The clinical utility of immediate post-operative PACU plain film radiographs following uncomplicated open Latarjet procedure - An institutional series of consecutive patients.

Background: Immediate post-operative plain film radiograph x-rays in PACU following open Latarjet procedure are often ordered as routine. However, such radiographs utilize institutional cost and time, whilst potentially exposing patients to often-unnecessary additional radiation. This study sought to evaluate whether routine immediate post-operative radiographs following uncomplicated open Latarjet procedures impacted clinical decision-making in our institution. Methods: From 2017 to 2020, patients who underwent open Latarjet procedure by one of four fellowship-trained upper limb surgeons at a single institution were included in this study. Post-operative radiographs taken immediately in PACU were reviewed to determine if any reported radiographic findings impacted on clinical decision-making in the immediate post-operative setting. SPSS was used for descriptive statistics. Results: A total of 337 patients underwent an X-ray in PACU immediate after uncomplicated open Latarjet procedure. Overall, 98.5% were male (n = 332), the mean patient age of included patients was 22.9 ± 4.2 years. No patient had an abnormal finding on their post-operative x-ray. Two patients returned to the operating room in the immediate post-operative period, both requiring washout and debridement due to haemtoma or superficial wound infection. Conclusion: The findings of this study suggest that the use of post-operative plain films in PACU following open Latarjet procedure remains a costly use of resources, with little ultimate impact on clinical decision making in the short-term post-operatively. Level of Evidence: IV - Institutional Case Series of Consecutive Patients.

90-Day Complication Rate After the Latarjet Procedure in a High-Volume Center.

BACKGROUND: The Latarjet procedure is indicated for patients with recurrent anterior shoulder instability, previous failed soft tissue stabilization, glenoid bone loss, or high-risk factors for recurrence, although there is still a concern with the surgical complication rates associated with the Latarjet procedure. PURPOSE: To evaluate the 90-day complication rate after the open Latarjet procedure in a high-volume center. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review was performed of patients who underwent an open Latarjet procedure at our institution over a 5-year period between January 2015 and December 2019. The complications, readmissions, and reoperations within 90 days were evaluated. RESULTS: A total of 441 patients with a mean age of 23.0 ± 5.7 years was included; 97.5% of the patients were male. There were 2 intraoperative complications (0.5%): 1 coracoid fracture and 1 anaphylactic reaction to vancomycin. Overall, there were 19 postoperative complications (4.3%) in 18 patients, with 4 (0.9%) readmissions for revision surgery. Hematomas were the most common complication, occurring in 12 patients (2.7%), with 9 (2.0%) requiring a return to the operating theater during their stay for an evacuation. In those who required a readmission for a reoperation, 1 was for a hematoma requiring a washout, 2 were for irrigation and debridement of a surgical site infection, and the third was for a biceps tenodesis in a patient with severe bicipital pain. No patients had recurrence or any postoperative graft complications; additionally, there were no neurovascular complications. CONCLUSION: We found that in a high-volume center, the open Latarjet procedure has a low 90-day complication rate with a low revision rate. Hematomas were the most common complication experienced by patients who underwent the Latarjet procedure, while there was no recurrent instability or neurological or hardware complications reported among the 441 patients included in this study.

Anterior Cruciate Ligament Reconstruction with Platelet-Rich Plasma: A Systematic Review of Randomized Control Trials.

PURPOSE: To perform a systematic review of the randomized controlled trials (RCTs) evaluating the efficacy of platelet-rich plasma (PRP) to augment anterior cruciate ligament (ACL) reconstruction. METHODS: Two independent reviewers screened the MEDLINE, The Cochrane Library, and EMBASE databases using Preferred Reporting for Systematic Reviews and Meta-Analyses guidelines for applicable RCTs evaluating the efficacy of PRP in ACL reconstruction. A meta-analysis was performed on the papers involving bone-patellar tendon-bone (BPTB) grafting. RESULTS: Thirteen RCTs fulfilled the inclusion criteria involving 765 patients. There was no clinical improvement (Tegner, Lysholm, Knee Injury and Osteoarthritis Outcome Score, or International Knee Documentation Committee scores) in any of the 7 studies evaluating PRP alongside the hamstring tendon autograft ACL reconstructions versus the control. Two studies evaluating PRP for hamstring tendon autograft demonstrated significantly improved magnetic resonance imaging findings. Two studies analyzed the use of PRP with allograft ACL reconstruction showed no clinical, biochemical, or radiologic improvements in postoperative follow-up. No functional improvements were found when PRP was used alongside BPTB in 4 studies. There was no significant difference in visual analog scale score in the BPTB group (1.1 vs 1.5, P = .18), or tibial filling defects (P = .30). CONCLUSIONS: This study found that the current level I evidence does not support the use of PRP to improve graft healing, improve donor-site morbidity, reduce postoperative pain levels, or improve functional outcomes following ACL reconstruction. LEVEL OF EVIDENCE: Level I; systematic review of level I evidence.

