Lateral Extra-articular Tenodesis Does Not Decrease Graft Failure in Revision Anterior Cruciate Ligament Reconstruction When Combined With Quadriceps or Patellar Tendon Grafts.

PURPOSE: To compare return-to-sport (RTS) rates, graft failure rates, and clinical outcomes in patients who underwent revision anterior cruciate ligament reconstruction (R-ACLR) with additional lateral extra-articular tenodesis (LET) versus isolated R-ACLR. METHODS: A retrospective review of the medical records of patients who underwent R-ACLR with or without a modified Lemaire LET procedure was performed. Seventy-four patients with at least 2 years of follow-up who had high-grade positive pivot-shift test findings were included. Concomitant procedures such as meniscectomy and meniscal repair were collected, along with any complications and/or graft failure. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee Subjective Knee Form score were collected. The ability to RTS was defined as fully, partially, or not returned. RESULTS: Of the patients, 39 underwent isolated R-ACLR (mean age ± standard deviation, 29.2 ± 12.2 years) whereas 35 underwent an additional LET procedure (mean age, 24.6 ± 7.4 years). The mean length of follow-up in the R-ACLR group was 56.6 ± 26.5 months compared with 44.3 ± 17.6 months in the R-ACLR-LET group (P = .02) (range, 24-120 months). Patient-reported outcome measures were higher in the R-ACLR-LET group, with the KOOS Activities of Daily Living (93.5 ± 2.0 vs 97.2 ± 1.6, P = .03) and KOOS Sport (63.0 ± 3.6 vs 74.3 ± 3.8, P = .05) subdomain scores reaching the level of statistical significance. No differences were found in the other KOOS subdomain scores or the International Knee Documentation Committee scores. Failure rates were not significantly different between the groups (12.8% for R-ACLR vs 11.4% for R-ACLR-LET, P = .99). There were 13 patients (72.2%) in the R-ACLR group and 14 patients (60.8%) in the R-ACLR-LET group who did not RTS. CONCLUSIONS: R-ACLR with additional LET showed similar failure and RTS rates to isolated R-ACLR after failed ACLR. The R-ACLR-LET group showed better functional results with significantly higher KOOS subdomain scores for activities of daily living, as well as sports and recreation. However, this study was unable to recommend the modified Lemaire LET procedure to be routinely used in R-ACLR patients. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Osteochondral Allograft Transplant for Combined Medial and Lateral Patellar Cartilage Lesions: The Osteochondral Wide Lesion (OWL) Technique.

Symptomatic articular cartilage injuries are often seen in young active patients and athletes. Magnetic resonance imaging screening examinations have frequently identified such lesions in athletic patients. Patellofemoral chondral defects were previously identified as the most common knee cartilage lesion in high-level athletes. Chondral defects measuring 2 cm2 or greater and complex cartilage defects involving bone loss are ideally replaced with fresh osteochondral allograft. We describe a technique indicated for patients with symptomatic and recurrent anterior knee pain associated with osteochondral patellar defects including the lateral and medial patellar facets. Patients who have undergone previous interventions, including membrane techniques, microfracture, or autologous chondral transplantation, without clinical benefit are also eligible to undergo osteochondral allograft transplantation for combined medial and lateral patellar cartilage lesions, that is, the osteochondral wide lesion (OWL) technique.

Treatment of Distal Patellar Tendon Chronic Rupture: The X-Wave Technique.

Injuries to the patellar tendon (PT) are associated with knee function deterioration and loss of the capacity to perform daily and sports activities. Patellar tendon injury is often misdiagnosed at emergency rooms, leading to chronic proximal retraction and a challenging clinical scenario. Proximal PT injuries are more common, while distal ones, which can involve tibial bone avulsion fractures or direct tendon avulsion, are rarer. The low incidence of distal PT rupture and the variety of injury patterns make a personal approach reasonable when based on the intraoperative findings and the surgeon's experience. Our purpose is to describe a surgical technique to restore the knee extensor mechanism after chronic distal PT rupture using two kinds of graft, one as a waveform augmentation of the native tendon and the other as reinforcement in a letter X aspect.

Posterior-Medial Meniscal Root Repair Through Lateral Tibial Tunnel Combined With Medial Opening Osteotomy and Homologous Graft.

