Outcomes following gel-based autologous chondrocyte implantation for articular cartilage defects of the knee.

BACKGROUND: Gel-based autologous chondrocyte implantation (GACI) enables a simpler and more effective delivery of chondrocytes with reproducible three-dimensional structural restoration of the articular cartilage surface. There is limited documentation of medium-term outcomes. This study assessed safety and effectiveness of GACI for treatment of cartilage defects of the knee. METHODS: This multicentric retrospective study was conducted across eight hospitals in India. Patients who had undergone GACI (CARTIGROW®) between 2008 and 2014 for the treatment of focal articular cartilage defects of the knee (mean defect size 4.5 ± 5.8 cm2) in limbs with normal alignment were analyzed. Primary outcomes were changes in Lysholm Knee Scoring Scale score, and Knee Outcome Sports Activity Scale (SAS). RESULTS: A total of 107 patients (110 knee joints) with mean age 31.0 ± 10.5 years were included. The mean follow-up was 9.8 ± 1.5 years (range 7.85-13.43). Majority had osteochondritis dissecans (n = 51; 46.4%). The mean Lysholm Knee Scoring Scale score (81.23 ± 13.21 vs. 51.32 ± 17.89; p < 0.0001) and SAS score (80.93 ± 8.26 vs. 28.11 ± 12.28; p < 0.0001) improved significantly at follow-up as compared to pre-operative. Magnetic Resonance Observation of Cartilage Repair Tissue score in 39 patients at minimum 2 years follow-up was 84.5 ± 4.3. Among 30 patients who were playing sports before treatment, 17 patients (56.7%) could return to the same or higher level of sports post-transplantation. No major intra-operative or post-operative complications were noted. Four patients warranted revision surgery. CONCLUSION: GACI is an effective treatment option for large focal articular cartilage defects of the knee with a low complication rate and revision rate and significant improvement in functional scores.

Criterion-Based Rehabilitation and Return to Play in Fast Bowlers Following Arthroscopic Bankart Repair: Recommendations Based on a Detailed Clinical Review.

Background: Anterior shoulder instability due to labral tears in the dominant arm of cricket fast bowlers can be particularly disabling and results in significant match time loss. This often follows injuries sustained during fielding and training, although micro-instability following repetitive throwing progressing to overt anterior shoulder instability is also known. To ensure ball release speeds of over 140 km/h with different ball variations, these athletes require not only physical fitness and technical skill, but also a completely stable shoulder. Methods: A literature search of "MEDLINE", "SPORT DISCUSS", and "GOOGLE SCHOLAR" was done to identify relevant articles published till the year 2023. Results: A treatment approach that involves anatomic restoration of the shoulder via an arthroscopic Bankart capsulo-labral repair, followed by functional and biomechanical restoration via rehabilitation is the most predictable method to ensure a successful return to pre-injury fast-bowling status. A post-operative rehabilitation program that ensures a quick return to fast bowling without disrupting the surgical repair is crucial. Timely integration of exercises to recruit and strengthen the kinetic chain used for bowling and throwing plays a key role in this faster recovery. This current review provides a phase-wise, evidence-based rehabilitation guideline for return to competitive cricket after arthroscopic Bankart repair in a fast bowler. This review also highlights a structured return to bowling, throwing, and fielding program with a clinical decision-making process. Conclusion: Exercise selection at an early stage that does not compromise the healing tissue, and timely integration of workouts to recruit and strengthen the kinetic chain used for bowling and throwing is the key strategy to allow faster recovery. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-023-00931-5.

Chronic Irreducible Knee Dislocations: Outcomes following Open Reduction and Reconstructive Surgery.