Video Analysis of Shoulder Dislocations in Rugby: Insights Into the Dislocating Mechanisms.

BACKGROUND: Mechanisms previously described for traumatic shoulder injuries in rugby may not adequately describe all the mechanisms that result in shoulder dislocations. PURPOSE: To investigate the mechanism of shoulder dislocation events in professional rugby players through use of systematic video analysis. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In our series, 39 cases of shoulder dislocations from games played in top professional leagues and international matches across a 2-year period were available for video analysis. All cases were independently assessed by 2 analysts to identify the sequence of events occurring during shoulder dislocation. This included injury circumstance such as contact with another player or the ground, game scenario, injury timing, and the movements and force vectors involved in the dislocation mechanism. RESULTS: We identified 4 distinct injury mechanisms. The previously described mechanisms "try scorer,""tackler," and "direct impact" were identified in 67% of cases. We describe a new injury mechanism occurring in the "poach position," accounting for 18% of all shoulder dislocations studied. The remaining 15% could not be categorized. Shoulder dislocations occurred to a ball carrier in 15% of cases (n = 6) and a non-ball carrier in 85% of cases (n = 33). The injury most commonly occurred during a tackle (49%; n = 19) followed by ruck/maul (26%; n = 10). Time of injury showed that 36% (n = 14) of cases occurred in the last quarter of the game. CONCLUSION: Shoulder dislocations have now been shown to occur predominantly as a result of 1 of 4 distinct mechanisms, most frequently in the second half of the game. A new mechanism for shoulder dislocation has been described in this series, termed the poach position.

Nonoperative Treatment of Rotator Cuff Disease With Platelet-Rich Plasma: A Systematic Review of Randomized Controlled Trials.

PURPOSE: To perform a systematic review of randomized controlled trials on the use of platelet-rich plasma (PRP) for nonoperative treatment of rotator cuff disease. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 2 reviewers independently screened the MEDLINE, Embase, and Cochrane Library databases for prospective, randomized controlled trials comparing PRP with a control in the nonoperative treatment of chronic rotator cuff disease for inclusion. Clinical data were extracted and evaluated. The quality of evidence was assessed using The Cochrane Collaboration risk-of-bias tool. RESULTS: Five randomized controlled trials met the inclusion criteria, with 108 patients treated with PRP and 106 treated with a control. The mean age was 53.7 years, and 61.6% of patients were female patients. All of the studies found that the groups receiving PRP injections experienced improved clinical outcomes at final follow-up compared with baseline. Two studies found that PRP resulted in improved outcomes, mostly pain scores, compared with a control. One study compared PRP with formal exercise versus a saline solution injection with formal exercise therapy. It showed no difference in clinical outcomes between PRP and a saline solution injection when formal exercise therapy was used. Two other studies reported that PRP alone resulted in inferior outcomes to control groups receiving formal exercise therapy. CONCLUSIONS: The currently limited available evidence on PRP for nonoperative treatment of chronic rotator cuff disease suggests that in the short term, PRP injections may not be beneficial. When directly compared with exercise therapy, PRP does not result in superior functional outcomes, pain scores, or range of motion. However, interpretation of this literature is confounded by the lack of reporting of the cytology and characteristics of PRP. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II evidence.

