All-Arthroscopic Matrix-Associated Autologous Chondrocyte Implantation for a Trochlear Defect.

Matrix-associated autologous chondrocyte implantation (MACI) is a 2-step technique designed to treat symptomatic full-thickness articular cartilage defects of the knee. In this technique article, MACI (autologous cultured chondrocytes on porcine collagen membrane) is used to treat a femoral trochlear defect of the knee. Treating a defect with this technique leads to improved clinical outcomes by restoring the native chondral surface architecture and biomechanics of the knee. In addition, it has the potential to prevent or delay further progressive degeneration of the joint. It is a 2-stage procedure consisting of an initial arthroscopic cartilage biopsy, followed by 4 to 6 weeks of in vitro chondrocyte expansion and, finally, re-implantation. We recommend performing the MACI procedure arthroscopically for the second stage to treat a femoral trochlear defect. During the second surgical procedure, we examine and prepare the recipient site, followed by graft introduction in an all-arthroscopic manner via dry scoping, secured by a thin layer of fibrin glue.

Consensus on Rehabilitation Guidelines among Orthopedic Surgeons in the United States following Use of Third-Generation Articular Cartilage Repair (MACI) for Treatment of Knee Cartilage Lesions.

OBJECTIVE: The aim of this study was to evaluate levels of consensus in rehabilitation practices following MACI (autologous cultured chondrocytes on porcine collagen membrane) treatment based on the experience of an expert panel of U.S. orthopedic surgeons. DESIGN: A list of 24 questions was devised based on the current MACI rehabilitation protocol, literature review, and discussion with orthopedic surgeons. Known areas of variability were used to establish 4 consensus domains, stratified on lesion location (tibiofemoral [TF] or patellofemoral [PF]), including weightbearing (WB), range of motion (ROM), return to work/daily activities of living, and return to sports. A 3-step Delphi technique was used to establish consensus. RESULTS: Consensus (>75% agreement) was achieved on all 4 consensus domains. Time to full WB was agreed as immediate (with bracing) for PF patients (dependent on concomitant procedures), and 7 to 9 weeks in TF patients. A progression for ROM was agreed that allowed patients to reach 90° by week 4, with subsequent progression as tolerated. The panel estimated that the time to full ROM would be 7 to 9 weeks on average. A range of time was established for release to activities of daily living, work, and sports, dependent on lesion and patient characteristics. CONCLUSIONS: Good consensus was established among a panel of U.S. surgeons for rehabilitation practices following MACI treatment of knee cartilage lesions. The consensus of experts can aid surgeons and patients in the expectations and rehabilitation process as MACI surgery becomes more prevalent in the United States.

The Four Most Common Types of Knee Cartilage Damage Encountered in Practice: How and Why Orthopaedic Surgeons Manage Them.

Cartilage damage of the knee is common and may present in patients as a variety of symptoms. These conditions can be classified based on location, etiology, and/or pathophysiology. A systematic approach to the evaluation and classification of chondral injuries helps improve definitive management. The four most common types of knee cartilage damage are osteochondritis dissecans, incidental chondral defects, patellofemoral defects, and defects encountered after meniscectomy.

Comparisons of three radiographic views in assessing for scapholunate instability.

BACKGROUND: Multiple wrist x-ray images have been described to assess for scapholunate (SL) instability. Some views may be redundant. The purpose of this study was to compare three plain x-ray views in identifying a traumatic diastasis of the SL interval. METHODS: Nineteen patients (19 wrists) with a positive scaphoid shift test and surgically confirmed SL ligament damage were identified. There were 15 males and 4 females with a mean age of 39 years. Pre-operative x-rays were reviewed, including posteroanterior (PA) neutral and PA ulnar deviation views of the injured wrist, and PA clenched fist views of the injured and uninjured wrists. Dynamic SL instability was defined by an SL mid-interval gap of <3 mm and static SL instability by a gap of ≥3 mm in the PA neutral views. The mid-interval measurements were compared between x-ray images. RESULTS: There were 10 dynamic and 9 static SL instability cases. The PA ulnar deviation and the PA clenched fist views showed significantly greater SL gaps in comparison to the PA neutral views in dynamic but not static SL instability cases. In both categories of instability, there was no significant difference in the SL gaps between the two stress images. The PA clenched fist view of the uninjured wrist revealed SL gapping of >3 mm in 50% of patients but with generally greater gapping in the clenched fist view of the injured wrist. CONCLUSIONS: The PA ulnar deviation and clenched fist stress views were equally effective in showing a dynamic SL diastasis following wrist injury. Neither view was more effective than a neutral PA view in diagnosing static SL instability.

Outcomes after primary open or endoscopic abductor tendon repair in the hip: a systematic review of the literature.

