Acellular Aragonite-Based Scaffold for the Treatment of Joint Surface Lesions of the Knee: A Minimum 5-Year Follow-Up Study.

OBJECTIVE: A novel aragonite-based scaffold has been developed. In this study, mid-term clinical and magnetic resonance imaging (MRI) results on 12 patients affected by isolated chondral or osteochondral lesions of the knee treated by the scaffold implantation have been evaluated at a mean follow-up of 6.5 (range: 5-8) years. DESIGN: The study population consisted of 3 females and 9 males, mean age 34.4 (20-51) years. The lesion was located on the medial femoral condyle, the trochlea, and the lateral femoral condyle in 5, 5, and 2 patients, respectively. In all cases, a single lesion over grade 3 of the International Cartilage Restoration and Joint Preservation Society (ICRS) classification was treated: in 9 cases by implantation of one plug, and in 2 cases with 2 plugs; the mean size of the lesion was 2.5 cm2 (1-7). RESULTS: One patient failed and was revised with a custom-made metal implant (Episealer). Overall, Knee Injury and Osteoarthritis Outcome Score (KOOS) significantly improved from 45 ± 13 preoperatively to 86 ± 13 at final follow-up. All KOOS subscales improved significantly: pain subscale increased from 48 ± 12 to 92 ± 11; symptoms from 66 ± 13 to 91 ± 13; activity of daily living (ADL) from 60 ± 19 to 90 ± 21; sport from 23 ± 20 to 75 ± 20; finally, quality of life (QoL) increased from 27 ± 14 to 77 ± 19. Long-term MRI MOCART score was 64. CONCLUSIONS: This study shows continued significant clinical improvement and good magnetic resonance imaging (MRI) findings with a minimum 5 years follow-up after implantation of a novel aragonite derived scaffold for the treatment of cartilage lesions of the knee. One patient failed and was revised with a custom-made metal implant (Episealer).

Accuracy of Magnetic Resonance Imaging in the Diagnosis of Multiple Ligament Knee Injuries: A Multicenter Study of 178 Patients.

BACKGROUND: Magnetic resonance imaging (MRI) has shown limited diagnostic accuracy for multiple ligament knee injuries (MLKIs), especially posterolateral corner (PLC) injuries. HYPOTHESIS: The diagnostic accuracy of MRI for MLKIs will only be moderate for some knee structures. Patient-related factors and injury patterns could modify the diagnostic accuracy of MRI. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All patients with MLKIs surgically treated between January 2014 and December 2020 in the centers participating in the study were reviewed. We recorded sex, age, mechanism of injury, time from injury to MRI, and vascular and neurological associated lesions. Lesions to the anterior cruciate ligament (ACL), posterior cruciate ligament, medial collateral ligament, lateral collateral ligament (LCL), popliteus tendon, popliteofibular ligament, iliotibial band, biceps tendon, medial and lateral meniscus, and articular cartilage from MRI reports and surgical records were also collected. The sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy, diagnostic odds ratio, positive and negative likelihood ratio, and intraclass correlation coefficient of MRI were calculated for each knee structure. With logistic regression, associations between patient and injury characteristics and MRI accuracy were assessed. RESULTS: A total of 178 patients (127 male; mean age, 33.1 years) were included. High-energy trauma was the most common mechanism of injury (50.6%), followed by sports trauma (38.8%) and low-energy trauma (8.4%). The ACL was the structure with the best diagnostic accuracy, diagnostic odds ratio, and positive predictive value (94.4%, 113.2, and 96.8%, respectively). PLC structures displayed the worst diagnostic accuracy among knee ligaments (popliteus tendon: 76.2%; LCL: 80.3%) and diagnostic odds ratio (popliteus tendon: 9.9; LCL: 17.0; popliteofibular ligament: 17.5). MRI was more reliable in detecting the absence of meniscal and chondral lesions than in identifying them. Logistic regression found that the diagnostic accuracy was affected by the Schenck classification, with higher Schenck grades having worse diagnostic accuracy for peripheral structures (iliotibial band, popliteus tendon, and biceps tendon) and improved diagnostic accuracy for the ACL and posterior cruciate ligament. CONCLUSION: The diagnostic accuracy of MRI for MLKIs largely varied among knee structures, with many of them at risk of a misdiagnosis, especially PLC, meniscal, and chondral lesions. The severity of MLKIs lowered the diagnostic accuracy of MRI for peripheral structures.

Arthroscopic lateral collateral ligament imbrication of the elbow: short-term clinical results.