The Efficacy of Platelet-Rich Plasma and Platelet-Rich Fibrin in Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Basic science studies suggest that platelet-rich therapies have a positive effect on tendon repair. However, the clinical evidence is conflicted on whether this translates to increased tendon healing and improved functional outcomes. PURPOSE: To perform a systematic review of randomized controlled trials (RCTs) in the literature to ascertain whether platelet-rich plasma (PRP) or platelet-rich fibrin (PRF) improved patient outcomes in arthroscopic rotator cuff repair. STUDY DESIGN: Meta-analysis. METHODS: Two independent reviewers performed the literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with a third author resolving any discrepancies. RCTs comparing PRP or PRF to a control in rotator cuff repair were included. Quality of evidence was assessed using the Jadad score. Clinical outcomes were compared using the risk ratio for dichotomous variables and the mean difference for continuous variables. A P value <.05 was deemed statistically significant. RESULTS: Eighteen RCTs with 1147 patients were included in this review. PRP resulted in significantly decreased rates of incomplete tendon healing for all tears combined (17.2% vs 30.5%, respectively; P < .05), incomplete tendon healing in small-medium tears (22.4% vs 38.3%, respectively; P < .05), and incomplete tendon healing in medium-large tears (12.3% vs 30.5%, respectively; P < .05) compared to the control. There was a significant result in favor of PRP for the Constant score (85.6 vs 83.1, respectively; P < .05) and the visual analog scale score for pain at 30 days postoperatively (2.9 vs 4.3, respectively; P < .05) and at final follow-up (1.2 vs 1.4, respectively; P < .05) compared to the control. PRF did not result in a significantly decreased rate of incomplete tendon healing for all tears combined (23.0% vs 24.6%, respectively; P = .74) or an improved Constant score (80.8 vs 79.8, respectively; P = .27) compared to the control. PRF resulted in a significantly longer operation time (99.1 vs 83.3 minutes, respectively; P< .05) compared to the control. CONCLUSION: The current evidence indicates that the use of PRP in rotator cuff repair results in improved healing rates, pain levels, and functional outcomes. In contrast, PRF has been shown to have no benefit in improving tendon healing rates or functional outcomes.

Biceps tenodesis versus labral repair for superior labrum anterior-to-posterior tears: a systematic review and meta-analysis.

BACKGROUND: This study systematically reviewed the comparative studies in the literature to ascertain whether biceps tenodesis or labral repair results in superior clinical outcomes in the treatment of superior labrum anterior-to-posterior (SLAP) tears. METHODS: A systematic search of articles in PubMed, EMBASE and The Cochrane Library databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Cohort studies of biceps tenodesis compared with labral repair of SLAP tears were included. Statistical analysis was performed using Review Manager software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). A P value of <.05 was considered to be statistically significant. RESULTS: Included were 5 studies with 234 patients. Biceps tenodesis resulted in improved rates of patient satisfaction (95.6% vs. 76.2%, P = .01) and rate of return to sport (81.3% vs, 64.3%, P = .02), compared with SLAP repair. Although the difference in reoperation rates was not statistically significant, there was a trend toward higher reoperation rates in patients treated with SLAP repair (14.2% vs 6.5%, P = .09). In addition, there was no difference in complication rates or functional outcomes. CONCLUSION: Our study found that biceps tenodesis resulted in higher rates of patient satisfaction and return to sport in the studies published in the literature and that biceps tenodesis and SLAP repair resulted in similar functional outcome scores.

Quadriceps Tendon Autograft in Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To systematically review the current evidence to ascertain whether quadriceps tendon autograft (QT) is a viable option in anterior cruciate ligament reconstruction. METHODS: A literature review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Cohort studies comparing QT with bone-patellar tendon-bone autograft (BPTB) or hamstring tendon autograft (HT) were included. Clinical outcomes were compared, with all statistical analyses performed using IBM SPSS Statistics for Windows, version 22.0, with P < .05 being considered statistically significant. RESULTS: We identified 15 clinical trials with 1,910 patients. In all included studies, QT resulted in lower rates of anterior knee pain than BPTB. There was no difference in the rate of graft rupture between QT and BPTB or HT in any of the studies reporting this. One study found that QT resulted in greater knee stability than BPTB, and another study found increased stability compared with HT. One study found that QT resulted in improved functional outcomes compared with BPTB, and another found improved outcomes compared with HT, but one study found worse outcomes compared with BPTB. CONCLUSIONS: Current literature suggests QT is a viable option in anterior cruciate ligament reconstruction, with published literature showing comparable knee stability, functional outcomes, donor-site morbidity, and rerupture rates compared with BPTB and HT. LEVEL OF EVIDENCE: Level III, systematic review of Level I, II, and III studies.

Mechanisms of ACL injury in professional rugby union: a systematic video analysis of 36 cases.

