Bone Marrow Aspirate Concentrate versus Platelet Rich Plasma or Hyaluronic Acid for the Treatment of Knee Osteoarthritis.

Background: In the last decade, regenerative therapies have become one of the leading disease modifying options for treatment of knee osteoarthritis (OA). Still, there is a lack of trials with a direct comparison of different biological treatments. Our aim was to directly compare clinical outcomes of knee injections of Bone Marrow Aspirate Concentrate (BMAC), Platelet-rich Plasma (PRP), or Hyaluronic acid (HA) in the OA treatment. Methods: Patients with knee pain and osteoarthritis KL grade II to IV were randomized to receive a BMAC, PRP, and HA injection in the knee. VAS, WOMAC, KOOS, and IKDC scores were used to establish baseline values at 1, 3, 6, 9, and 12 months. All side effects were reported. Results: A total of 175 patients with a knee osteoarthritis KL grade II-IV were randomized; 111 were treated with BMAC injection, 30 with HA injection, and 34 patients with PRP injection. There were no differences between these groups when considering KL grade, BMI, age, or gender. There were no serious side effects. The mean VAS scores after 3, 7, 14, and 21 days showed significant differences between groups with a drop of VAS in all groups but with a difference in the BMAC group in comparison to other groups (p < 0.001). There were high statistically significant differences between baseline scores and those after 12 months (p < 0.001) in WOMAC, KOOS, KOOS pain, and IKDC scores, and in addition, there were differences between these scores in the BMAC group in comparison with other groups, except for the PRP group in WOMAC and the partial IKDC score. There were no differences between the HA and PRP groups, although PRP showed a higher level of clinical improvement. Conclusions: Bone marrow aspirate concentrate, Leukocyte rich Platelet Rich Plasma, and Hyaluronic acid injections are safe therapeutic options for knee OA and provide positive clinical outcomes after 12 months in comparison with findings preceding the intervention. BMAC could be better in terms of clinical improvements in the treatment of knee OA than PRP and HA up to 12 months. PRP provides better outcomes than HA during the observation period, but these results are not statistically significant. More randomized controlled trials and high quality comparative studies are needed for direct correlative conclusions.

Treatment of hallux rigidus by a novel bi-phasic aragonite-based implant: results of a two year multi-centre clinical trial.

PURPOSE: The two year results of a multi-centre clinical trial were examined to evaluate surgical treatment of hallux rigidus using a novel, bi-phasic, biodegradable, and cell-free aragonite-based scaffold (Agili-C™, CartiHeal Ltd, Israel). METHODS: Twenty patients with moderate-to-severe hallux rigidus were recruited. After thorough metatarsophalangeal joint (MTPJ-1) debridement, the scaffolds were implanted into the defect centre. Eight patients received concomitant osteotomy. Treatment outcome was followed clinically (Pain VAS, FAAM-ADL, FAAM-Sport, AOFAS-HMIS, maximum active range of extension ROM-EXT, and flexion ROM-FLEX), and by medical imaging, at six month intervals for two years. Adverse events were recorded throughout the study follow-up period. RESULTS: Significant clinical improvement over time was observed in all evaluated parameters (screening to final evaluation averages: Pain VAS 59 to 26, FAAM-ADL 57 to 77, FAAM-Sport 39 to 66, AOFAS-HMIS 51 to 81, ROM-EXT 18° to 36°), except for ROM-FLEX. Radiographs showed stable MTPJ-1 width over the two years in 17/18 cases (94%). MRI demonstrated progressive implant biodegradation, coupled with articular cartilage and subchondral bone regeneration, with a repair tissue defect fill of 75-100% in 14/17 (82%) subjects at their final visit. Revision surgery with implant removal was performed in two patients. CONCLUSION: Bi-phasic, osteochondral, biodegradable, aragonite-based scaffold demonstrated positive clinical outcome and a good safety profile in the treatment of medium-to-advanced hallux rigidus. According to the medical imaging, this implant has the potential to restore the entire osteochondral unit of metatarsal head.

