Use of an Elastomeric Knee Brace in Patellofemoral Pain Syndrome: Short-Term Results.

Purpose This article verifies the effectiveness of a new brace on patellofemoral pain syndrome (PFPS) in adjunct to a specifically developed rehabilitation program. Methods Two groups of 30 patients with PFPS were prospectively and randomly allocated to a rehabilitation protocol, with (group A) or without (group B) the use of a specific brace. All the patients were assessed at 3, 6, and 12 months using the disease-specific Kujala scale and a visual analog scale (VAS) for pain; time to return to sport and patient satisfaction with the brace were also recorded. Results Kujala scale's values showed constant and progressive improvement. The mean score at 6 months was 79.8 ± 6.8 points in group A and 76.8 ± 8.6 in group B, rising at 12 months to 80.9 ± 7.5 in group A and 78.4 ± 8.3 in group B. VAS scores significantly differed ( p < 0.05) between the two groups at both 6 and 12 months; the score recorded at 12 months was 0.9 ± 1.3 in the brace-treated group and 1.8 ± 1.6 in the controls. The patients who used a brace showed a quicker return to sports and 75% of the patients in this group were satisfied. Conclusion All the scores improved progressively in both groups. The most significant improvement concerned pain, showing that the brace used in this study may allow a better subjective outcome and a quicker return to sport. Level of Evidence Level II, prospective randomized controlled trial.

Second Generation Needling Techniques for the Treatment of Chondral Defects in Animal Model.

Purpose To compare the macroscopic, histological, and immunohistochemical characteristics of the repair tissue of chondral defects treated with microfracture and nanofracture in an ovine model. Methods Full-thickness chondral lesions were created in the medial femoral condyle of both knees in four adult sheep and were treated with microfracture on one side and with nanofracture on the contralateral side. Chondral repair was assessed after 12 months by macroscopic, histological, and immunohistochemical analyses. Results Histological cartilage repair significantly improved in the samples treated with nanofracture for cellular morphological characteristics and cartilage architecture. The immunohistochemical analysis showed a significantly higher immunoreactivity to type II collagen in the defects treated with nanofracture. Conclusion Nanofracture provided better repair tissue than microfracture, with a more satisfactory cartilage architecture renovation and tissue having greater type II collagen content. Clinical Relevance Mesenchymal stem cell stimulation is the most frequently used primary cartilage repair procedure. Nanofracture represents a novel technique to stimulate bone marrow that results into a successful repair of chondral defects.

The use of embryonic cells in the treatment of osteochondral defects of the knee: an ovine in vivo study.

PURPOSE: the aim of this study was to determine whether local delivery of embryonic stem-like (ESL) cells into osteochondral defects in the femoral condyles of sheep would enhance regeneration of hyaline articular cartilage. METHODS: male ESL cells embedded in fibrin glue were engrafted into osteochondral defects in the medial condyles (ESL-M) of the left femur in 22 ewes. An identical defect was created in the medial condyle of the contralateral stifle joint and left untreated as a control (empty defect, ED). The ewes were divided into 5 groups. Four sheep each were euthanized at 1, 2, 6, and 12 months from surgery, and 6 ewes were euthanized 24 months post-implantation. To study the effect of varying loads on the long-term regeneration process, an identical defect was also created and ESL cell engraftment performed in the lateral condyle (ESL-L) of the left stifle joint of the animals in the 12- and 24-month groups. The evaluation of regenerated tissue was performed by biomechanical, macroscopic, histological, immunohistochemical (collagen type II) and fluorescent in situ hybridization (FISH) assays. RESULTS: no significant differences were found between treated and control sites in the biomechanical assays at any time point. ESL cell grafts showed significantly greater macroscopic evidence of regeneration as compared to controls at 24 months after surgery; significantly better histological evidence of repair in ESL-M samples versus controls was found throughout the considered period. At 24 months from surgery there was significantly improved integration of graft edges with the host tissue in the ESL-M as compared to the ESL-L samples, demonstrating that load bearing positively affects the long-term regeneration process. CONCLUSIONS: ESL cells enhanced the regeneration of hyaline cartilage. FISH confirmed that the regenerative tissue originated from ESL cells. CLINICAL RELEVANCE: ESL cells are able to self-renew for prolonged periods without differentiation and, most importantly, to differentiate into a large variety of tissues.

Subchondral bone remodeling: comparing nanofracture with microfracture. An ovine in vivo study.

PURPOSE: microfracture, providing direct stimulation of chondrogenic mesenchymal stem cells (MSCs) in the subchondral bone, remains the most frequently used primary cartilage repair technique. However, the newly formed type I collagen-rich fibrocartilaginous tissue has poor biomechanical properties and a tendency to degenerate. To overcome these limitations the nanofracture technique was introduced. Our purpose was to compare subchondral bone remodeling 6 months after microfracture versus nanofracture (subchondral needling) treatment in an ovine model. METHODS: full-thickness chondral lesions were created in the load-bearing area of the medial femoral condyles in four adult sheep. Each animal was then treated on one side with microfracture and on the contralateral side with nanofracture. Subchondral bone remodeling was assessed by micro-CT using a Bruker(®) SKYSCAN and CTVOX 2.7 software (Bruker Corp., Billerica, MA, USA) for image reconstruction; trabecular bone density measurements were performed through a color-representation structure thickness analysis. RESULTS: at the six-month endpoint, the microfracture-treated samples showed limited perforation depth and cone-shaped channels with large diameters at the joint surface. The channel walls displayed a high degree of regularity with significant trabecular bone compaction leading to a sealing effect with limited communication with the surrounding trabecular canals. Condyles treated with nanofracture showed channels characterized by greater depth and smaller diameters and natural irregularities of the channel walls, absence of trabecular compaction around the perforation, remarkable communication with trabecular canals, and neo-trabecular remodeling inside the channels. CONCLUSIONS: nanofracture is an effective and innovative repair technique allowing deeper perforation into subchondral bone with less trabecular fragmentation and compaction when compared to microfracture; it results in better restoration of the normal subchondral bone architecture at six months. CLINICAL RELEVANCE: our data support the use of smaller-diameter and deeper subchondral bone perforation for MSC stimulation; this technique may prove to be an attractive alternative to standard microfracture procedures.