BACKGROUND: The mechanisms of ACL injury in rugby are not well defined. AIM: To describe the mechanisms of ACL injury in male professional rugby players using systematic video analysis. METHODS: 36 cases from games played in top professional leagues and international matches were analysed. 5 analysts independently assessed all videos to record the estimated frame/time of initial ground contact, frame/time of ACL tear and a range of play specific variables. This included contact versus non-contact ACL injuries, injury timing, joint flexion angles and foot contact with the ground. 37 side-stepping manoeuvres from a control game were analysed to allow comparison of non-injury versus injury situations. RESULTS: 57% of ACL injuries occurred in a contact manner. 2 main scenarios were identified: (1) offensive running and (2) being tackled, indicating that the ball carrier might be at higher risk of ACL injury. The majority of non-contact ACL injuries resulted from a side-stepping manoeuvre. In most non-contact cases, initial ground contact was through heel strike. Statistical assessment of heel strike at initial ground contact versus non-heel strike cases showed a significant difference in injury versus non-injury outcomes, with heel strike associated with higher injury risk. Non-contact ACL injuries had lower median knee flexion angles and a more dorsiflexed ankle when compared with a control group (10° vs 20°, p≤0.001 and 10° vs 0°, p=0.033 respectively). CONCLUSIONS: Over half of ACL injuries in rugby in our analysis resulted from a contact mechanism. For non-contact injuries, lower knee flexion angles and heel-first ground contact in a side-stepping manoeuvre were associated with ACL injury.

Chondrocyte-based intraoperative processing strategies for the biological augmentation of a polyurethane meniscus replacement.

Purpose/aim of study: Menisectomies account for over 1.5 million surgical interventions in Europe annually, and there is a growing interest in regenerative strategies to improve outcomes in meniscal replacement. The overall objective of this study was to evaluate the role of intraoperatively applied fresh chondrocyte (FC) isolates compared to minced cartilage (MC) fragments, used without cell isolation, to improve bioactivity and tissue integration when combined with a polyurethane replacement. MATERIALS AND METHODS: First, to optimize the intraoperative cell isolation protocol, caprine articular cartilage biopsies were digested with 750 U/ml or 3000 U/ml collagenase type II (ratio of 10 ml per g of tissue) for 30 min, 1 h or 12 h with constant agitation and compared to culture-expanded chondrocytes in terms of matrix deposition when cultured on polyurethane scaffolds. Finally, FCs and MC-augmented polyurethane scaffolds were evaluated in a caprine meniscal explant model to assess the potential enhancements on tissue integration strength. RESULTS: Adequate numbers of FCs were harvested using a 30 min chondrocyte isolation protocol and were found to demonstrate improved matrix deposition compared to standard culture-expanded cells in vitro. Upon evaluation in a meniscus explant defect model, both FCs and MC showed improved matrix deposition at the tissue-scaffold interface and enhanced push-out strength, fourfold and 2.5-fold, respectively, compared with the acellular implant. CONCLUSIONS: Herein, we have demonstrated a novel approach that could be applied intraoperatively, using FCs or MC for improved tissue integration with a polyurethane meniscal replacement.

Clinical Application of Scaffolds for Partial Meniscus Replacement.

Meniscal tears are common injuries often treated by partial meniscectomy. This may result in altered joint contact mechanics which in turn may lead to worsening symptoms and an increased risk of osteoarthritis. Meniscal scaffolds have been proposed as a treatment option aimed at reducing symptoms while also potentially reducing progression of degenerative change. There are 2 scaffolds available for clinical use at the present time; Collagen Meniscus Implant and Actifit. Medium-term to long-term data (4.9 to 11.3 y) demonstrate efficacy of partial meniscus replacement. The patients who seem to benefit most are chronic postmeniscectomy rather than acute meniscal injuries. Herein we report on available clinical data for Collagen Meniscus Implant and Actifit while describing our preferred surgical technique and postoperative rehabilitation program.

Biological augmentation and tissue engineering approaches in meniscus surgery.