PURPOSE: The purpose of this study was to systematically appraise the evidence on primary open and endoscopic abductor tendon repair. METHODS: A systematic review of the literature was performed to (1) identify the demographic undergoing abductor tendon repair, (2) summarize the overall outcomes after primary surgical abductor tendon repair, (3) identify the type of tear most commonly encountered intraoperatively, (4) summarize the repair methods used, and (5) identify the published complication and tendon retear rates. RESULTS: A total of 8 articles were identified as eligible for inclusion. All studies were Level IV Evidence. Of the patients undergoing surgical repair, 90% were women. As assessed by a variety of outcome measures, most patients reported good to excellent functional outcomes and pain reduction after open or endoscopic repair. Intraoperatively, tears of the gluteus medius and partial-thickness tears were encountered most often. Tears involving both the gluteus medius and minimus occurred 29% of the time. Complication rates were low for both the open and endoscopic approaches. No tendon retears were documented after endoscopic repair, whereas the retear rate after open repair was 9%. CONCLUSIONS: Patients undergoing surgical repair for partial- and full-thickness tears are mostly women. Intraoperatively, tears almost always include the gluteus medius, with concomitant tearing of the gluteus minimus in approximately one-third of cases. Both open and endoscopic techniques are viable surgical approaches to repairing abductor tendon tears in the hip that produce good to excellent functional results and reduce pain; however, endoscopic repair appears to result in fewer postoperative complications including tendon retear. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Flexor pollicis longus dysfunction after volar plate fixation of distal radius fractures.

PURPOSE: To evaluate the natural history and etiology of decreased thumb interphalangeal (IP) joint flexion after volar plate fixation of distal radius fractures. METHODS: A total of 46 patients who underwent volar plating of 48 distal radius fractures by a single surgeon were retrospectively studied. Of those patients, 24 (24 wrists) exhibited loss of thumb IP joint flexion (group 1) and 22 (24 wrists) retained thumb IP joint flexion (group 2) with attempted thumb opposition to the small finger after surgery. All patients were seen at regular intervals until IP joint flexion returned and fracture healing was confirmed radiographically. Patient demographics, fracture patterns, surgical variables, and final radiographs were compared between groups. Twenty patients in group 1 were seen after a mean of 6.5 months (range, 5-12 mo) for specific outcome measurements. Eight cadaveric specimens were used to replicate the flexor carpi radialis approach to the distal radius and evaluate flexor pollicis longus tendon excursion. RESULTS: There were no significant differences in fracture pattern, patient age or sex, injured extremity dominance, time to surgery, incision length, plate composition, plate length, tourniquet time, or final wrist radiographs between groups. In group 1, active thumb IP joint flexion returned on average 52 days (range, 19-143 d) postoperatively. At final evaluation in this group, mean IP joint flexion was 11° less than the contralateral thumb IP joint; however, patient-determined outcomes were favorable in most cases. In the cadaveric specimens, excursion of the flexor pollicis longus tendon decreased with sequential soft tissue dissection and retraction. CONCLUSIONS: Loss of thumb IP joint flexion after volar plating of distal radius fractures was common, and motion returned to near normal in most cases within 2 months. Partial stripping of the flexor pollicis longus muscle from investing fascia and bone and retraction of soft tissues are likely etiological factors.

Hand surface landmarks and measurements in the treatment of trigger thumb.

PURPOSE: To determine hand surface landmarks and measurements that may be useful in localizing the A1 pulley and digital neurovascular structures in the treatment of trigger thumb. METHODS: We highlighted 4 surface landmarks in 20 adult cadaveric hands: the radial border of the index finger, the ulnar border of the thumb, the thumb interphalangeal joint flexion creases, and the thumb metacarpophalangeal joint creases. We injected the radial arteries with red latex and dissected the thumbs. RESULTS: The proximal margin of the A1 pulley was located an average of 0.3 mm proximal (range, 3.2 mm proximal to 2.3 mm distal) to the most proximal metacarpophalangeal joint flexion crease. The ratio of measurements from the thumb tip to the midpoint of the interphalangeal joint flexion creases and from this point to the proximal margin of the A1 pulley averaged 1.1:1. The radial digital nerve crossed obliquely over the flexor pollicis longus tendon and approached the proximal margin of the A1 pulley at a mean distance of 2.7 mm (range, 0-12.9 mm). The ulnar digital nerve was located deep to intersecting lines drawn along the radial border of the index finger and the ulnar border of the thumb and coursed parallel to the A1 pulley at a mean distance of 5.4 mm (range, 0-11.1 mm). At the level of the A1 pulley, the digital arteries were positioned dorsal to the digital nerves, and both nerves were located 1.0 to 4.2 mm from the skin surface. CONCLUSIONS: The findings from our study clarify hand surface landmarks in localizing the thumb A1 pulley and digital neurovascular structures. CLINICAL RELEVANCE: Awareness of topographical landmarks in localizing the A1 pulley and digital neurovascular structures and the relationships between the digital neurovascular structures and the A1 pulley may improve the safety and efficacy of trigger thumb treatment.