Combined reconstruction of the posterior cruciate ligament and medial collateral ligament using a single femoral tunnel

Purpose

Lesions of the medial collateral ligament (MCL) are the most common knee ligament injuries, and lesions associated with the anterior cruciate ligament or the posterior cruciate ligament (PCL) in knee dislocations should be reconstructed to prevent failure of the central pivot reconstruction. The purpose of this study was to evaluate the outcomes of combined PCL/MCL reconstruction using a single femoral tunnel with a minimum 2-year follow-up.

Method

A retrospective study of thirteen patients with combined PCL/MCL injuries was conducted. The patients underwent PCL and MCL reconstruction using an Achilles tendon allograft with a single tunnel in the medial femoral condyle, thereby avoiding tunnel conversion.

Results

All patients achieved a range of motion of at least 100°. The mean loss of extension and flexion values compared to the contralateral side was 1° ± 2° and 9° ± 10°, respectively. Our results included 26 reconstructions with three (11.5 %) failures, two in the PCL (15.3 %) and one in the MCL (7.6 %), in three different patients. In the final evaluation, the mean IKDC subjective score was 71.63 ± 16.23, the mean Lysholm score was 80.08 ± 13.87, and the median Tegner score was 6 (range = 2–7).

Conclusion

The PCL/MCL reconstruction technique using a single femoral tunnel and an Achilles tendon allograft is safe, avoids the convergence of tunnels in the medial femoral condyle, has excellent results, and is reproducible.

Level of evidence

IV.

     

A new technique in double-bundle anterior cruciate ligament reconstruction with implant-free tibial fixation

Purpose

This case-series outcome study presents a surgical technique for anatomic double-bundle anterior cruciate ligament (ACL) reconstruction with 4-tunnel using two interference screws. There was a 2-year minimum follow-up.

Methods

From January to December 2009, an ACL 4-tunnel, anatomic, double-bundle reconstruction was performed on 27 patients. Double-strand hamstring tendon grafts were used in each femoral tunnel as well as two interference screws. Tibial fixation was insured through manual tension, by tying non-absorbable sutures on the bone bridge between the two tunnels at 20° of knee flexion. Clinical assessments included the International Knee Documentation Committee (IKDC) and Lysholm knee scores, range of motion (ROM), pivot-shift test, single-leg hop, and quadriceps-hamstrings strength tests using a hand-held dynamometer. Anterior knee laxity was also assessed using a rolimeter. A single examiner performed all testing pre-operatively at 6 months and during the 2-year follow-up.

Results

All patients were assessed during the 2-year follow-up. At that time, 92 % of the patients presented normal anterior laxity (average, 1.3 ± 0.5 mm) and rotational knee stability. No statistical side-to-side difference was found for ROM, muscle strength, single-leg hop, and function (n.s.). All patients presented a normal knee function according to the IKDC and the Lysholm score. In addition, no infection, graft failure, or pain were observed at the harvesting site.

Conclusion

The study shows that satisfactory results in relation to knee laxity, function, and strength can be achieved with the implant-free tibial fixation in the ACL double-bundle reconstruction with two interference screws.

Level of evidence

Therapeutic case series, Level IV.

     

Interference screw insertion angle has no effect on graft fixation strength for insertional Achilles tendon reconstruction

Purpose

To compare the effect of two interference screw insertion angles on the biomechanical properties of the insertional Achilles tendon (IAT) reconstruction.

Methods

Nine matched pairs of fresh-frozen human cadaveric Achilles tendon specimens were randomized to two groups with interference screw insertion angles of 60° and 120°. The IAT reconstruction was performed by fixing the graft tendon with the interference screw. Each specimen was loaded to failure. The load at failure, stiffness, and mode of failure were documented. Differences in load at failure and stiffness were analysed.

Results

There was no statistically significant difference between the 60° and 120° groups for failure load (149.137?±?20.836 versus 155.428?±?28.343 N, respectively, n.s.) and stiffness (14.523?±?2.824 N/mm versus 14.727?±?2.192 N/mm, respectively, n.s.). The most common mode of failure was the graft pulling out of the bone tunnel when the screw broke.