PURPOSE: The purpose of this review was to evaluate the role of biological augmentation and tissue engineering strategies in meniscus surgery. Although clinical (human), preclinical (animal), and in vitro tissue engineering studies are included here, we have placed additional focus on addressing preclinical and clinical studies reported during the 5-year period used in this review in a systematic fashion while also providing a summary review of some important in vitro tissue engineering findings in the field over the past decade. METHODS: A search was performed on PubMed for original works published from 2009 to March 31, 2014 using the term "meniscus" with all the following terms: "scaffolds," "constructs," "cells," "growth factors," "implant," "tissue engineering," and "regenerative medicine." Inclusion criteria were the following: English-language articles and original clinical, preclinical (in vivo), and in vitro studies of tissue engineering and regenerative medicine application in knee meniscus lesions published from 2009 to March 31, 2014. RESULTS: Three clinical studies and 18 preclinical studies were identified along with 68 tissue engineering in vitro studies. These reports show the increasing promise of biological augmentation and tissue engineering strategies in meniscus surgery. The role of stem cell and growth factor therapy appears to be particularly useful. A review of in vitro tissue engineering studies found a large number of scaffold types to be of promise for meniscus replacement. Limitations include a relatively low number of clinical or preclinical in vivo studies, in addition to the fact there is as yet no report in the literature of a tissue-engineered meniscus construct used clinically. Neither does the literature provide clarity on the optimal meniscus scaffold type or biological augmentation with which meniscus repair or replacement would be best addressed in the future. There is increasing focus on the role of mechanobiology and biomechanical and biochemical cues in this process, however, and it is hoped that this may lead to improvements in this strategy. CONCLUSIONS: There appears to be significant potential for biological augmentation and tissue engineering strategies in meniscus surgery to enhance options for repair and replacement. However, there are still relatively few clinical studies being reported in this regard. There is a strong need for improved translational activities and infrastructure to link the large amounts of in vitro and preclinical biological and tissue engineering data to clinical application. LEVEL OF EVIDENCE: Level IV, systematic review of Level I-IV studies.

Cell distribution and regenerative activity following meniscus replacement.

PURPOSE: Meniscus replacement is of clinical benefit, but universal efficacy remains elusive. A greater understanding of the biological activity within implanted allografts or synthetic scaffolds may assist the development of improved surgical strategies. MATERIALS: Biopsies of fresh-frozen allograft (n=20), viable allograft (n=18) and polyurethane scaffolds (n=20) were obtained at second-look arthroscopy. Histological evaluation of tissue morphology and cell density/distribution was performed using haematoxylin-eosin (H&E) staining. Immunohistochemistry was used to detect the presence of CD34 (on progenitor cells and blood vessels) and smooth muscle actin (SMA)-positive structures and aggrecan. Collagen presence was investigated using picrosirius red staining. RESULTS: Cell density in the deep zone of the meniscus replacement was significantly higher in polyurethane scaffolds versus allograft transplants (p<0.01) and also significantly higher in viable allograft compared with deep-frozen allograft (p<0.01). CD34 staining was significantly higher in polyurethane and viable allografts versus deep-frozen allograft (progenitor cells p<0.05; blood vessels p<0.01). There were no significant differences in SMA or aggrecan staining across groups. All three specimen types demonstrated strong presence of collagen type I. CONCLUSIONS: Both viable allograft and a polyurethane meniscal scaffold show enhanced morphological, cell-distribution and regenerative patterns over deep-frozen allograft following surgical implantation. Given the limitations in viable allograft availability, these findings support the continued development of synthetic scaffolds for meniscus replacement surgery.

Arthroscopic double-row anterior stabilization and bankart repair for the "high-risk" athlete.

In addition to operative intervention for the patient with recurrent shoulder instability, current literature suggests that younger athletic patients unwilling to modify their activities may benefit from an early surgical shoulder stabilization procedure. Although open shoulder stabilization clearly has a role to play in some cases, we believe that further optimization of arthroscopic fixation techniques may allow us to continue to refine the indications for open stabilization. In particular, when an arthroscopic approach is used for capsulolabral repair in relatively high-risk groups, it may be beneficial to use a double-row repair technique. We describe our technique for shoulder stabilization through double-row capsulolabral repair of a soft-tissue Bankart lesion in the high-risk patient with shoulder instability or the patient with a small osseous Bankart lesion.

Restoration of articular cartilage.