Early joint degeneration and antagonism between growth factors and reactive oxygen species. Is non-surgical management possible?

PURPOSE: in pathological conditions such as osteo-arthritis (OA), overproduction of reactive oxygen species (ROS) may overwhelm the antioxidant defenses of chondrocytes, thus promoting oxidative stress and cell death. It can be hypothesized that increasing the antioxidant machinery of chondrocytes may prevent the age-associated progression of this disease. Growth factors (GFs) play an important role in promoting both the resolution of inflammatory processes and tissue repair. In view of these considerations, we set out to investigate the protective effect, against H2O2-induced oxidative cell death, potentially exerted by fluid drained from the joint postoperatively. METHODS: the present study was conducted in 20 patients diagnosed with bilateral knee osteoarthritis and treated, between January 2013 and June 2014, with prosthetic knee implantation on the side more affected by the arthritic process, together with intraoperative placement of a closed-circuit drainage aspiration system. As a result, 20 different serum samples were collected from the drained articular fluid, prepared using two different methodologies. In addition, forty blood serum samples were obtained and prepared: 20 from the surgically treated patients and 20 from healthy controls. The present work was undertaken to investigate the potential protective effect of sera obtained from articular fluid drainage against hydrogen peroxide-induced oxidative stress in cultured human chondrocytes. RESULTS: exposure of chondrocytes to hydrogen peroxide elicited a dose-dependent increase in oxidative stress and chondrocyte cell death, phenomena that were significantly counteracted by the pre-treatment of cell cultures with sera from articular fluid drainage. CONCLUSIONS: oxidatively stressed chondrocytes treated with sera obtained from articular fluid drainage lived longer than those treated with blood serum samples and longer than untreated ones. CLINICAL RELEVANCE: synovial fluids are usually discarded once the drainage reservoir is full; instead they could benefit the patients from whom they are collected, as they are rich in growth factors and they may act as antagonists of ROS effects. Accordingly, they could be used to treat chondropathies, early OA, and mild OA located in other sites.

Sports-related changes of the synovial membrane.

PURPOSE: the aim of this study is to differentiate the behavior of the synovial membrane in the presence of various stimuli in patients who practice sports. METHODS: fifty one patients (30 males and 21 females, mean age 48 years, range 31-59 years) who actively practiced non-competitive sports underwent a biopsy of the synovial membrane during arthroscopic surgery performed for joint effusion secondary to meniscal lesion (24 cases), anterior cruciate ligament injury (ACL) (17 cases), postoperative knee joint stiffness (2 cases), aseptic loosening or dislocation of the polyethylene component of uni-compartmental knee arthroplasty (5 cases), and anterior fibrous impingement of the ankle (3 cases). Synovial tissue samples were obtained during surgery from all the patients and processed for light microscopy, transmission electron microscopy and scanning electron microscopy observation. RESULTS: circulatory phenomena were observed in acute inflammatory processes, characterized by hyperemia and vasodilation. Exudative and infiltrative phenomena were observed in the presence of foreign bodies and were characterized by leukocytic exudation (presence of polynuclear neutrophils), accompanied by lymphomonocytic infiltration. Proliferative phenomena were observed in post-traumatic forms of synovitis (ACL and meniscal injuries), characterized by hypertrophy and proliferation of villous formations. Degenerative and regressive phenomena were observed in cases of fibrous reaction (ankle impingement and joint stiffness) and were characterized by formation of dense fibrous connective tissue with hyaline patches, evolving towards sclerosis. CONCLUSIONS: the activation of inflammatory processes in patients who expose their joints to excessive stress may lead to the formation of hyperplastic tissue. Ultramicroscopic debris is usually capable of transforming the structural organization of the synovial tissue. LEVEL OF EVIDENCE: Level IV, observational case series.

Meniscal injuries in basketball players.

Basketball is a highly competitive sport in which the knee joint is constantly subject to physical stresses. Basketball-related traumatic injuries are the result of specific technical movements. Even though basketball is not considered a contact sport, injuries in basketball players are due both to athletes' handling of the ball and to their intense physical interaction during games. Nowadays, traumatic meniscal injuries are constantly on the increase, especially in young athletes, and they are generally the result of compressive forces together with knee flexion rotation. Recognition of the great importance of meniscal biomechanics and of the functional role of the meniscus has resulted in the adoption of an increasingly preserving approach, also in the light of the effects, in terms of articular degeneration, of removing meniscal tissue. Even though recent decades have seen considerable developments in arthroscopic meniscectomy techniques, geared at preserving as much meniscal tissue as possible, basketball players undergoing this treatment often present, in the long run, clinical symptomatology severe enough to compromise their participation in competitive sport. Hence the treatment of meniscal injuries in athletes has become more and more preserving in recent years, through recourse to surgical techniques such as meniscal repair, biological replacement implantation and donor meniscus implantation, which allow pain relief, return to competitive activities and stable long-term results, slowing down arthritic progression. Therefore, considering the increasing number of meniscal injuries in basketball players, which can jeopardize their sporting careers, great importance is now attached to early diagnosis and to the correct choice of meniscal injury treatment in these athletes.