Comparative study on clinical outcomes in autologous chondrocyte implantation using three-dimensional cultured JACC® with collagen versus periosteum coverings.

This study investigates the efficacy of a collagen membrane as a substitute for autologous periosteum in atelocollagen-assisted autologous chondrocyte implantation (ACI) using J-TEC autologous cultured cartilage (JACC®). Sixty-nine patients with knee joint chondral defects underwent ACI using JACC®-34 with periosteum-covered ACI (P-ACIs) and 35 with collagen-covered ACI (C-ACIs). Clinical outcomes were compared through patient-reported measures, International Cartilage Repair Society (ICRS) Cartilage Repair Assessment (CRA) scores at second-look arthroscopy one year postoperatively, and adverse event incidence. Postoperative subjective scores significantly improved up to two years, with no significant differences between P-ACI and C-ACI groups. However, C-ACI exhibited a lower adverse event rate (p = 0.034) and significantly higher ICRS CRA scores (p = 0.0001). Notably, C-ACI outperformed P-ACI in both femoral condyle and trochlea assessments (p = 0.0157 and 0.0005, respectively). While clinical outcomes were comparable, the use of a collagen membrane demonstrated superiority in ICRS CRA during second-look arthroscopy and adverse event occurrence.

Do standardization of the procedure reduce measurement variability of the sonographic anterior drawer test of the ankle?

BACKGROUND: In quantitative ankle stress sonography, different examiners use different techniques, which may cause measurement variability. This study aimed to clarify whether standardizing stress sonography techniques reduces variability in the quantitative measurement of anterior talofibular ligament length change. METHODS: Fourteen examiners with a mean ultrasound experience of 8.7 years participated in this study. Each examiner performed stress ultrasonography of the ankle using their preferred method on one patient with an intact anterior talofibular ligament (Patient 1) and on two patients with chronic ankle instability (Patient 2 and 3). Changes in the ligament length between the resting and stressed positions were determined. A consensus meeting was then conducted to standardize the sonographic technique, which was used by the examiners during a repeat stress sonography on the same patients. The variance and measured values were compared between the preferred and standardized techniques using F-tests and paired t-tests, respectively. RESULTS: At a consensus meeting, a sonographic technique in which the examiner pushed the lower leg posteriorly against the fixed foot was adopted as the standardized technique. In Patient 1, the change in the anterior talofibular ligament length was 0.4 (range, -2.3-1.3) mm and 0.6 (-0.6-1.7) mm using the preferred and standardized techniques, respectively, with no significant difference in the variance (P = 0.51) or the measured value (P = 0.52). The length changes in Patient 2 were 2.0 (0.3-4.4) mm and 1.7 (-0.9-3.8) mm using the preferred and standardized techniques, respectively. In Patient 3, the length changes were 1.4 (-2.7-7.1) mm and 0.7 (-2.0-2.3) mm. There were no significant differences between the techniques in either patient group. CONCLUSION: Variability in the quantitative measurement of ankle stress sonography was not reduced despite the standardization of the technique among examiners. Hence, comparing the measured values between different examiners should be avoided.

Sonographically Guided Anchor Placement in Anterior Talofibular Ligament Repair Is Anatomic and Accurate.