The management of unreduced knee dislocations who present late is challenging. The aim of this study was to determine the clinical, radiological, and functional outcomes following open reduction and reconstructive surgery for chronic irreducible knee dislocations. This retrospective study analyzed prospectively collected data of patients with an unreduced fixed anterior or posterior knee dislocation of 1 to 6 months' duration, treated with open reduction, hinged external fixator application, and ligament reconstruction who had a minimum 2-year follow-up. Patients were classified based on presence of prior periarticular surgery and direction of dislocation. Data on pre- and posttreatment clinical, radiological, and functional scores were analyzed. A total of 21 patients (age range: 19-43 years) fulfilled all inclusion criteria. These included 13 missed dislocations and 8 neglected postoperative dislocations. There were 18 posterior and 3 anterior dislocations. The mean follow-up was 6.9 years (range: 2.7-16.2 years). On final follow-up, all 21 patients were independently ambulatory with mean knee range of motion 127 degrees. No patient had symptomatic knee instability at final follow-up, despite four having isolated grade-III posterior cruciate ligament (PCL) laxity. Anatomical reduction was achieved in 19 patients, whereas 2 patients had incomplete joint reduction with a persistent grade-II fixed posterior subluxation. Scanograms revealed coronal alignment within 5 degrees of the opposite unaffected limb in 17 patients. Mean functional scores improved from preoperative 9.4 ± 4.7 (range: 2-19) to postoperative 75.9 ± 8.0 (range: 64-95) for Lysholm's and preoperative 10.7 ± 1.8 (range: 8.3-13.7) to postoperative 73.5 ± 6.7 (range: 66.7-88.7) for knee injury and osteoarthritis outcome score (KOOS) scores. Prior periarticular surgery was associated with significantly inferior Lysholm's scores (p < 0.04). Although 23.8% knees developed posttraumatic knee arthritis, no patient had undergone conversion to knee arthroplasty or arthrodesis. The study concludes that open reduction and reconstructive surgery is an effective surgical treatment for chronic irreducible knee dislocations of up to 6 months duration. An individualized, often staged approach that prioritizes joint reduction, early knee mobilization, and knee stability, ensures satisfactory clinical, radiological, and functional outcomes in the medium term. This is a clinical case series and reflects level of evidence IV.

Arthroscopic biological internal bracing with remnant repair for subacute ACL femoral avulsions.

Arthroscopic anterior cruciate ligament (ACL) reconstruction predictably restores sagittal plane knee stability, however its inability to replicate a complex fan-shaped ligament of multiple fascicles, along with deficient restoration of normal rotational knee kinematics, results in failure to reverse a high risk for premature post-traumatic osteoarthritis. Although arthroscopic repair for acute ACL femoral avulsions is proposed to counter these deficiencies, the risk of early failure following non-healing, along with lack of convincing evidence of efficacy has impeded its universal acceptance. Moreover, since ACL repair needs to be performed in the acute phase following injury, it has an increased risk of developing arthrofibrosis, besides precluding any possibility to achieve natural healing of an ACL avulsion with non-operative treatment. The technique of biological internal bracing with remnant repair incorporates the advantages of both reconstruction and repair, and is indicated for patients with persistent ACL deficiency in the subacute phase (6-12 weeks) following an ACL femoral avulsion. This operation essentially involves two steps. The step of biological internal bracing is similar to a conventional ACL reconstruction using a small diameter hamstring graft that is targeted to the centre of the anteromedial ACL bundle on the femur, whereas the tibial socket is located posteriorly within the ACL tibial footprint so as to preserve the anterior fan-shaped morphology of the ACL tibial insertion. The second step involves repairing the remnant ACL tibial stump using one of three techniques. Although technically more complex than an ACL reconstruction, this novel technique provides native anatomy restoration with potential biomechanical and functional advantages, and should be considered for unhealed subacute ACL avulsion injuries.

Trends in Practice Among Shoulder Specialists in the Management of Frozen Shoulder: A Consensus Survey.