INTRODUCTION: Chronic posterolateral rotatory instability (PLRI) of the elbow results from an insufficient lateral collateral ligament (LCL) complex. Arthroscopic LCL imbrication may prove a minimally invasive alternative to open lateral ulnar collateral ligament (LUCL) reconstruction with a quicker rehabilitation. The purpose of this study is to analyze the validity of a modified arthroscopic imbrication technique. We hypothesized that arthroscopic LUCL imbrication would yield stable elbows in patients with grade 1 or 2 chronic PLRI at a minimum of 2 year of follow-up. METHODS: We retrospectively assessed data of all PLRI patients who underwent arthroscopic LUCL imbrication from 2010 to 2013 (n = 20). Stage 3 PLRIs (frank ulnohumeral dislocations) were excluded from this treatment. After confirmation of PLRI during standard elbow arthroscopy, a doubled absorbable suture is shuttled through as much LCL tissue as possible (from the lateral ulnar border to the area proximal to the lateral epicondyle) and the sutures are tied. This results in a plication of the entire LCL complex. Objective elbow stability was assessed using a combination of the pivot shift, table top, and posterior drawer tests. RESULT: Of 20 included patients, 18 were stable subjectively and objectively at a minimum of 2 year of follow-up. Mean Mayo Elbow Performance Score improved from 48 preoperatively to 88.9 at final follow-up (P < .001). Mean Quick-Disabilities of the Arm, Shoulder, and Hand score improved from 53 preoperatively to 10.3 at final follow-up (P < .001). One patient developed elbow stiffness. Two patients reported tenderness of the subcutaneous PDS knots. CONCLUSION: As a less invasive alternative to open LCL reconstruction using a graft, arthroscopic LCL imbrication has demonstrated acceptable rates of perceived elbow stability among patients with stage 1 or 2 PLRI.

Autologous Micro-Fragmented Adipose Tissue (MFAT) to Treat Symptomatic Knee Osteoarthritis: Early Outcomes of a Consecutive Case Series.

The study aimed to evaluate the short-term clinical effect, therapeutic response rate (TRR%), and therapy safety of a single intra-articular autologous MFAT injection for symptomatic knee OA. Secondly, patient- and pathology-related parameters were investigated to tighten patient selection for MFAT therapy. Sixty-four subjects with symptomatic mild-severe knee OA were enrolled in a single-center trial and received a unilateral (n = 37) or bilateral (n = 27) MFAT injection. After liposuction, the adipose tissue was mechanically processed with the Lipogem® device, which eventually produced 8-10 cc of MFAT. Subjects were clinically assessed by means of the KOOS, NRS, UCLA, and EQ-5D at baseline and 1, 3, 6, and 12 months after injection. Adverse events were recorded at each follow-up timepoint. The TRR was defined according to the OMERACT-OARSI criteria and baseline MRI was scored following the MOAKS classification. The TRR of the index knee was 64% at 3 months and 45% at 12 months after injection. Therapy responders at 12 months improved with 28.3 ± 11.4 on KOOS pain, while non-responders lost -2.1 ± 11.2 points. All clinical scores, except the UCLA, improved significantly at follow-up compared to baseline (p < 0.05). In the bilateral cohort, no difference in baseline scores or TRR was found between the index knee and contralateral knee (n.s.). An inflammatory reaction was reported in 79% of knees and resolved spontaneously within 16.6 ± 13.5 days after MFAT administration. Numerous bone marrow lesions (BML) were negatively correlated with the TRR at 12 months (p = 0.003). The study demonstrated an early clinical improvement but a mediocre response rate of 45% at 12 months after a single intra-articular injection with autologous MFAT. Assessment of bone marrow lesions on MRI can be helpful to increase the therapeutic responsiveness of MFAT up to 70% at 12 months. In comparison to repetitive injection therapies such as cortisone, hyaluronic acid, and PRP, administration of MFAT might become a relevant alternative in well-selected patients with symptomatic knee OA.

Joint Surface Lesions in the Knee Treated with an Acellular Aragonite-Based Scaffold: A 3-Year Follow-Up Case Series.