➤ Novel (i.e., quantitative and semiquantitative) cartilage imaging techniques can evaluate cartilage composition to augment information obtained from traditional magnetic resonance imaging sequences that detail morphology.➤ A well-defined role for drugs leading to chondroprotection has not yet been determined.➤ Shortcomings of bone marrow stimulation include limited production of hyaline repair tissue, unpredictable repair cartilage volume, and a negative impact on later cellular transplantation if required.➤ The role of biological augments, such as cellular concentrates or platelet-rich plasma, remains undefined. When their use is reported in the literature, it is important that their process of production and characterization be detailed.➤ Rehabilitation programs, incorporating controlled exercise and progressive partial weight-bearing, are an important part of cartilage repair surgery and should be detailed in reports on operative techniques applied.➤ Malalignment, meniscal injury, and ligament deficiency should be corrected in a staged or concomitant fashion to reduce the overall likelihood of mechanical failure in cartilage repair surgery.

Restoration of the meniscus: form and function.

Over the past 2 decades there has been a profound shift in our perception of the role of the meniscus in the knee joint. Orthopaedic opinion now favors salvaging and restoring the damaged meniscus where possible. Basic science is characterizing its form (anatomy) and functionality (biological and biomechanical) in an attempt to understand the effect of meniscal injury and repair on the knee joint as a whole. The meniscus is a complex tissue and has warranted extensive basic science, translational, and clinical research to identify techniques to augment healing and even replace the meniscus. The application of quantitative magnetic resonance image sequencing to the meniscus and articular cartilage of the affected compartment promises to add a quantifiable outcome measure to the body of clinical evidence that supports restoration of the meniscus. This article discusses the recent advances and outcomes in the pursuit of meniscal restoration with particular focus on the use of augmentation strategies in meniscal repair, meniscal imaging, and translational strategies.

Osteochondritis dissecans of the knee in children and adolescents.

PURPOSE OF REVIEW: Osteochondritis dissecans (OCD) of the knee is a well-described condition that can cause significant morbidity in children and adolescents; timely diagnosis is key to preventing compromise to the articular cartilage and maximizing opportunity to perform a restorative procedure. Juvenile OCD has a better prognosis than does adult OCD, with higher rates of spontaneous healing with conservative treatment. Still, there are certain indications for surgical restoration procedures. Controversies arise over when to decide surgical procedure and what is the best surgical treatment option in this young population. RECENT FINDINGS: Some authors believe nonoperative management should be the first-line treatment for stable OCD lesions in children. The only consensus in regard to this modality is that, if a patient is truly asymptomatic or experiencing low-level symptoms, then the duration of nonoperative treatment should be at least 3-6 months before opting for operative treatment. In the case of failed nonsurgical management or in the setting of an unstable fragment, surgical intervention should be implemented. Recent published data suggest no difference in clinical or radiographic outcome when comparing different surgical techniques. SUMMARY: OCD of the knee requires a timely diagnosis to maximize opportunity to perform a reparative procedure. Indications for surgical treatment are based on lesion stability, skeletal maturity, and clinical symptoms. Reestablishing the joint surface, improving the blood supply of the fragment, rigid fixation, and early motion are primary goals for osteochondral fragment preservation. When the fragment is not suitable for preservation, careful consideration of defect location and the patient's clinical presentation will determine when cartilage restoration procedures should be utilized.

Advancing regenerative surgery in orthopaedic sports medicine: the critical role of the surgeon.

The constant desire to improve outcomes in orthopaedic sports medicine requires us to continuously consider the challenges faced in the surgical repair or reconstruction of soft tissue and cartilaginous injury. In many cases, surgical efforts targeted at restoring normal anatomy and functional status are ultimately impaired by the biological aspect of the natural history of these injuries, which acts as an obstacle to a satisfactory repair process after surgery. The clinical management of sports injuries and the delivery of appropriate surgical intervention are continuously evolving, and it is likely that the principles of regenerative medicine will have an increasing effect in this specialized field of orthopaedic practice going forward. Ongoing advances in arthroscopy and related surgical techniques should facilitate this process. In contrast to the concept of engineered replacement of entire tissues, it is probable that the earliest effect of regenerative strategies seen in clinical practice will involve biological augmentation of current operative techniques via a synergistic process that might be best considered "regenerative surgery." This article provides an overview of the principles of regenerative surgery in cartilage repair and related areas of orthopaedic surgery sports medicine. The possibilities and challenges of a gradual yet potential paradigm shift in treatment through the increased use of biological augmentation are considered. The translational process and critical role to be played by the specialist surgeon are also addressed. We conclude that increased understanding of the potential and challenges of regenerative surgery should allow those specializing in orthopaedic surgery sports medicine to lead the way in advancing the frontiers of biological strategies to enhance modern clinical care in an evidence-based manner.