Conclusions

Graft fixation at two different interference screw insertion angles for IAT reconstruction exhibited equivalent biomechanical performance. When performing this procedure, surgeons may choose the interference screw insertion angle based on personal preference.

     

Clinical outcome of exercise therapy and early post-operative rehabilitation for treatment of neglected Achilles tendon rupture: a randomized study

Purpose

Treatment of neglected Achilles tendon rupture is very challenging. This randomized study aimed to compare the clinical outcome of early post-operative rehabilitation (EPR) with post-operative cast immobilization (PCI).

Methods

Fifty-seven patients with neglected Achilles tendon rupture were randomized to receive EPR (n = 26) or PCI (n = 31) management following surgery. Clinical outcome was monitored by follow-up at weeks 8, 12, 18 and 26 and year 2. The significance of intergroup differences from the Leppilahti scoring system (LSS), ultrasonography, multislice spiral computerized tomography (MSCT) and electromyography was assessed.

Results

Ultrasonography and MSCT revealed no occurrence of tendon elongation or adhesion. Four patients could perform sustained single-leg heel-raise exercise for 60 s at post-operative day 40. The PCI group also showed increased post-operative LSS score, but recovery was slower. Post-operative complications, such as ankle joint ankylosis and osteoporosis, only occurred in the PCI group.

Conclusions

Compared with cast immobilization, early post-operative rehabilitation results in better clinical outcome and faster overall tendon regeneration of neglected Achilles tendon rupture.

Level of evidence

II.

     

Do ground reaction forces during unilateral and bilateral movements exhibit compensation strategies following ACL reconstruction?

Purpose

The aims of the study were (1) to evaluate the leg asymmetry assessed with ground reaction forces (GRFs) during unilateral and bilateral movements of different knee loads in anterior cruciate ligament (ACL) reconstructed patients and (2) to investigate differences in leg asymmetry depending on the International Knee Documentation Committee Subjective Form (IKDC) in order to identify potential compensation strategies.

Methods

The knee function of 50 ACL reconstructed (patella tendon) patients was examined at 31 ± 7 months after the surgery. GRFs were quantified during the sit-to-stand and stand-to-sit test, the step-up and step-down test, and the two- and one-leg vertical jump. Further, the IKDC score, the anterior–posterior knee laxity, and the concentric torque of the quadriceps and hamstring muscles were evaluated.

Results

Differences between the operated and non-operated leg were found in the knee laxity, the quadriceps torque, and GRFs. The patients with low IKDC scores demonstrated greater leg asymmetries in GRFs compared to the patients with high IKDC scores.

Conclusions

ACL reconstructed patients showed GRF asymmetries during unilateral and bilateral movements of different knee loads. Three compensation strategies were found in patients with low subjective knee function: (1) a reduced eccentric load, (2) an inter-limb compensation during bilateral movements, and (3) the avoidance of high vertical impact forces. These compensation strategies may be indicative of a protective adaptation to avoid excessive ACL strain. GRF measurements are practicable and efficient tools to identify individual compensation strategies during early rehabilitation.

     

Patellofemoral arthrodesis as pain relief in extreme patella alta

Purpose

There is no golden standard management for neglected, chronic patellar tendon rupture as they are fairly rare. Nevertheless, accompanying pain can be highly debilitating. By presenting a case of patellar tendon repair, the exceptional results of a patellofemoral arthrodesis are described.

Methods

A patient presented herself with a sustained patellar tendon rupture which was neglected for several years, causing a complete extensor mechanism dysfunction. Her most debilitating complaint was pain. As ligament reconstruction in this case was not possible, patellofemoral arthrodesis was aimed for. The pain resulting from micromotions was subsided by implementing a unique technique using a lock-key principle to obtain a patellofemoral arthrodesis.

Results

The procedure proceeded without complications. The patient followed a regular post-operative plan and is now successful in maximum weight bearing her knee without pain.

Conclusions

A patellofemoral arthrodesis can be regarded safe and also very effective in the relief of pain in extreme patella alta.

Level of evidence

Therapeutic studies, Level IV.