Background: The management of frozen shoulder (FS) differs depending on experience level and variation between scientific guidelines and actual practice. Purpose: To determine the current trends and practices in the management of FS among shoulder specialists and compare them with senior shoulder specialists. Study Design: Consensus statement. Methods: A team of 15 senior shoulder specialists (faculty group) prepared a questionnaire comprising 26 questions regarding the definition, terminology, clinical signs, investigations, management, and prognosis of FS. The questionnaire was mailed to all the registered shoulder specialists of Shoulder and Elbow Society, India (SESI) (specialist group; n = 230), as well as to the faculty group (n = 15). The responses of the 2 groups were compared, and levels of consensus were determined: strong (>75%), broad (60%-74.9%), inconclusive (40%-59.9%), or disagreement (<40%). Result: Overall, 142 of the 230 participants in the specialist group and all 15 participants in the faculty group responded to the survey. Both groups strongly agreed that plain radiographs are required to rule out a secondary cause of FS, routine magnetic resonance imaging is not indicated to confirm FS, nonsteroidal anti-inflammatory drugs should be administered at bedtime, steroid injection (triamcinolone or methylprednisolone) is the next best option if analgesics fail to provide pain relief, passive physical therapy should be avoided in the freezing phase, <10% of patients would require any surgical intervention, and patients with diabetes and thyroid dysfunction tend to fare poorly. There was broad agreement that routine thyroid dysfunction screening is unnecessary for women, a single 40-mg steroid injection via intra-articular route is preferred, and arthroscopic capsular release (ACR) results in a better outcome than manipulation under anesthesia (MUA). Agreement was inconclusive regarding the use of combined random blood sugar (RBS) and glycosylated hemoglobin versus lone RBS to screen for diabetes in patients with FS, preference of ACR versus MUA to treat resistant FS, and the timing of surgical intervention. There was disagreement over the most appropriate term for FS, the preferred physical therapy modality for pain relief, the most important movement restriction for early diagnosis of FS, and complications seen after MUA. Conclusion: This survey summarized the trend in prevalent practices regarding FS among the shoulder specialists and senior shoulder surgeons of SESI.

Prophylaxis for preventing venous thromboembolism in knee arthroscopy and soft tissue reconstruction: consensus statements from an international panel of experts.

PURPOSE: There is a lack of consensus regarding need for Venous Thrombo Embolism (VTE) prophylaxis following arthroscopic knee surgery and open soft tissue knee reconstruction. Clear cut guidelines like ones for trauma surgery and arthroplasty do not exist and the published literature is limited to case reports with a few society guidelines. Given this lack of consensus, we conducted a modified Delphi questionnaire of international experts to provide recommendations on this topic. METHODS: The consensus statements were generated using an anonymised 3 round modified Delphi questionnaire, sent to an international panel of 38 knee surgeons, with an 80% agreement being set as the limit for consensus. The responses were analysed using descriptive statistics with measures like mode, median and box plots. Feedback was provided to all panelists based on responses from the previous rounds to help generate the consensus. RESULTS: Six consensus statements were generated after the three rounds of Delphi. Patient factors, prolonged surgery duration and family history of thrombogenic events emerged as the main points to be taken into consideration for prophylaxis. CONCLUSION: It was established through this study, that there exists a select group of patients undergoing arthroscopic surgery that justify the usage of VTE prophylaxis. The expert responses to most of the questions in different scenarios favoured usage of VTE prophylaxis based on patient factors like advanced age, past history of VTE, smoking, oral contraceptive use etc. LEVEL OF EVIDENCE: Level V.

Osteochondritis dissecans of the glenoid: an analysis of grades, treatment, and outcomes.