BACKGROUND: Arthroscopic repair is a widely accepted surgical treatment for chronic ankle instability; however, recent studies have shown that arthroscopic repair is nonanatomic in its anchor placement and resultant biomechanics. Ultrasound may improve the accuracy of the anchor placement. HYPOTHESIS: Our hypothesis was that the accuracy of anchor placement in sonographically guided anterior talofibular ligament (ATFL) repair will be comparable with that in open ATFL repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The study included 26 patients who received surgical treatment between April 2012 and October 2019 for chronic ankle instability. Fifteen patients underwent open modified Broström repair and 11 underwent sonographically guided ATFL repair. The distance between the anchor hole and the fibular obscure tubercle was measured using 3-dimensional computed tomography and was compared between the operative procedures. For comparison, a noninferiority trial was employed, with open modified Broström repair as the reference surgery. The noninferiority margin was defined as 5 mm. RESULTS: The mean ± SD distance between the anchor and fibular obscure tubercle was 6.0 ± 2.7 mm in open repair and 5.6 ± 3.3 mm in sonographically guided repair. The mean difference in distance between the techniques (open repair - sonographically guided repair) was 0.37 mm (95% CI, -2.1 to 2.9 mm). The lower margin of the confidence interval was within the noninferiority margin (-5 to 5 mm). CONCLUSION: Anchor placement under sonographically guided ATFL repair was equivalent to that of open ATFL repair and can be considered anatomic and accurate.

Dorsiflexion is more feasible than plantar flexion in ultrasound evaluation of the calcaneofibular ligament: a combination study of ultrasound and cadaver.

PURPOSE: Ultrasound (US) is a valuable tool for the evaluation of chronic lateral instability of the ankle; however, the feasibility of US for calcaneofibular ligament (CFL) assessment remains unknown. This study aimed to depict and compare CFL on US in various ankle positions to determine the optimal method for evaluating CFL with US and to interpret US findings using cadaveric specimens. METHODS: The US study included 43 ankles of 25 healthy individuals. The CFL was scanned with US in 20° plantar flexion, neutral position, 20° dorsiflexion and maximum dorsiflexion. The distances between fibula and CFL were compared. The cadaveric study included macroscopic qualitative observation of the dynamic change of CFL in 7 ankles and quantitative observation of the directions of CFL and footprints in 17 ankles. RESULTS: In the US study, the mean distance (mm) between fibula and CFL was 7.3 ± 1.3 in 20° plantar flexion, 6.7 ± 1.6 in neutral position, 4.3 ± 2.5 in 20° dorsiflexion and 3.1 ± 2.1 in maximum dorsiflexion. The more dorsiflexed the ankle was, the shorter the distance between fibula and CFL was (Jonckheere's trend test p < 0.001). In the cadaveric study, the CFL fibres were aligned parallel between the mid-substance and the fibular attachment in maximum dorsiflexion, whilst CFL was reflected and rotated in plantar flexion. CONCLUSIONS: The whole length of the CFL, including its fibular attachment, is more likely to be visualized with US in dorsiflexion than in plantar flexion due to the direction of the CFL at the fibular attachment, which is parallel with the mid-substance in maximum dorsiflexion. LEVEL OF EVIDENCE: IV.

Dynamic high-resolution ultrasound in the diagnosis of calcaneofibular ligament injury in chronic lateral ankle injury: a comparison with three-dimensional magnetic resonance imaging.

PURPOSE: To date, no gold standard imaging method has been used to assess calcaneofibular ligament (CFL) injuries. Ultrasound (US) has become increasingly important in the assessment of ligaments around the ankle. However, very few reports in the literature have focused on detecting CFL injuries. The objective of this study was to determine the effectiveness of ultrasound in detecting CFL injuries in comparison with magnetic resonance imaging (MRI). METHODS: A retrospective study was conducted in 21 patients with chronic lateral ankle injury, 10 males and 11 females with a mean age of 27.6 ± 14.5 years (range 14-68 years). High-frequency US and three-dimensional (3D) MRI of the affected ankle were performed. Evaluations of the CFL were performed by two orthopedic surgeons experienced in US, while the MRI findings were interpreted by two musculoskeletal radiologists. The US findings were then compared with the MRI findings. RESULTS: US detected CFL injury in 9/21 patients, and these findings were confirmed by the MRI findings. However, one patient with a normal CFL on US was evaluated as laxity on MRI. In this study, US sensitivity and specificity in detecting CFL injuries was 90% (9/10) and 100% (10/10), respectively, with a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 91.7% in comparison with MRI. CONCLUSION: With the proper technique and knowledge of the ankle anatomy, high-frequency US proved to be an effective imaging modality in the diagnosis of CFL lesions in chronic lateral ankle injuries. US had a high sensitivity and specificity in the evaluation of the CFL when MRI findings were regarded as the reference standard.