When there is a rupture in the meniscal roots or close to them, the menisci suddenly and considerably reduce their capacity to absorb the axial mechanical load that passes through the knee, quickly leading to the development of a process of chondral degeneration. The varus deformity of the lower limb (when the mechanical axis crosses the medial compartment of the knee) favors this type of injury owing to the overload in the medial compartment. When the patient has both varus deformity and medial meniscal posterior root injury, there is a clear indication for surgical realignment of the affected lower limb. There is still not a consensus regarding combining meniscal root repair with corrective osteotomy, although there is a tendency to perform both procedures aiming at long-term joint preservation. We present a safe alternative technique for simultaneous medial meniscal posterior root repair using a lateral tibial transosseous tunnel associated with a valgus-producing high tibial osteotomy with homologous bone grafting, allowing a full return to daily activities and sports.

Protocol for Harvest, Transport and Storage of Human Osteochondral Tissue.

Objective To elaborate a protocol for the harvest, transport, and preservation of human osteochondral tissue for use in tissue banks (TBs). Methods Osteochondral fragments measuring 2 cm 3 of 5 corpse donors aged between 15 and 45 years old were analyzed. The samples were stored in cell preservation medium containing: human albumin, Iscove's and vancomycin preserved at 4°C. The concentration of proteoglycans in the extracellular medium was quantified by the use of Safranin-O, while tissue structural analysis was assessed by histological study with hematoxylin-eosin stained slides. The images obtained were analyzed according to the histological scores of Mankin and the score proposed by the OsteoArthritis Research Society International. The samples were analyzed with 0, 15, 30 and 45 days of preservation. Results The osteochondral fragments studied showed a progressive decrease in proteoglycan concentration with increased preservation time. After 30 days of preservation, structural changes were identified with discontinuity of the cartilage surface layer. According to the results obtained by the Mankin score, there was a statistically significant difference between 15 and 30 days of tissue preservation. Conclusion The protocol described defined knee transport immersed in Lactated Ringer at a controlled temperature of 10° C until its arrival at the TB. After processing, the preservation solution was composed of Iscove's serum-free cell culture medium supplemented with 10% human albumin and 100 µg/ml vancomycin. The tissue was preserved at a temperature of 4°C until the moment of transplantation characterizing the fresh preservation.

Protocol for Harvest, Transport and Storage of Human Osteochondral Tissue / Protocolo para captação, transporte e preservação de tecido osteocondral humano

Abstract Objective To elaborate a protocol for the harvest, transport, and preservation of human osteochondral tissue for use in tissue banks (TBs). Methods Osteochondral fragments measuring 2 cm3 of 5 corpse donors aged between 15 and 45 years old were analyzed. The samples were stored in cell preservation medium containing: human albumin, Iscove's and vancomycin preserved at 4ºC. The concentration of proteoglycans in the extracellular medium was quantified by the use of Safranin-O, while tissue structural analysis was assessed by histological study with hematoxylin-eosin stained slides. The images obtained were analyzed according to the histological scores of Mankin and the score proposed by the OsteoArthritis Research Society International. The samples were analyzed with 0, 15, 30 and 45 days of preservation. Results The osteochondral fragments studied showed a progressive decrease in proteoglycan concentration with increased preservation time. After 30 days of preservation, structural changes were identified with discontinuity of the cartilage surface layer. According to the results obtained by the Mankin score, there was a statistically significant difference between 15 and 30 days of tissue preservation. Conclusion The protocol described defined knee transport immersed in Lactated Ringer at a controlled temperature of 10º C until its arrival at the TB. After processing, the preservation solution was composed of Iscove's serum-free cell culture medium supplemented with 10% human albumin and 100 µg/ml vancomycin. The tissue was preserved at a temperature of 4ºC until the moment of transplantation characterizing the fresh preservation.

Resumo Objetivo Elaborar um protocolo para a captação, transporte e preservação de tecido osteocondral humano para utilização em banco de tecidos (BT). Métodos Foram analisados fragmentos osteocondrais com dimensão de 2 cm3 de 5 doadores cadáveres com idades entre 15 e 45 anos. As amostras foram armazenadas em meio de preservação celular contendo: albumina humana, Iscove's e vancomicina preservados à temperatura de 4ºC. A concentração de proteoglicanos no meio extracelular foi quantificada pelo uso de Safranina-O, enquanto a análise estrutural do tecido foi avaliada através de estudo histológico com lâminas coradas em hematoxilina-eosina. As imagens obtidas foram analisadas segundo os escore histológicos de Mankin e o escore proposto pela OsteoArthritis Research Society International. As amostras foram analisadas com 0, 15, 30 e 45 dias de preservação. Resultados Os fragmentos osteocondrais estudados apresentaram diminuição progressiva na concentração de proteoglicanos com o aumento do tempo de preservação. Após 30 dias de preservação, foram identificadas alterações estruturais com descontinuidade da camada superficial da cartilagem. Segundo os resultados obtidos pelo escore de Mankin, houve diferença com significância estatística entre 15 e 30 dias de preservação do tecido. Conclusão O protocolo descrito definiu o transporte de joelho em bloco imerso em Ringer Lactato em temperatura controlada a 10ºC até sua chegada ao BT. Após o processamento, a solução de preservação foi composta por meio de cultura celular sem soro Iscove's suplementado com albumina humana a 10% e vancomicina 100 µg/mL. O tecido foi preservado à temperatura de 4ºC até o momento do transplante caracterizando a preservação a fresco.