BACKGROUND: Osteochondritis dissecans (OCD) is an idiopathic disorder of subchondral bone that causes focal articular cartilage disruption with the potential long-term consequence of premature osteoarthritis. Glenoid OCD is exceedingly rare. This case series aims to identify the grades of glenoid OCD and report its grade-specific treatment with clinical, radiological, and functional outcomes. METHODS: Prospectively collected data of consecutive patients diagnosed with a symptomatic glenoid OCD, who had a minimum 2-year follow-up, following nonoperative or surgical treatment, was retrospectively analyzed. Osteochondral defects secondary to acute trauma, instability, and primary osteoarthritis were excluded. Pretreatment and posttreatment clinical, radiological, and sports participation data were collected. This included pretreatment MRI for grading of glenoid OCD according to the International Cartilage Research Society (ICRS) OCD staging system, and postoperative MRI for grading of articular cartilage repair using the MOCART (MRI observation of cartilage repair tissue) scoring system. RESULTS: The study identified 7 competitive overhead athletes with symptomatic unilateral glenoid OCD, with a post-treatment minimum 2-year follow-up. Of 4 patients with ICRS OCD I, 3 healed with nonoperative treatment, whereas 1 progressed to ICRS OCD II. This patient along with another 3 patients with unstable glenoid OCD underwent arthroscopic OCD excision with bone marrow stimulation cartilage repair. All patients improved following treatment and had full passive and active range of shoulder movements, with normal strength and stability at the 2- year follow-up. The mean MOCART score on MRI at 2 years for the 4 patients who underwent surgery was 82.5 (range, 75-90). MRI documented healing in all 3 patients with ICRS OCD I who underwent nonoperative treatment. All patients returned to the same or higher level of sport following treatment, with mean time to return to sports being 8.0 months (range, 6-11 months) for nonoperative treatment, and 6.8 months (range, 5-10 months) for operative treatment. This difference was not statistically significant (P value .55). No patient had recurrence of symptoms till latest follow-up. CONCLUSION: Despite the glenoid being a concave non-weight-bearing articular surface, OCD at this site has pathological grades similar to other convex weight-bearing articular surfaces. Notwithstanding the limited number of cases, it would appear that ICRS OCD I can often be successfully treated with nonoperative treatment, whereas ICRS OCD II, III, IV, warrant operative treatment. Bone marrow stimulation is a safe and predictable option for glenoid OCD cartilage repair and allows athletes a quick and successful return to sports.

Management Guidelines for Infection After ACL Reconstruction: Expert Opinion Statement Based on the Modified Delphi Survey of Indian Arthroscopy Surgeons.

AIM: Infection after anterior cruciate ligament (ACL) reconstruction, though rare, is a potentially devastating complication and the evidence-based recommendation on the various topics in its management is limited. The purpose of this study was to develop recommendations for the prevention and management of infections in ACL reconstruction surgery by performing a structured expert consensus survey using Delphi methodology. MATERIALS AND METHODS: 22 topics of relevance in the prevention and management of infection following ACL reconstruction were chosen from an extensive literature review. 30 panelists were requested to respond to a three-round survey, with feedback, to develop a consensus statement on the topics. RESULTS: Consensus statements could be prepared in eleven out of twenty-two topics including: the graft is retained at the first arthroscopic debridement, the graft is removed when repeated debridement are needed, and revision ACL reconstruction is needed only if the patient develops instability. Concurrence could be obtained in the topics including: longer duration of antibiotics is needed in immunocompromised patients, soaking graft in antibiotic solution reduces infection risk, and knee swelling without warmth does not suggest infection. CONCLUSIONS: A proper skin preparation, a longer course of antibiotics in immunocompromised patients, and soaking the graft in antibiotics reduces the risk of infection. In case of infection, a healthy-looking graft must be retained at the first debridement and if the graft must be removed, revision ACL reconstruction is advised only if the patient develops instability. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00363-z.

Badminton Injuries in Elite Athletes: A Review of Epidemiology and Biomechanics.