     

Surgical reconstruction is a cost-efficient treatment option for isolated PCL injuries

Purpose and hypothesis

The main purpose of the study is to put focus on the costs related to treating posterior cruciate ligament (PCL) injuries and the possible implications of chosen treatment strategy to the respective institutions and society.

Methods

Costs of treating PCL injuries nonoperatively and for both single-bundle (SB) and double-bundle (DB) reconstruction were estimated. These costs were translated into equivalent quality-adjusted life years (QALY) given a threshold value of Euro (€) 70,000 per QALY. Expected gain in knee osteoarthritis outcome score (KOOS) quality of life (QoL) following surgery based on KOOS data from 112 patients was used as a basis for calculating the cost efficiency ratio.

Results

The average calculated cost of nonoperative treatment was €3382. Incremental cost for SB PCLR was €8585 (154%) and another increment of €5220 (61%) for DB PCLR using numbers from a European hospital. This is equivalent to increments of 0.074 (SB) and another 0.075 (DB) QALYs given the €70,000 threshold. For DB to be as cost efficient as SB reconstruction, the incremental gain in KOOS QoL has to be at the same level as for SB reconstruction compared to nonoperative treatment.

Conclusion

Though surgical reconstruction adds a substantial cost to nonoperative treatment alone, it can be considered cost-effective. Double-bundle reconstruction is less cost efficient than SB reconstruction, but should probably still be considered the treatment of choice for certain patient categories. Randomized controlled trials looking at outcome following nonoperative, SB and DB PCL reconstruction are needed. The clinical relevance of this is that surgical reconstruction of PCL injuries is a cost-efficient treatment alternative in patients with an isolated PCL injury. This finding should be taken into consideration when deciding on how to treat these injuries.

Level of evidence

III.

     

Landing mechanics during single hop for distance in females following anterior cruciate ligament reconstruction compared to healthy controls

Purpose

To determine possible differences in single-hop kinematics and kinetics in females with anterior cruciate ligament reconstruction compared to healthy controls. A second purpose was to make comparisons between the healthy and reconstructed limbs.

Methods

Subjects were grouped based on surgical status (33 ACLR patients and 31 healthy controls). 3D motion capture synchronized with force plates was used to capture the landing phase of three successful trials of single hop for distance during a single data collection session. Peak values during the loading phase were analysed. Subjects additionally completed three successful trials of the triple hop for distance Tegner activity scale and International Knee Document Committee 2000 (IKDC).

Results

Controls demonstrated greater peak knee flexion and greater internal knee extension moment and hip extension moment than ACLR subjects. Within the ACLR group, the healthy limb exhibited greater peak knee flexion, hip flexion, hip extension moment, single hop and triple hops for distance and normalized quadriceps strength.

Conclusion

Patients who undergo anterior cruciate ligament reconstruction land in a more extended posture when compared to healthy controls and compared to their healthy limb.

Level of evidence

III.

     

A matched pairs comparison of single- versus double-bundle anterior cruciate ligament reconstructions,clinical results and manual laxity testing

Purpose

To compare the subjective clinical results as well as manual anterior and rotational stability in patients treated with either single- (SB) or double-bundle (DB) anterior cruciate ligament (ACL) reconstructions.

Methods

Sixty-four patients who had undergone SB or DB hamstring ACL reconstruction with hamstrings were included in a retrospective matched pair analysis. At follow-up IKDC subjective, CKS, KOOS, CKS and a visual analogue satisfaction scale was assessed. A blinded surgeon examined the joint laxity and completed the objective IKDC. The KT-1000 was used to bilaterally test anterior tibial translation. Patients with confounding variables, which statistically influenced the clinical outcome (passive flexion and extension deficits, persistent quadriceps deficit, tibiofemoral osteoarthritis and non-repairable medial meniscus injury), were identified and excluded from the statistical analysis (n = 10).

Results

For all subjective scores, DB patients reported increased scores compared with SB patients. While consistently higher scores were demonstrated, statistical significance was only achieved for the IKDC subjective (P = 0.04) and VAS satisfaction (P = 0.02). Graded stability results of the Lachman, anterior drawer and pivot-shift tests were significantly higher in the DB group and KT-1000 side-to-side difference was significantly better for DB (P = 0.01).