Do knee injection portals affect clinical results of bone marrow aspirate concentrate injection in the treatment of osteoarthritis? A prospective randomized controlled study.

Aim: To explore the effect that the location of needle placement has on efficacy and tolerability of bone marrow aspirate concentrate injections during treatment of knee osteoarthritis. Methods: Bone marrow aspirate concentrate injections were administered to 111 patients via superolateral, anteromedial or anterolateral portals. Pain was assessed by visual analog scale before and 3, 7, 14 and 21 days after intervention. Knee function was assessed by Western Ontario and McMaster Universities Osteoarthritis Index, Knee Injury and Osteoarthritis Outcome Score and International Knee Documentation Committee scores before and 1, 3, 6, 9 and 12 months after intervention. Results: Significant differences in Western Ontario and McMaster Universities Osteoarthritis Index, Knee Injury and Osteoarthritis Outcome Score and International Knee Documentation Committee scores were observed 12 months post intervention compared with baseline (p < 0.001 for all comparisons). No significant differences in outcome or pain scores were observed among groups. Conclusion: All portals demonstrated similar clinical benefits up to 12 months after intervention. Trial registration number: ClinicalTrials.gov (NCT03825133).

Disruption of the knee extensor apparatus complicating anterior cruciate ligament reconstruction.

Disruption of the knee extensor apparatus, after harvesting the central third of the patellar tendon for a bone-tendon-bone autograft, is a rare complication. We made 2215 reconstructions of the anterior cruciate ligament of the knee using bone-patellar tendon-bone technique, and 10 patients had fracture of the patella (0.45%), and fore patients had rupture of the patellar tendon (0.18%). The fracture of the patella in two patients was treated nonoperatively and 8 patients was treated with operative reduction and osteosynthesis. Reconstruction of the patellar ligament in four patients with a rupture of patellar tendon (0.18%) was performed by a technique previously published with BTB allograft taken from the local bone bank. The mean Lysholm score was 90 (85-100), and all of them have continued to engage in sporting activities. In all patients the Lachman test was with the firm stop compared to the other leg. X-ray changes in the patella were found in 2 patients, who had multifragmentary fractures of the patella. Disruption of the knee extensor apparatus, after harvesting the central third of the patellar tendon for a bone-tendon-bone autograft, can be prevented by avoiding to take too much bone graft, by using the most precise tools for cutting, while rehabilitation must be carefully planned. The optimal treatment disruption of the knee extensor apparatus after the reconstruction of the anterior cruciate ligament is a operative reconstruction, which allows continuation of the rehabilitation program.

Dislocation of the proximal tibiofibular joint.

INTRODUCTION: Dislocation of the proximal tibiofibular joint is a rare injury. It occurs during a sports activity that includes rough twisting movements of the bent knee. The role of the proximal tibiofibular joint is to reduce torsional loads to the ankle, to distribute the bending moment of the outer side of tibia, and transfer the vertical load while standing. In the literature there is no larger series; only several cases of the proximal tibiofibular joint dislocation treated by different methods have been published so far. CASE REPORT: A 23-year-old male soccer player sustained an injury after he had joined the game without previous warming-up. He fell on his right side because of a sudden change of direction while his foot was fixed to the base. He felt a severe pain and had a sensation as if something had snapped in his right knee. Pain and swelling at the head of fibula were found by physical examination, which, however, did not reveal any pain, swelling and instability of the ankle or peroneal nerve palsy. The x-ray showed anterolateral dislocation of the proximal tibiofibular joint, Ogden type II. Since manual reposition in general anesthesia failed, open reduction internal fixation was performed and proximal tibiofibular joint was transfixed with a screw After the wound closure, the above-the-knee plaster cast was applied. The screw was extracted six weeks later, full weight bearing was allowed and he started with physical therapy. Four months after the injury he returned to sports activities. On the follow-up one year after the injury he had the full range of motion of the knee, no complains, and continued with active soccer playing. X-ray showed no signs of arthrosis of the proximal tibiofibular joint. CONCLUSION: The proximal tibiofibular joint dislocation may be the cause of the chronic pain of the knee so it has to be taken into account when making differential diagnosis in case of the pain at the lateral side of the knee. The key for making the accurate diagnosis is the technically correct X-ray of the injured knee compared with the opposite one, showing the displacement of fibular head. If manual reposition fails, open reduction internal fixation and screw transfixation of the proximal tibiofibular joint allow good results and fast return to sport activities.