Protocolo para a captação, transporte e armazenamento de tecido osteocondral humano / Evaluation of the protocol for harvest, transport and storage of human osteochondral tissue

O tratamento das lesões osteocondrais representa um desafio ao cirurgião ortopédico. Diversas técnicas biológicas visam a restauração do tecido lesionado, estando limitadas a formação de fibrocartilagem ou a dimensão da área a ser restaurada. O transplante alógeno osteocondral representa o único método biológico capaz de fornecer cartilagem hialina para o tratamento das lesões maiores que 2cm². A viabilidade celular do tecido no momento da cirurgia representa um fator indispensável para que haja sucesso no tratamento. A ausência de um protocolo definido pelos órgãos reguladores de saúde nos levou a necessidade de elaborar uma metodologia própria para captação, transporte e armazenamento de tecido osteocondral humano. Foram analisados fragmentos osteocondrais com dimensão de 2cm³ de cinco doadores cadáveres com idade entre 15 e 45 anos. As amostras foram armazenadas em meio de preservação celular contendo: albumina humana, Iscove's e vancomicina preservados à temperatura de 4°C. A concentração de proteoglicanos no meio extracelular foi quantificada pelo uso de Safranina-O, enquanto a análise estrutural do tecido foi avaliada através de estudo histológico com lâminas coradas em hematoxilinaeosina. As imagens obtidas foram analisadas segundo os escore histológicos de Mankin e o escore proposto pela OsteoArthritis Research Society International. As amostras foram analisadas com 0, 15, 30 e 45 dias de preservação. Os fragmentos osteocondrais estudados apresentaram diminuição progressiva na concentração de proteoglicanos com o aumento do tempo de preservação, soretudo na camada de superficial da cartilagem. Após 30 dias de preservação foram identificadas alterações estruturais com descontinuidade da camada superficial da cartilagem. As demais camadas do tecido osteocondral mantiveram suas estruturas preservadas após 45 dias de preservação. Segundo os resultados obtidos pelo escore de Mankin, houve diferença com significância estatística entre 15 e 30 dias de preservação do tecido. Os resultados encontrados definiram o protocolo de preservação transporte e armazenamento de tecido osteocondral humano a ser aplicado pelo Banco de Tecidosmultiesquelético lotado no Instituto Nacional de Ortopedia e Traumatologia.

The treatment of osteochondral lesions remains a challenge to the orthopedic surgeon. Various biological techniques aim at the restoration of the injured tissue, being limited the formation of fibrocartilage or the size of the area to be restored. The allogeneic osteochondral transplantation represents the only biological method capable of providing hyaline cartilage after lesions larger than 2cm². The cellular viability of the tissue at the time of surgery is an essential factor for successful treatment. The absence of a protocol defined by the health regulatory agencies has led us to the need to develop a proper methodology for harvest, transporting and storing human osteochondral tissue. Osteochondral fragments measuring 2cm³ of five cadaveric donors aged between 15 and 45 years were analyzed. The samples were stored in cell preservation medium containing: human albumin, Iscove's and vancomycin maintained at 4 ° C. Immunohistochemical study with antibodies to the Caspase 3 protein evaluated the presence of cell death by apoptosis. The concentration of proteoglycans in the extracellular matrix was quantified by the use of Safranin-O, while tissue structural analysis was assessed by histological study with hematoxylin-eosin stained slides. The images obtained were analyzed according to the histological scores of Mankin, OsteoArthritis Research Society International and the score proposed by the authors. The samples were analyzed with 0, 15, 30 and 45 days of preservation. The samples studied presented a progressive decrease in the concentration of proteoglycans with the increase of preservation time. After 30 days of preservation, structural changes were identified in the superficial layer of the cartilage. The remaining layers of the osteochondral tissue maintained their structures preserved after 45 days of preservation. According to the results obtained by the Mankin score, there were differences with statistical significance between 15 and 30 days of preservation. The results found defined the protocol for the preservation of the transport and storage of human osteochondral tissue to be applied by the Bank of Tissues, located in the National Institute of Orthopedics and Traumatology