Conclusion

DB ACL reconstruction appeared to more consistently result in significantly higher subjective outcome scores and manual tests of joint stability than SB ACL reconstruction. Besides the surgical technique, normal extension and quadriceps strength after surgery were identified to be an essential component in order to provide the patient with a successful outcome.

Level of evidence

II.

     

No negative effect on patient-reported outcome of concomitant cartilage lesions 5–9 years after ACL reconstruction

Purpose

To compare patient-reported outcome 5–9 years after anterior cruciate ligament (ACL) reconstruction in patients with and without a concomitant full-thickness [International Cartilage Repair Society (ICRS) grade 3–4] cartilage lesion.

Methods

This is a prospective follow-up of a cohort of 89 patients that were identified in the Norwegian National Knee Ligament Registry and included in the current study in 2007, consisting of 30 primary ACL-reconstructed patients with a concomitant, isolated full-thickness cartilage lesion (ICRS grade 3 and 4) and 59 matched controls without cartilage lesions (ICRS grade 1–4). At a median follow-up of 6.3 years (range 4.9–9.1) after ACL reconstruction, 74 (84 %) patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS), which was used as the main outcome measure. Secondary outcomes included radiographic evaluation according to the Kellgren–Lawrence criteria of knee osteoarthritis (OA).

Results

At follow-up, 5–9 years after ACL reconstruction, no statistically significant differences in KOOS were detected between patients with a concomitant full-thickness cartilage lesion and patients without concomitant cartilage lesions. Radiographic knee OA of the affected knee, defined as Kellgren and Lawrence ≥2, was significantly more frequent in subjects without a concomitant cartilage lesion (p = 0.016).

Conclusion

ACL reconstruction performed in patients with an isolated concomitant full-thickness cartilage lesion restored patient-reported knee function to the same level as ACL reconstruction performed in patients without concomitant cartilage lesions, 5–9 years after surgery. This should be considered in the preoperative information given to patients with such combined injuries, in terms of the expected outcome after ACL reconstruction and in the counselling and decision-making on the subject of surgical treatment of the concomitant cartilage lesion.

Level of evidence

Prognostic; prospective cohort study, Level I.

     

Complications after epiphyseal reconstruction of the anterior cruciate ligament in prepubescent children

Purpose

Reconstruction of the anterior cruciate ligament (ACL) remains a major concern in the prepubescent, skeletally immature patient with wide open growth plates. Different surgical techniques have been proposed. This study reports the results and complications of ACL reconstruction in young children using an all epiphyseal technique.

Methods

Between 2006 and 2010, 12 patients (10–13 years, median 12.1 years) underwent epiphyseal primary ACL reconstruction, with a total of 13 knee procedures. Patients were assessed retrospectively with a median follow-up of 54 months (range 39–80 months) consisting of a clinical examination, instrumented arthrometer testing and radiological analysis. Functional status was assessed using the Lysholm knee score, Tegner activity scale and IKDC-2000 form.

Results

According to the IKDC examination form, five knees were rated as normal, six near normal and two abnormal. The median IKDC score at follow-up was 88.5 points (range 75–99 points). The mean side–to-side difference in KT-1000 ligament laxity testing was 1.5 mm (±2.5 mm). In two patients, reoperation was necessary due to graft failure. Two patients developed significant leg length inequality; one with 20 mm overgrowth and varus malalignment after re-reconstruction and the second developed arthrofibrosis and overgrowth of 16 mm. Four patients had minor limb length discrepancy ranging between +5 and +10 mm; no growth arrest was noted. One patient with an intact but slightly elongated graft required a meniscal suture 34 months after ACL reconstruction following a traumatic medial meniscal lesion.

Conclusion

Despite using the epiphyseal technique in ACL reconstruction, relevant growth discrepancy can occur. Thereby, overgrowth rates appear to potentially pose a major clinical problem, which has remained unreported so far. Overall, there is a considerable high risk of complications in this patient group.

Level of evidence

IV.