Badminton is a popular sport in India and with multiple medal prospects will be closely followed at the Tokyo 2020 Olympics. Considered the fastest of the racquet sports, players require aerobic stamina, agility, strength, speed, and precision, besides requiring good motor coordination and complex racquet movements. Injuries in badminton are common despite it not being a contact sport, and include overuse injuries, and acute traumatic events. The game is physically challenging and demands complex repetitive upper and lower extremity movements with constant postural variations and poses a high risk of overuse injuries to both the appendicular and axial musculoskeletal systems. Badminton also necessitates short bursts of movement with sudden sharp changes in direction, which places players at risk of non-contact traumatic injuries to joints and muscle-tendon units. Preventing injuries and decreasing time away from training and competition are critical in an elite badminton player's sporting career. This analytical review identifies the incidence, severity, and profile of badminton injuries in elite players, and discusses the biomechanical basis of these injuries.

Latissimus Dorsi Tear in an Olympics-Level Tennis Player: Case Report and Review of Literature.

Latissimus dorsi tears are extremely rare and are encountered primarily in high-level athletes. Noted initially in baseball pitchers, cases have been described in other sports too, with one report of a latissimus dorsi tear at the muscle-tendon junction in a tennis player. Anecdotal outcomes have been comparative after both non-operative and operative treatments. Although no clear indications for operative intervention exist, there is a general consensus that partial non-retracted tears can be managed with non-operative treatment, whereas complete tears warrant surgical repair. This case report describes a complete rupture with retraction of the latissimus dorsi tendon that occurred during a competitive match in an international level tennis player. Due to compelling sports participation reasons, this tear was managed with non-operative treatment. The player returned to competitive tennis within 6 weeks and won the Asian Games men's doubles tennis gold medal 53 days following his injury. He has had no subsequent shoulder-related symptoms despite his continuous participation in international level tennis for the past 18 months. We analyse the role of the latissimus dorsi in tennis and also review the available literature on this uncommon sports injury.

Injuries in Cricket.

CONTEXT: Cricket is a popular global sport that requires a combination of physical fitness, skill, and strategy. Although a noncontact sport, overuse and impact injuries are common since players engage in a wide range of physical activities, including running, throwing, batting, bowling, catching, and diving. Significant or match time-loss injuries are defined as those that either prevent a player from being fully available for selection in a major match, or during a major match, cause a player to be unable to bat, bowl, or keep wicket when required by either the rules or the team's captain. This review describes the various region-wise injuries sustained in cricket along with their epidemiology, biomechanics, treatment, and prevention. EVIDENCE ACQUISITION: Data were collected from peer-reviewed articles (obtained via PubMed search) published through November 2016 that involved the medical, biomechanical, and epidemiological aspects of cricket injuries. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: Cricket was one of the first sports to publish recommended methods for injury surveillance in 2005 from England, South Africa, Australia, the West Indies, and India. While the incidence of injuries is about the same, the prevalence of injuries has increased due to game format changes, increasing number of matches played, and decreased rest between matches. Bowling (41.3%), fielding, and wicket keeping (28.6%) account for most injuries. Acute injuries are most common (64%-76%), followed by acute-on-chronic (16%-22.8%) and chronic ones (8%-22%). The most common modern-day cricket injury is hamstring strain, and the most severe is lumbar stress fracture in young fast bowlers. CONCLUSION: With improved understanding of the scientific and medical aspects of cricket, along with advances in surgical and nonsurgical treatment techniques, the time to return to play has shortened considerably. While the prevalence of cricket injuries has increased, their severity has decreased over the past decades.

Knee Dislocations in Sports Injuries.

Knee dislocations are devastating when they occur on the athletic field or secondary to motor sports. The complexity of presentation and spectrum of treatment options makes these injuries unique and extremely challenging to even the most experienced knee surgeons. An astute appreciation of the treatment algorithm is essential to plan individualized management since no two complex knee dislocations are ever the same. Moreover, attention to detail and finesse of surgical technique are required to obtain a good functional result and ensure return to play. Over the past 10 years, our service has treated 43 competitive sportsmen with knee dislocations, and this experience forms the basis for this narrative review.