Use of intraarticular injections of platelet-rich plasma in the treatment of knee osteoarthritis: A review article.

Osteoarthritis is one of the most common degenerative conditions affecting knee joint. As our understanding in the disease pathogenesis is evolving, so do the treatment modalities. One of the postulated mechanisms suggests the production of inflammatory cytokines secondary to repeated micro trauma than in turn lead to cartilage damage overtime. Cartilage being avascular structure has limited potential for repair. Based on this, recent studies have been focusing on stimulating cartilage-healing process by growth factors. This is where platelet-rich plasma comes in to light. Literature is showing promising results of platelet-rich plasma in treating knee osteoarthritis. In this review we have discussed the preparation, composition, classification, uses of platelet-rich plasma as well as evidence for its efficacy and complications.

Ultrasonography-Guided Muscle Hematoma Evacuation.

Muscle injuries commonly occur in athletes, and in severe cases, they can result in hematoma formation, leading to pain and loss of function. A technique for minimally invasive ultrasound-guided evacuation of muscle hematoma is presented. A simple and quick outpatient procedure done under local anesthesia for faster muscle recovery provided immediate decompression of the muscle compartment, leading to early return to play.

Changes in calcaneal pitch and heel fat pad thickness in static weight bearing radiographs while wearing shoes with arch support and heel cup orthotics.

BACKGROUND: Foot orthoses have been shown to reduce the collapse of the longitudinal arch and to constrain soft tissue displacement under the heel. However, there has not been a study that has shown the effectiveness of both the arch and heel features in the same orthosis. This study quantitatively analyzed if the calcaneal pitch and the heel pad thickness will be affected by the use of an arch support and heel cup insole in a static weightbearing stance while wearing sports shoes. METHODS: Twenty-four (24) feet from 12 elite-level female soccer players with a mean age of 25 ±â€¯3.99 years (20-33 years old) were studied. Lateral weightbearing radiographs with and without orthotics were obtained in order to measure the calcaneal pitch angle and heel fat pad thickness for each foot. A subjective outcome measure was used and the scores were classified as bad (0-2), fair (3-5), good (6-8), or excellent (9-10). RESULTS: The calcaneal pitch angle increased in all but three cases by an average of 1.05° (range, -1.14 to 3.19) after wearing orthotics (p < 0.01). The heel fat pad thickness increased in all cases with an average of 1.25 mm (range, 1.05 to 1.47; p < 0.01)). 9 of 12 subjects (75%) reported excellent (n = 2) or good (n = 7) overall subjective scores with insole wear. CONCLUSION: Under static weightbearing conditions, the arch support and heel cup features of a foot orthosis help improve the height of the calcaneal pitch and the thickness of the heel fat pad, respectively.

Beta-Tricalcium Phosphate Block for Donor Site Morbidity of the Patella in Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Graft.

PURPOSE: This study aimed to investigate anterior knee symptoms in patients who underwent anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) graft followed by implantation of a beta-tricalcium phosphate (ß-TCP) block as a bone void filler. MATERIALS AND METHODS: We retrospectively reviewed 84 cases of synthetic bone grafting using a ß-TCP block for the patellar bone defect in ACL reconstruction with a BPTB autograft. Computed tomography of the operated knee was performed immediately after the surgery to evaluate whether the grafted ß-TCP block protruded forward from the anterior surface of the patella. On the basis of the results, the cases were divided into a protrusion group (n=31) and a non-protrusion group (n=53). Anterior knee symptoms at 12 months postoperatively and absorption of the grafted ß-TCP block were compared between the two groups. RESULTS: Except for patellofemoral crepitus, there was no significant difference in anterior knee symptoms between the two groups (p>0.05). The incidence of patellofemoral crepitus was significantly lower in the protrusion group than in the non-protrusion group (p=0.027). The groups showed no significant difference in ß-TCP absorption. CONCLUSIONS: The present study demonstrated that the protrusion of ß-TCP that was used as a bone void filler had no adverse effects.