     

Surgical repair of chronic patellar tendon rupture in total knee replacement with ipsilateral hamstring tendons

Purpose

Patellar tendon rupture is a serious complication of total knee arthroplasty (TKA). Its reconstruction in patients with chronic ruptures is technically demanding. This article reports the results of surgical reconstruction of neglected patellar tendon rupture in TKA using autologous hamstring tendons.

Methods

Nine TKA patients (six women and three men) (mean age at index surgery 68 years) with chronic patellar tendon tears underwent reconstruction with ipsilateral hamstrings tendon, leaving the distal insertion in situ. The clinical diagnosis was supported by imaging (anterior–posterior and 30° flexion lateral radiographs). Insall–Salvati index, range of motion, and leg extension test were recorded preoperatively and at last follow-up. The modified Cincinnati rating system and the Kujala score were administered. The patients sustained the patellar tendon tear an average of 8 weeks before the procedure.

Results

At final follow-up of 4 years (range 2–8 years), the median of extension lag was 5° (range 0°–15°; DS = 5). The median of post-operative Insall–Salvati index was 1.4 (range 1.3–1.8; SD = 0.15; p = 0.002) compared to the preoperative index of 1.7 (range 1.5–2.2; SD = 0.23). The mean modified Cincinnati and Kujala scores significantly increased compared with the preoperative ones (p < 0.01). At final follow-up, all patients were able to walk without brace or aids, and they were satisfied with the procedure.

Conclusion

Based on our retrospective study of nine patients, reconstruction of neglected patellar tendon rupture in TKA with autologous hamstring tendons is feasible and safe, and provides good functional recovery.

Level of evidence

Case series, Level IV.

     

The horizontal Y-shaped graft with respective graft tension angles in anatomical two-bundle medial patellofemoral ligament reconstruction

Purpose

Various techniques for medial patellofemoral ligament (MPFL) reconstruction have been described with two bundles of graft tensioned simultaneously. The present study was to introduce an anatomical reconstruction procedure using a horizontal Y-shaped graft with respective graft tension angles and report the preliminary results.

Methods

A surgical technique for MPFL reconstruction using a horizontal Y-shaped semitendinosus tendon autograft with two bundles tensioned at 0° and 30° of knee flexion was described in detail. The patellar stability was evaluated with the apprehension test and an axial computed tomography (CT) scan at 30° of knee flexion. The knee function was evaluated using the Lysholm and Kujala scores.

Results

No recurrent dislocation or subluxation was reported for 45 patients at a mean of 33.7-month follow-up. On CT images, congruence angle, patellar tilt angle, lateral patellar angle and lateral displacement were restored to the normal range. At the last follow-up, the mean Lysholm score improved from 51.8 ± 6.2 to 91.7 ± 4.1 and mean Kujala score was from 53.4 ± 5.3 to 90.9 ± 6.6 (P < 0.01).

Conclusions

The present anatomical MPFL reconstruction technique with a horizontal Y-shaped two-bundle graft tensioned at respective knee flexion angles could not only recreate the fan-shape of MPFL but also mimic the function bundles of native ligament. Clinical follow-up confirms the good restoration of the patellar stability and significant improvement of knee function without special complications.

Level of evidence

Therapeutic, Level IV.

     

The popliteus tendon provides a safe and reliable location for all-inside meniscal repair device placement

Purpose

Repairs of the posterior horn of the lateral meniscus can be technically challenging. In contrast to medial meniscus repairs, the capsule around the posterior segment attachment of the lateral meniscus is quite thin. This study evaluates the clinical results of an arthroscopic all-inside repair technique for unstable, vertical, lateral meniscus tears, using a suture repair placed directly into the popliteus tendon.

Methods

A retrospective analysis of prospectively collected data from the SANTI database was performed. All patients who had undergone combined ACL reconstruction with lateral meniscus all-inside repair, using sutures placed in the popliteus tendon, between 2011 and 2015, were included. Patients were reviewed clinically at 1 and 2 years’ follow-up. At final follow-up, all patients were contacted to identify if they underwent further surgery or had knee pain, locking or effusion. Symptomatic patients were recalled for clinical evaluation by a physician and Magnetic Resonance Imaging of the knee. Operative notes for those undergoing further surgery were reviewed and rates and type of re-operation, including for failed lateral meniscal repair were recorded.