OBJECTIVE: The study aimed to evaluate the clinical outcome and repair capacity of a cell-free aragonite-based scaffold in patients with an isolated symptomatic joint surface lesion (JSL) of the knee. DESIGN: Thirteen patients (age 33.5 ± 8.9; female 23%; body mass index 25.3 ± 3.4, K/L [Kellgren-Lawrence] 1.8) with a JSL (2.6 ± 1.7 cm2 [1.0-7.5 cm2]) of the distal femur were enrolled in a single-center prospective case series. Safety and clinical outcome was assessed by the KOOS (Knee Injury and Osteoarthritis Outcome Score), IKDC (International Knee Documentation Committee), Lysholm, and Tegner activity scale at baseline and 6, 12, 18, 24, and 36 months follow-up. The MOCART 2.0 and scaffold integration were evaluated on magnetic resonance imaging at 12, 24, and 36 months postoperatively. RESULTS: Primary outcome (KOOS pain) improved with 36.5 ± 14.7 points at 12 months (P = 0.002) and 41.2 ± 14.7 points at 36 months (P = 0.002) follow-up. Similar increasing trends were observed for the other KOOS subscales, IKDC, and Lysholm score, which were significantly better at each follow-up time point relative to baseline (P < 0.05). Activity level increased from 2.75 ± 1.6 to 4.6 ± 2.2 points at final follow-up (P = 0.07). The MOCART was 61.7 ± 12.6 at 12 months and 72.9 ± 13.0 at 36 months postoperatively. Sixty-six to 100% implant integration and remodeling was observed in 73.3% cases at 36 months. No serious adverse events were reported. CONCLUSION: The study demonstrated that the biphasic aragonite-based scaffold is a safe and clinically effective implant for treating small-medium sized JSLs of the distal femur in a young and active patient cohort. The implant showed satisfying osteointegration and restoration of the osteochondral unit up to 3 years postimplantation.

Autologous protein solution as selective treatment for advanced patellofemoral osteoarthritis in the middle-aged female patient: 54% response rate at 1 year follow-up.

PURPOSE: The study wanted to investigate the benefit, durability and safety of autologous protein solution (APS) injection(s) in a middle-aged female-only cohort suffering predominantly from patellofemoral osteoarthritis. METHODS: Fifty females (aged 50.4 ± 6.5) with mainly moderate-severe (86%) patellofemoral cartilage wear (PFCW) were treated with a unilateral intra-articular APS injection. The KOOS, NRS, Kujala, UCLA and EQ-5D were assessed at baseline and 1, 3, 6, and 12 months post-injection. Therapeutic response rate (TRR) was based on KOOS pain improvement > 10 points. Absolute improvement for, respectively, therapy responders and non-responders was determined. Second APS injection was administered if improvement was deemed insufficient by the patient after 3 months. RESULTS: The TRR remained stable averaging to 53.7% at final follow-up with subjects improving overall from 40.3 ± 18.7 to 57.3 ± 24.8 points on KOOS pain (p = 0.0002) and from 48.4 ± 13.0 to 56.3 ± 18.1 points on Kujala (p = 0.0203) at 12 months. Significant improvement was observed for the other KOOS subscales and NRS at each follow-up. In absolute values, APS responders improved with 30.5 ± 11.4 points on KOOS pain at 12 months. In contrast, non-responders deteriorated with 5.9 ± 8.9 points relative to baseline. A second APS injection was administered in 28 subjects. Patients with definite synovitis improved more on KOOS symptoms (p = 0.017) and KOOS ADL (p = 0.037) at 12 months compared to non-synovitis subjects. Mild-moderate arthralgia (46%) and effusion (29%) were commonly observed during the first month post-injection. CONCLUSION: This study evidenced a 54% response rate at 12 months to a single or second APS injection in a middle-aged female population with advanced patellofemoral cartilage wear. Moderate temporary flares can be expected without affecting clinical outcomes. Second APS injection has low efficacy in initially poor responding patients after 3 months. Major synovitis on baseline MRI appeared to be a beneficial prognosticator for pain relief and functional improvement after APS. LEVEL OF EVIDENCE: IV.

Patient-specific instrument guidance of glenoid component implantation reduces inclination variability in total and reverse shoulder arthroplasty.