Ultrasonographic diagnostics and evaluation of calcaneal fracture: case report.

INTRODUCTION: Radiography is the standard tool in the diagnostics of bone fractures. This paper presents a case of calcaneal fracture diagnosed by ultrasonography that was also used in the follow-up of recovery progress. CASE OUTLINE: A 68-year-old male patient was diagnosed avulsion fracture of the calcaneus by ultrasonography (US) examination using a multi-frequency linear probe (7-15 MHz) and confirmed by X-ray findings; US also provided insight into the dynamics of the reparatory processes. Control examinations were performed on day 14, 21, 30, 60 and 300 (10 months) after the occurrence of the fracture. During this time rehabilitation process was carried out. The diameters of the wedge defect of the calcaneus were measured by US for the follow-up of the healing process of the injured bone. Postero-anterior (PA) or longitudinal diameter and latero-medial or medio-lateral or transverse diameter were measured. CONCLUSION: Study results indicate a possible use of US in the diagnostics of fractures and monitoring of calcaneal healing.

[Patellar fracture after reconstruction of the anterior cruciate ligament--case report]. / Prelom patele posle rekonstrukcije prednjeg ukrstenog ligamenta--prikaz slucaja.

INTRODUCTION: The most frequent procedure in treatment of acute or chronic anterior cruciate ligament (ACL) rupture is the so called bone-tendon-bone reconstruction. A transverse dislocated patella fracture is a rare complication of this procedure with an incidence of 0.23%-2.3%. In a five year period, (1998-2002), 407 arthroscopic reconstructions of the anterior cruciate ligaments were done at our Clinic, and there was only one case of patella fracture. CASE REPORT: An 18-year-old female patient, a handball player, suffered an acute rupture of anterior cruciate ligament of the left knee, so arthroscopic bone-tendon-bone reconstruction of the anterior cruciate ligament was performed. After adequate skin incision, a bone graft was taken from the patella and upper part of trapezoid tibia, which was 25 mm long, 10 mm wide and 5 mm thick, together with a part of patellar ligament. After the remains of the anterior cruciate ligament had been arthroscopically removed, tunnels were made in tibia and femur and a graft was inserted and fixed with two metal interference screws. Knee stability was tested, and drainage was put in the knee joint. The wound was closed by layers. The quadriceps exercises and passive knee movements started immediately. Full range of movements was accomplished six weeks later when the patient started to walk with full weight-bearing on her operated leg. Three weeks later, (nine weeks after the operation), the patient has accidentally lost her balance and fell. A transverse, dislocated fracture of the left patella was diagnosed and osteosynthesis of the fractured patella with two Kirschner wires and a metallic loop was performed. Postoperatively, full range of movement was allowed. Six months later, the patient felt no pain, there was no swelling, full range of knee movement was achieved, while the Lachman Test was identical in both knees and the pivot shift test was negative. DISCUSSION: Fracture of patella after ACL reconstruction is due to several reasons: size and shape of the graft, technique of its taking, disturbed patellar blood supply, incomplete filling of patella defect after graft taking, and inappropriate postoperative rehabilitation. If a patellar fracture occurs after anterior cruciate ligament reconstruction, the best treatment is firm osteosynthesis, which enables bone healing and immediate continuation of the previously resumed rehabilitation program. However, this complication prolongs the rehabilitation period and slows down return to sports.