Results

Two hundred patients (mean age 28.6?±?10.2 years) with a mean follow-up of 45.5?±?12.8 months (range 24.7–75.2) were included. The mean Subjective International Knee Documentation Committee (IKDC) at final follow-up was 85.0?±?11.3. The post-operative mean side-to-side laxity measured at 1 year was 0.6?±?1.0 mm. Twenty-six patients underwent re-operation (13%) at a mean follow-up of 14.8?±?7.8 months. The ACL graft rupture rate was 5.0%. Other causes for re-operation included medial meniscus tear (2.5%), cyclops lesion (1.5%) and septic arthritis (0.5%). The lateral meniscus repair failure rate was 3.5%. No specific complications relating to placement of sutures in the popliteus tendon were identified.

Conclusion

Arthroscopic all-inside repair of unstable, vertical, lateral meniscus tears using a suture placed in the popliteus tendon is a safe technique. It is associated with a very low failure rate with no specific complications.

Level of evidence

Level IV.

     

Recurrent posterior knee laxity: diagnosis,technical aspects and treatment algorithm

Purpose

Aim of this study was to determine the characteristics, clinical and radiological diagnostic methods of PCL isolated and combined knee injuries.

Methods

One hundred and twelve patients with a recurrent posterior knee laxity were surgically treated. Clinical examination, MRI, Telos? stress dynamic X-rays, KT-1000 measurements and the IKDC questionnaire were used to diagnose and evaluate these injuries.

Results

Median follow-up was 4.5 years (2–11 years). Thirty-two patients (28.6 %) had an isolated posterior laxity, 53 (47.3 %) a posterior posterolateral laxity, 21 (18.7 %) a posterior posteromedial laxity and six (5.4 %) patients had a complex posterior and mediolateral laxity. Road traffic accidents and sports injuries were the main causes of trauma. The mean preoperative value of posterior tibial translation was 13.5 mm (SD 1.4) and the mean postoperative value was 4.4 mm (SD 1.7) as measured with the Telos device. In the cases with a concomitant ACL rupture, the mean preoperative value of anterior tibial translation was 6.5 mm (SD 1.3) and the mean postoperative value was 1.7 mm (SD 0.8). The mean pre- and postoperative IKDC scores were 74.5 (SD 4.2) and 87.9 (SD 3.1), respectively. Meniscal and/or cartilage injuries were found in 80 patients (71.4 %).

Conclusions

Recurrent posterior knee laxity can be restored with the one-stage PCL reconstruction using a quadriceps graft and reconstruction of the posteromedial-posterolateral lesions using the LaPrade techniques. The benefits of this study include enabling surgeons to accurately manage these injuries from a clinical perspective, and treating them with a specific surgical algorithm.

Level of evidence

III.

     

Medial meniscal and chondral pathology at the time of revision anterior cruciate ligament reconstruction results in inferior mid-term patient-reported outcomes

Purpose

Anterior cruciate ligament (ACL) injuries are frequently not isolated injuries and damage to the menisci and articular cartilage surfaces is common. The concomitant presence of meniscal and chondral damage has the potential to influence patient outcomes following ACL reconstruction surgery and especially following revision ACL reconstruction where these findings are more common. However, study results regarding the mid-term outcome have been inconsistent. The purpose of this study was to compare mid-term patient-reported outcomes and return to sport in patients with and without meniscal and chondral pathology at the time of revision ACL reconstruction surgery.

Methods

A cohort of 180 patients (131 males, 49 female) with a mean age of 25.3 (SD 7.8) years participated at an average follow-up time of 4.6 (SD 1.3) years after revision ACL reconstruction surgery. All patients completed the IKDC Subjective, Marx Activity, KOOS-Quality of Life (QOL) and Single Numerical Assessment (SANE) scores. In addition, patients were asked to indicate the highest level of sport to which they had returned following their revision surgery. Any further injuries to either knee were also documented. Patients were grouped according to whether or not they had medial or lateral meniscal pathology at the time of revision surgery; and whether or not they had?>?50% depth chondral damage (ICRS 3 or 4). All outcomes were compared between these groupings.