A large knee osteochondral lesion treated using a combination of osteochondral autograft transfer and second-generation autologous chondrocyte implantation: A case report.

BACKGROUND: Full-thickness knee cartilage defects greater than 4 cm2 are best treated with autologous chondrocyte implantation (ACI). Since the articular cartilage surrounding the site of implantation does not always have the normal thickness desirable for successful engraftment, there may be benefit in combining ACI with osteochondral autograft transfer, which provides immediate restoration of condylar contour and mechanical function. CASE PRESENTATION: A 19 year-old male who sustained a traumatic anterolateral femoral condyle osteochondral fracture underwent arthroscopic knee surgery three months after injury to harvest healthy cartilage to be sent to the Japan Tissue Engineering Co., Ltd. (J-TEC) for cartilage culture. The patient was re-admitted after four weeks to undergo a procedure using the Osteochondral Autograft Transfer System (OATS®) and the J-TEC autologous cultured cartilage (JACC®) system. Three 4.75-mm osteochondral cylindrical cores were harvested from non-weight-bearing areas of the knee and were transplanted to the lateral periphery of the lateral femoral condyle defect. The cultured cartilage was implanted to the remaining defect with a periosteal cover harvested from the anterolateral ridge of the lateral femoral condyle. Continuous passive range of motion exercises and gait retraining were immediately initiated, with strict no weight-bearing precaution on the operated limb. Partial weight-bearing was allowed four weeks after surgery, which was progressed to full weight-bearing after another two weeks. CONCLUSION: ACI must be viewed as a complementary procedure to osteochondral transplantation and this hybrid technique appears to be a promising surgical approach and treatment option for large cartilage lesions, especially in the younger population.

Combined autologous chondrocyte implantation and meniscus reconstruction for large chondral defect in the lateral compartment due to discoid lateral meniscus tear: A case report.

Discoid lateral meniscus tear leads to large chondral defect in the lateral compartment of the knee joint. There are few effective treatments for large chondral defect in both the tibial and femoral sides with severe degenerative lateral meniscus. We have developed a combined autologous chondrocyte implantation and meniscus reconstruction technique using hamstring tendon. This technique allows biological reconstruction and avoids knee arthroplasty.

A new method for tensioning of a chronic tibial bony avulsion of the posterior cruciate ligament as a posteromedial bundle and augmentation by anterolateral bundle reconstruction in a bicruciate ligament injury: A case report.

Multiple ligament injury is associated with high instability; hence, it is necessary to restore stability through application of a reliable treatment strategy. We report our experiences in handling a case of ruptured anterior cruciate ligament (ACL) complicated by chronic bony avulsion of the posterior cruciate ligament (PCL). Favourable results were obtained as a result of ACR reconstruction following a new method for tensioning of the chronic tibial bony avulsion of PCL as a postero-medial bundle and augmentation by PCL anterolateral bundle reconstruction. Favourable posterior stability could be restored through application of this new technique incorporating post-reconstruction PCL reinforcement.

Ultrasonography and return to play of the different clinical grading of quadriceps contusions: a case series.

Prognostication of quadriceps contusion is based on the patient's active knee flexion after the injury. Unlike ultrasonography, clinical grading does not define the extent of soft tissue injury and may provide inaccurate time for return to play. The purposes of this report are to describe the ultrasound findings of the different clinical grading of quadriceps contusion and document the return to play of each case. Seven patients were evaluated in this series. Results showed discrepancies in the disability time between clinical grading and ultrasound findings. Clinical grading did not consistently estimate the return to play as described in previously published literature. Contusions with hyperechoic lesions had earlier return to play compared to patients with hypoechoic findings. Contusions with hypoechoic lesions might require aggressive monitoring and therapy to decrease disability time and avoid complications such as myositis ossificans.