Imaging of cartilage repair procedures.

The rationale for cartilage repair is to prevent precocious osteoarthritis in untreated focal cartilage injuries in the young and middle-aged population. The gamut of surgical techniques, normal postoperative radiological appearances, and possible complications have been described. An objective method of recording the quality of repair tissue is with the magnetic resonance observation of cartilage repair tissue (MOCART) score. This scoring system evaluates nine parameters that include the extent of defect filling, border zone integration, signal intensity, quality of structure and surface, subchondral bone, subchondral lamina, and records presence or absence of synovitis and adhesions. The five common techniques of cartilage repair currently offered include bone marrow stimulation (microfracture or drilling), mosaicplasty, synthetic resorbable scaffold grafts, osteochondral allograft transplants, and autologous chondrocyte implantation (ACI). Complications of cartilage repair procedures that may be demonstrated on magnetic resonance imaging (MRI) include plug loosening, graft protuberance, graft depression, and collapse in mosaicplasty, graft hypertrophy in ACI, and immune response leading to graft rejection, which is more common with synthetic grafts and cadaveric allografts.

Case Series: Cyclops lesion - extension loss after ACL reconstruction.

Localized anterior arthrofibrosis (cyclops lesion) is the second most common cause of extension loss after anterior cruciate ligament (ACL) reconstruction. We present and discuss two patients with prior ACL reconstructions, who presented with pain and loss of extension following surgery. MRI and arthroscopy of the knee revealed typical features of a cyclops lesion. The patients showed significant symptomatic improvement following arthroscopic resection of these lesions.

Arthroscopic chondral cyst excision in a stiff Perthes' hip.

Persistent hip stiffness in Perthes' disease indicates a poor prognosis and is a therapeutic challenge. We report a case of a 13-year-old boy with a stiff Perthes' hip that was nonresponsive to prolonged nonsurgical treatment. Imaging revealed Catterall group IV Perthes' disease in an advanced reossification stage, with a focal defect in the weight-bearing area of the capital femoral epiphysis. A focal, compressible chondral elevation was detected on hip arthroscopy; on incision, flocculent fluid was released. After the cyst was excised, microfracture revascularization of the chondral defect was undertaken. Postoperatively, the patient had immediate pain relief, correction of deformity, and restoration of painless range of motion; this has continued for 4 years since surgery was performed. Persistence of an unhealed necrotic segment in Perthes' disease has traditionally been associated with osteochondritis dissecans; however, in this case, the unhealed and nonossified segment produced an elevated painful chondral cyst that caused spasm and stiffness of the hip. Although 2 distinct types of chondral lesions have been described in Perthes' disease, stiffness arising because of these lesions has not been reported. Patients with this unusual third type of chondral lesion of the capital femoral epiphysis, which causes persistent stiffness in Perthes' hip, may be identified and successfully treated with the use of arthroscopic techniques.

Imaging of giant cell tumor of bone.

Giant cell tumor (GCT) of bone is a benign but locally aggressive and destructive lesion generally occurring in skeletally mature individuals. Typically involving the epiphysiometaphyseal region of long bones, the most common sites include the distal femur, proximal tibia and distal radius. On radiographs, GCT demonstrates a lytic lesion centered in the epiphysis but involving the metaphysis and extending at least in part to the adjacent articular cortex. Most are eccentric, but become symmetric and centrally located with growth. Most cases show circumscribed borders or so-called geographical destruction with no periosteal reaction unless a pathological fracture is present. There is no mineralized tumor matrix. Giant cell tumor can produce wide-ranging appearances depending on site, complications such as hemorrhage or pathological fracture and after surgical intervention. This review demonstrates a spectrum of these features and describes the imaging characteristics of GCT in conventional radiographs, computerized tomography scans, magnetic resonance imaging, bone scans, positron emission tomography scans and angiography.