Results

Patients with medial meniscal pathology had significantly lower Marx, KOOS-QOL and SANE scores than patients without. There were no differences in any outcome score between patients with and without lateral meniscal pathology. Patients with ICRS 3 or 4 chondral pathology had significantly lower scores on all patient-reported outcomes as well as a lower rate of return to the same level of pre-injury sport.

Conclusion

The presence of more severe chondral damage at the time of revision ACL reconstruction has a negative impact on functional outcomes, activity levels and return to sport rates. In addition, the presence of medial meniscal pathology was associated with significantly lower functional and quality of life scores than patients without pathology. These findings provide important clinically relevant data on the outcomes following revision ACL reconstruction with concomitant chondral and meniscal injury.

Level of evidence

III.

     

The safety and efficacy of magnetic targeting using autologous mesenchymal stem cells for cartilage repair

Purpose

A new cell delivery system using magnetic force, termed magnetic targeting, was developed for the accumulation of locally injected cells in a lesion. The aim of this study was to assess the safety and efficacy of mesenchymal stem cell (MSC) magnetic targeting in patients with a focal articular cartilage defect in the knee.

Methods

MSC magnetic targeting for five patients was approved by the Ministry of Health Labour and Welfare of Japan. Autologous bone marrow MSCs were cultured and subsequently magnetized with ferucarbotran. The 1.0-T compact magnet was attached to a suitable position around the knee joint to allow the magnetic force to be as perpendicular to the surface of the lesion as possible. Then 1?×?10⁷ MSCs were injected into the knee joint. The magnet was maintained in the same position for 10 min after the MSC injection. The primary endpoint was the occurrence of any adverse events. The secondary endpoints were efficacy assessed by magnetic resonance imaging (MRI) T2 mapping and clinical outcomes using the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation and the Knee Injury and Osteoarthritis Outcome Score (KOOS).

Results

No serious adverse events were observed during the treatment or in the follow-up period. Swelling of the treated knee joint was observed from the day after surgery in three of the five patients. The swelling resolved within 2 weeks in two patients. MRI showed that the cartilage defect areas were almost completely filled with cartilage-like tissue. MOCART scores were significantly higher 48 weeks postoperatively than preoperatively (74.8?±?10.8 vs 27.0?±?16.8, p?=?0.042). Arthroscopy in three patients showed complete coverage of their cartilage defects. Clinical outcome scores were significantly better 48 weeks postoperatively than preoperatively for the IKDC Subjective Knee Evaluation (74.8?±?17.7 vs 46.9?±?17.7, p?=?0.014) and knee-related quality-of-life (QOL) in the KOOS (53.8?±?26.4 vs 22.5?±?30.8, p?=?0.012).

Conclusion

Magnetic targeting of MSCs was safely performed and showed complete coverage of the defects with cartilage-like tissues and significant improvement in clinical outcomes 48 weeks after treatment. The magnetic targeting of MSCs is useful as a minimally invasive treatment for cartilage repair.

Level of evidence

IV.

     

Platelet-rich plasma in tendon-related disorders: results and indications

Purpose

Platelet-rich plasma (PRP) is currently the most exploited strategy in the clinical practice to provide a regenerative stimulus for tendon healing. The aim of the present study was to systematically review the available evidence on the treatment of the main tendon disorders where PRP is currently applied.

Methods

A systematic review of the literature was performed on the use of PRP as a treatment for tendinopathies focusing on the following sites: Achilles tendon, patellar tendon, rotator cuff tendons, and lateral elbow tendons. The following inclusion criteria for relevant articles were used: clinical trials written in English language up to 21 June 2016 on the use of PRP in the conservative or surgical treatment of the aforementioned tendinopathies.