Ultrasound-Assisted Posteromedial Portal Placement of the Elbow Joint to Prevent Ulnar Nerve Injury.

Direct posterior and posterolateral portals are the standard portals used in posterior elbow arthroscopy. A posteromedial portal in the elbow is not recommended because of its proximity to the ulnar nerve. However, iatrogenic injuries to the ulnar nerve have been reported after elbow arthroscopy using the standard posterior portals, especially in posteromedial elbow joint pathologies. We present a surgical technique applicable to posteromedial elbow pathology by using ultrasound-assisted posteromedial portal placement of the elbow joint. Through this technique, the position of the ulnar nerve is identified prior to portal creation and the instruments are introduced from an ulnar to radial direction, thus avoiding ulnar nerve injury.

Editorial Commentary: Full Extension or 30° Flexion in Graft Fixation for Anatomic Anterior Cruciate Ligament Reconstruction. Is This Surgeons' Preference?

An anatomic anterior cruciate ligament reconstruction with the graft fixed at 30° knee flexion may be the best solution for preventing rotational instability.

Ultrasound-Assisted Endoscopic Carpal Tunnel Release.

Various surgical procedures for carpal tunnel syndrome exist, such as open release, ultrasound-guided percutaneous release, and endoscopic release. Postoperative pain, scarring, and slow recovery to normal function are reported complications of open release. Damage to vessels and the median nerve and its branches underlying the transverse carpal ligament is a reported complication of ultrasound-guided percutaneous release. Damage to the superficial palmar arch and incomplete release are reported complications of endoscopic release. By performing endoscopic carpal tunnel release with ultrasound assistance, we could visualize neurovascular structures directly with the endoscope and also indirectly with ultrasound to minimize complications. We could also evaluate the morphologic changes of the median nerve dynamically before and after the release. We discuss the technique for this procedure and outline pearls and pitfalls for success.

Editorial Commentary: All-Inside or Inside-Out Meniscal Repair for the Posterior Thirds in Meniscus Allograft Transplantation? Which to Choose and What Difference It Makes.

Performing an all-inside repair or inside-out fixation for the posterior third in meniscus allograft transplantation is discussed. Less invasiveness is always important when the results are the same, and surgeons' personal experience may be a determining factor for this procedure.

Ultrasound-assisted endoscopic partial plantar fascia release.

Various surgical treatment procedures for plantar fasciitis, such as open surgery, percutaneous release, and endoscopic surgery, exist. Skin trouble, nerve disturbance, infection, and persistent pain associated with prolonged recovery time are complications of open surgery. Endoscopic partial plantar fascia release offers the surgeon clear visualization of the anatomy at the surgical site. However, the primary medial portal and portal tract used for this technique have been shown to be in close proximity to the posterior tibial nerves and their branches, and there is always the risk of nerve damage by introducing the endoscope deep to the plantar fascia. By performing endoscopic partial plantar fascia release under ultrasound assistance, we could dynamically visualize the direction of the endoscope and instrument introduction, thus preventing nerve damage from inadvertent insertion deep to the fascia. Full-thickness release of the plantar fascia at the ideal position could also be confirmed under ultrasound imaging. We discuss the technique for this new procedure.

Off-pump resection of a coronary arterial fistula using the Harmonic Scalpel.

Off-pump surgery was performed in a patient with post-infarction angina complicated with aneurysmal coronary-pulmonary arterial fistula. Epicardial echocardiography localized the artery feeding the fistula in the myocardium, which had not been revealed by visual inspection, palpation, or transesophageal echocardiography. The patient underwent off-pump coronary artery bypass grafting concomitant with aneurysmectomy. The feeding arteries were dissected easily using a Harmonic Scalpel and ligated. The flow in the aneurysm disappeared immediately and aneurysmectomy was performed without bleeding.