitation and return to activity.

CONTEXT: Matrix-induced autologous chondrocyte implantation (MACI) is an established technique for the repair of knee chondral defects. Despite the reported clinical improvement in knee pain and symptoms, little is known on the recovery of knee strength and its return to an appropriate level compared with the unaffected limb. OBJECTIVE: To investigate the progression of isokinetic knee strength and limb symmetry after MACI. DESIGN: Prospective cohort. SETTING: Private functional rehabilitation facility. PATIENTS: 58 patients treated with MACI for full-thickness cartilage defects to the femoral condyles. INTERVENTION: MACI and a standardized rehabilitation protocol. MAIN OUTCOME MEASURES: Preoperatively and at 1, 2, and 5 y postsurgery, patients underwent a 3-repetition-maximum straight-leg raise test, as well as assessment of isokinetic knee-flexor and -extensor torque and hamstring:quadriceps (H:Q) ratios. Correlation analysis investigated the association between strength and pain, demographics, defect, and surgery characteristics. Linear-regression analysis estimated differences in strength measures between the operated and nonoperated limbs, as well as Limb Symmetry Indexes (LSI) over time. RESULTS: Peak knee-extension torque improved significantly over time for both limbs but was significantly lower on the operated limb preoperatively and at 1, 2, and 5 y. Mean LSIs of 77.0%, 83.0%, and 86.5% were observed at 1, 2, and 5 y, respectively, while 53.4-72.4% of patients demonstrated an LSI < or = 90% across the postoperative timeline. Peak knee-flexion torque was significantly lower on the operated limb preoperatively and at 1 year. H:Q ratios were significantly higher on the operated limb at all time points. CONCLUSIONS: While peak knee-flexion and hip-flexor strength were within normal limits, the majority of patients in this study still demonstrated an LSI for peak knee-extensor strength < or = 90%, even at 5 y. It is unknown how this prolonged knee-extensor deficit may affect long-term graft outcome and risk of reinjury after return to activity.

Correlation Between Clinical and Radiological Outcomes After Matrix-Induced Autologous Chondrocyte Implantation in the Femoral Condyles.

BACKGROUND: Matrix-induced autologous chondrocyte implantation (MACI) is an established technique for the repair of knee chondral defects, although the correlation between clinical and radiological outcomes after surgery is poorly understood. PURPOSE: To determine the correlation between clinical and radiological outcomes throughout the postoperative timeline to 5 years after MACI. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: This retrospective study was undertaken in 83 patients (53 male, 30 female) with complete clinical and radiological follow-up at 1, 2, and 5 years after MACI. The mean age of patients was 38.9 years (range, 13-62 years), with a mean body mass index (BMI) of 26.6 kg/m(2) (range, 16.8-34.8 kg/m(2)), mean defect size of 3.3 cm(2) (range, 1-9 cm(2)), and mean preoperative duration of symptoms of 9.2 years (range, 1-46 years). Patients indicated for MACI in this follow-up were 13 to 65 years of age, although they were excluded if they had a BMI >35 kg/m(2), had undergone prior extensive meniscectomy, or had ongoing progressive inflammatory arthritis. Patients were assessed clinically using the Knee Injury and Osteoarthritis Outcome Score (KOOS). Magnetic resonance imaging (MRI) was used to evaluate the graft using a 1.5-T or 3-T clinical scanner; the MRI assessment included 8 parameters of graft repair (infill, signal intensity, border integration, surface contour, structure, subchondral lamina, subchondral bone, and effusion) based on the magnetic resonance observation of cartilage repair tissue (MOCART) score as well as an MRI composite score. The degree of an association between the MRI parameters and the KOOS subscales at each postoperative time point was assessed with the Spearman correlation coefficient (SCC), and significance was determined at P < .05. Ethics approval was obtained from the appropriate hospital and university Human Research Ethics Committees, and informed consent was gathered from all patients. RESULTS: The only MRI parameter displaying consistent evidence of an association with the KOOS subscales was effusion, with a pattern of increasing strength of correlations over time and statistically significant associations at 5 years with KOOS-Pain (SCC, 0.25; P = .020), KOOS-Activities of Daily Living (SCC, 0.26; P = .018), and KOOS-Sport (SCC, 0.32; P = .003). Apart from a significant correlation between subchondral lamina and KOOS-Sport at 1 year (SCC, 0.27; P = .016), no further significant findings were observed. CONCLUSION: Apart from some consistent evidence of an association between the KOOS and effusion, this analysis demonstrated a limited correlative capacity between clinical and radiological outcomes up to 5 years after surgery.

[Surgical stabilization of acute/chronic sternoclavicular instability with autologous gracilis tendon graft]. / Operative Stabilisierung der akuten/chronischen Sternoklavikulargelenkinstabilität mit autologem Grazilissehnengraft.

SURGICAL OBJECTIVE: Restoration of joint stability and unimpaired, painless shoulder function INDICATIONS: Chronic and recurrent painful instabilities of the sternoclavicular (SC) joint. Locked posterior instability. CONTRAINDICATIONS: A lack of autologous tendon grafts due to harvesting of all hamstring grafts during prior surgical procedures and general contraindications for surgery/anesthesia. SURGICAL TECHNIQUE: Joint stability is restored by a gracilis tendon allograft passed through two drill holes in the sternum and the medial clavicle using a figure-of-eight configuration. POSTOPERATIVE MANAGEMENT: Immobilization in a sling for 6 weeks with passive motion exercises followed by 6 weeks of active mobilization without weight-bearing. After 12 weeks, continuous remobilization with increasing weight-bearing. RESULTS: SC joint reconstruction using an autologous tendon graft in a figure-of-eight configuration can significantly improve shoulder function and pain relief. However, some impairment of shoulder function or persistent complaints may occur, which must be discussed with the patient in the preoperative setting.

Measuring physical activity and sports participation after autologous cartilage implantation: a systematic review.

CONTEXT: The assessment of physical activity and return to sport and exercise activities is an important component in the overall evaluation of outcome after autologous cartilage implantation (ACI). OBJECTIVE: To identify the patient-report instruments that are commonly used in the evaluation of physical activity and return to sport after ACI and provide a critical analysis of these instruments from a rehabilitative perspective. EVIDENCE ACQUISITION: A computerized search was performed in January 2013 and repeated in March 2013. Criteria for inclusion required that studies (1) be written in English and published between 1994 and 2013; (2) be clinical studies where knee ACI cartilage repair was the primary treatment, or comparison studies between ACI and other techniques or between different ACI generations; (3) report postoperative physical activity and sport participation outcomes results, and (4) have evidence level of I-III. EVIDENCE SYNTHESIS: Twenty-six studies fulfilled the inclusion criteria. Three physical activity scales were identified: the Tegner Activity Scale, Modified Baecke Questionnaire, and Activity Rating Scale. Five knee-specific instruments were identified: the Lysholm Knee Function Scale, International Knee Documentation Committee Score Subjective Form, Knee Injury and Osteoarthritis Outcome Score, Modified Cincinnati Knee Score, and Stanmore-Bentley Functional Score. CONCLUSIONS: Considerable heterogeneity exists in the reporting of physical activity and sports participation after ACI. Current instruments do not fulfill the rehabilitative needs in the evaluation of physical activity and sports participation.