Results

The research identified the following clinical trials dealing with the application of PRP in the selected tendons: 19 papers on patellar tendon (6 being RCTs: 4 dealing with PRP conservative application and 2 surgical), 24 papers on Achilles tendon (4 RCTs: 3 conservative and 1 surgical), 29 on lateral elbow tendons (17 RCTs, all conservative), and 32 on rotator cuff (22 RCTs: 18 surgical and 3 conservative).

Conclusion

Patellar tendons seem to benefit from PRP injections, whereas in the Achilles tendon, PRP application is not indicated neither as a conservative approach nor as a surgical augmentation. Lateral elbow tendinopathy showed an improvement in most of the high-level studies, but the lack of proven superiority with respect to the more simple whole-blood injections still questions its use in the clinical practice. With regard to rotator cuff pathology, the vast majority of surgical RCTs documented a lack of beneficial effects, whereas there is still inconclusive evidence concerning its conservative application in rotator cuff disorders.

Level of evidence

Systematic review of level I–IV trials, Level IV.

     

Osteoarthritis in morbidly obese children and adolescents,an age-matched controlled study

Purpose

Main objective of this study was to investigate the association of pain and early cartilage lesions in morbidly obese children and adolescents.

Methods

A total of 57 subjects were included in the study. Morbidly obese patients (n = 39) were subdivided into two groups: Group A: (11 males and 9 females, 14.2 ± 2.7 years) with permanent knee pain; and Group B: (10 males and 9 females, 14.4 ± 2.2 years) without permanent or without any knee pain. Group C (8 males and 10 females, 15.0 ± 2.9 years) included age-matched children and adolescents of normal weight. MRI examinations were performed in all subjects, and an extensive analysis of the images was conducted according to the condition of the cartilage surface and the meniscus. Patients’ subjective health was assessed by means of four well-known knee scores (IKDC, KOOS, Tegner/Lysholm, and VAS). Nonparametric Jonckheere–Terpstra test was used to test the trend of the natural order between the three groups.

Results

In 38 of 39 morbidly obese children and adolescents, in at least one region of the knee, a marked cartilage lesion could be shown by MRI. Group A showed significantly (p < 0.001) more cartilage lesions (mean 3.7) compared to Group B (mean 2.8) and Group C (mean 0.8). IKDC, and all the KOOS subunits, showed significantly (p < 0.001, p _Bonferroni < 0.001) increasing scores from Group A to B to C, in addition to KOOS symptoms.

Conclusions

Morbid obesity causes early lesions of the knee cartilage, even in young patients. Significantly, more patients with reported pain show more severe damages.

     

Quantitative ultrasound mapping of regional variations in shear wave speeds of the aging Achilles tendon

Objectives

Evaluate the effects of aging on healthy Achilles tendon and aponeurosis shear wave speed (SWS), a quantitative metric which reflects tissue elasticity.

Methods

Shear wave elastography was used to measure spatial variations in Achilles tendon SWS in healthy young (n?=?15, 25?±?4 years), middle-aged (n?=?10, 49?±?4 years) and older (n?=?10, 68?±?5 years) adults. SWS was separately measured in the free Achilles tendon, soleus aponeurosis and gastrocnemius aponeurosis in resting (R), stretched (dorsiflexed 15° from R) and slack (plantarflexed 15° from R) postures.

Results

SWS significantly increased with stretch and varied with age in all tendon regions. Slack free tendon SWS was significantly higher in older adults than young adults (p?=?0.025). However, stretched soleus aponeurosis SWS was significantly lower in older adults than young adults (p?=?0.01). Stretched gastrocnemius aponeurosis SWS was significantly lower in both middle-aged (p?=?0.003) and older (p?=?0.001) adults, relative to younger adults.

Conclusion

These results suggest that aging alters spatial variations in Achilles tendon elasticity, which could alter deformations within the triceps surae muscle–tendon units, thus affecting injury potential. The observed location- and posture-dependent variations highlight the importance of controlling ankle posture and imaging location when using shear wave approaches clinically to evaluate tendon disorders.

Key Points

? Shear wave elastography shows promise as a clinical quantitative ultrasound-based technique.? Aging induces location-dependent changes in Achilles tendon shear wave speed.? Spatial and postural dependence necessitates careful integration of this approach clinically.