BACKGROUND: The aim of this study was to assess the influence of 3-dimensional (3D) preoperative planning and patient-specific instrument (PSI) guidance of glenoid component positioning on its inclination in total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). MATERIALS AND METHODS: Thirty-six shoulder arthroplasties (12 TSAs, 24 RSAs) were analyzed, of which 18 procedures (6 TSAs, 12 RSAs) were executed using preoperative 3D planning and patient-specific guides to position the central guide pin for glenoid component implantation. In 9 cases, the glenoid anatomy was severely distorted through wear or previous surgery. The inclination of the glenoid component was measured by 2 observers, using the angle between the glenoid baseplate and the floor of the supraspinatus fossa (angle ß) on postoperative radiographs. RESULTS: For TSA, the average angle ß was 74 ± 9 in the PSI group and 86 ± 12 in the non-PSI group; for RSA, the average angle ß was 83 ± 7 in the PSI group and 90 ± 17 in the non-PSI group. Extreme angles ß, which represent extreme values of glenoid component inclination, are more likely to occur in the non-PSI group than in the PSI group (P < .001 for TSA; P = .02 for RSA). CONCLUSIONS: The3D preoperative surgical planning and PSI guidance reduce variability in glenoid component inclination and avoid extreme inclination errors for TSA and RSA.

Reliability analysis of glenoid component inclination measurements on postoperative radiographs and computed tomography-based 3D models in total and reversed shoulder arthroplasty patients.

BACKGROUND: Only a few articles describe the reproducibility and clinical feasibility of glenoid inclination measurements on conventional radiographs, and none of them validated their method in shoulder arthroplasty cases. From a clinical point of view, the angle measured between the supraspinatus fossa and the glenoid fossa line (angle ß) appears to be the most interesting angle to assess glenoid inclination. This study aimed to validate the angle ß in shoulder arthroplasty patients to facilitate the assessment of glenoid component inclination. MATERIALS AND METHODS: Seventeen patients who underwent total or reverse shoulder arthroplasty were evaluated. The angle ß was measured by 2 independent observers on postoperative radiographs and 3-dimensional (3D) models. The interobserver variability and accuracy of angle ß were analyzed by calculating the intraclass correlation coefficient (ICC) and by generating Bland-Altman plots. RESULTS: The angle ß showed a good interobserver variability (ICC = 0.971 for radiographs, ICC = 0.980 for 3D models) and a good agreement between the radiographic and 3D measurements (ICC = 0.904 for observer 1 and ICC = 0.908 for observer 2). Bland-Altman plots demonstrated that in 95% of the measurements on radiographs, the error will be <10. In the investigated population, 85% showed an error <6. CONCLUSION: This study demonstrates that angle ß can be measured on radiographs to assess glenoid component inclination in total and reverse shoulder arthroplasty, but clinicians and researchers should keep in mind that measurement errors of 10° may occur in a minority of cases.

[Posterior sternoclavicular dislocation: diagnosis initially easy to miss]. / Posterieure sternoclaviculaire luxatie: in eerste instantie vaak gemist.

Posterior sternoclavicular (SC) dislocation is a rare diagnosis, which tends to be missed initially. Here we report two cases of a dislocated SC joint: one left and one right. The first case describes a 25-year-old male who sustained a direct injury caused by his seatbelt during a car accident. The diagnosis was made 3 months after the initial trauma following performance of a CT scan. His left SC joint was stabilized using a hamstring tendon allograft. The second patient, a 55-year-old female, sustained an indirect injury following a fall onto her right shoulder. The diagnosis was made 6 weeks after the trauma had occurred. Her SC joint was also stabilized using a tendon allograft reconstruction. The clinical outcome of both cases was very satisfactory. Better diagnostics - more attention for subtle symptoms during physical examination, the right choice of imaging (CT scan) and meticulous following of Advanced Trauma Life Support (ATLS) protocols - could diminish the number of delayed diagnoses in this rare but potentially dangerous injury.

Paced visual serial addition test in multiple sclerosis.

The paced auditory serial addition test (PASAT), a subtest of the multiple sclerosis functional composite score (MSFC), is increasingly used in the evaluation of cognitive function in multiple sclerosis (MS). While patient acceptance for the PASAT is low, its visual version, the paced visual serial addition test (PVSAT), is perceived to be better tolerated. The aim of this study was to investigate the interchangeability of PVSAT and PASAT in the evaluation of cognitive function in MS. Twenty-one normal controls and 50 patients with clinically definite MS were tested with PASAT and PVSAT. Both for PASAT and PVSAT, 3 and 2-second versions of two parallel test forms were used. In the PVSAT, the PASAT stimuli were shown on a computer screen. Patients were also tested with the other two MSFC subtests, i.e. the nine-hole pegboard test and timed 25-foot walk test, to calculate MSFC scores. PASAT-3 correlated highly with both PVSAT-3 and PVSAT-2. MSFC-v scores calculated with PVSAT-2 and PVSAT-3 values correlated highly with MSFC scores calculated with PASAT-3 results. The results suggest that the PVSAT can be used as an alternative for the PASAT in the MSFC.