Morphological Assessment of MACI Grafts in Patients with Revision Surgery and Total Joint Arthroplasty.

OBJECTIVE: To compare the histological and immunohistochemical characteristics of matrix-assisted chondrocyte implantation (MACI) grafts between patients with revision surgery and patients with total joint arthroplasty. METHODS: Biopsies of MACI grafts from patients with revision and total joint arthroplasty. The graft tissue characteristics and subchondral bone were examined by qualitative histology, ICRS (International Cartilage Repair Society) II scoring and semiquantitative immunohistochemistry using antibodies specific to type I and type II collagen. RESULTS: A total of 31 biopsies were available, 10 undergoing total knee arthroplasty (TKA) and 21 patients undergoing revision surgery. Patients in the clinically failed group were significantly older (46.3 years) than patients in the revision group (36.6 years) (P = 0.007). Histologically, the predominant tissue in both groups was of fibrocartilaginous nature, although a higher percentage of specimens in the revision group contained a hyaline-like repair tissue. The percentages of type I collagen (52.9% and 61.0%) and type II collagen (66.3% and 42.2%) were not significantly different between clinically failed and revised MACI, respectively. The talar dome contained the best and patella the worst repair tissue. Subchondral bone pathology was present in all clinically failed patients and consisted of bone marrow lesions, including edema, necrosis and fibrosis, intralesional osteophyte formation, subchondral bone plate elevation, intralesional osteophyte formation, subchondral bone cyst formation, or combinations thereof. CONCLUSIONS: MACI grafts in patients with revision and total joint arthroplasty were predominantly fibrocartilage in repair type, did not differ in composition and were histologically dissimilar to healthy cartilage. Clinically failed cases showed evidence of osteochondral unit failure, rather than merely cartilage repair tissue failure. The role of the subchondral bone in relation to pain and failure and the pathogenesis warrants further investigation.

Current Perspectives of the Australian Knee Society on Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction.

CONTEXT: The importance of rehabilitation and evaluation prior to return to sport (RTS) in patients undergoing anterior cruciate ligament reconstruction has been reported. OBJECTIVE: This study sought to investigate current perspectives of Australian orthopedic surgeons on rehabilitation and RTS evaluation. DESIGN: Survey. PARTICIPANTS: Members of the Australian Knee Society. MAIN OUTCOME MEASURES: A 14-question survey was disseminated to Australian Knee Society members (orthopedic surgeons) to investigate (1) preferred graft choice, (2) estimated retear rate, (3) importance of preoperative and postoperative rehabilitation, and (4) preferred timing of RTS and evaluation prior to RTS discharge. RESULTS: Of all 85 Australian Knee Society members contacted, 86% (n = 73) responded. Overall, 66 respondents (90.4%) preferentially used hamstring tendon autografts. All surgeons estimated their retear rate to be ≤15%, with 31 (42.5%) <5%. Twenty-eight surgeons (38.4%) reported no benefit in preoperative rehabilitation. The majority of surgeons (82.2%-94.5%) reported that postoperative rehabilitation was important within various periods throughout the postoperative timeline. Most surgeons did not permit RTS until ≥9 months (n = 56, 76.7%), with 17 (23.3%) allowing RTS between 6 and 9 months. The most highly reported considerations for RTS clearance were time (90.4%), functional capacity (90.4%), and strength (78.1%). Most commonly, knee strength and/or function was assessed via referral to a preferred rehabilitation specialist (50.7%) or with the surgeon at their practice (11.0%). CONCLUSIONS: This survey revealed variation in beliefs and practices surrounding rehabilitation and RTS evaluation. This is despite the current evidence demonstrating the benefit of preoperative and postoperative rehabilitation, as well as the emerging potential of RTS assessments consisting of strength and functional measures to reduce reinjury rates.

Current perspectives of Australian therapists on rehabilitation and return to sport after anterior cruciate ligament reconstruction: A survey.

OBJECTIVES: To investigate views and practices of Australian therapists on rehabilitation and return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR). DESIGN: Survey-based study. SETTING: Online survey platform. PARTICIPANTS: Australian Physiotherapists and Accredited Exercise Physiologists (n = 223). MAIN OUTCOME MEASURES: 1) perceived benefit, timing and frequency of rehabilitation, 2) timing of RTS and information on RTS evaluation and discharge criteria. RESULTS: Therapists preferred to consult patients for the first time at 1-4 days (27.8%), ≤7 days (25.6%) or 7-14 days (30.5%) post-surgery. Within the first 6 weeks, 82.1% of therapists preferred patient visitation 1-2 times per week. Between 3 and 6 months, therapists mainly recommended less frequent visitation with a focus on home exercises. While 22.0% and 53.8% of therapists were willing to discharge patients for sport at 6-9 and 9-12 months, respectively, 22.9% preferred 12-18 months. Common RTS considerations were functional capacity (98.7%), strength (87.0%), lower limb and trunk mechanics (96.0%) and psychological readiness (87.9%). Knee strength was evaluated via manual muscle testing (33.0%), hand held (26.7%) and isokinetic (11.8%) dynamometry. For functional evaluation, 84.3% of therapists employed a hop battery (≥2 hop tests). CONCLUSIONS: This survey revealed variation in beliefs and practices surrounding rehabilitation and RTS evaluation in Australian therapists.

Patellar eversion during total knee replacement: a prospective, randomized trial.

BACKGROUND: Proponents of minimally invasive total knee arthroplasty argue that retracting rather than everting the patella results in quicker postoperative recovery and improved function. We aimed to investigate this in patients undergoing knee arthroplasty through a standard medial parapatellar approach. METHODS: In a prospective randomized double-blinded study, sixty-eight patients undergoing total knee arthroplasty through a standard medial parapatellar approach were assigned to either retraction or eversion of the patella. Postoperatively, at three months, and at one year after surgery, an independent observer assessed the primary outcome measure (i.e., knee flexion) and secondary outcome measures (i.e., Oxford knee score, Short Form-12 [SF-12] score, visual analog scale pain score, knee motion, and alignment and patellar height as measured on radiographs with use of the Insall-Salvati ratio). RESULTS: Early (three-month) follow-up showed no significant difference between patellar eversion and subluxation in flexion (mean and 95% confidence interval [CI], 101° ± 5.37° versus 102° ± 4.14°, respectively), Oxford knee scores (25 ± 3 versus 27 ± 2.69, respectively), SF-12, or visual analog scale pain scores (1.9 ± 0.54 versus 1.1 ± 0.44, respectively). A significant improvement in extension was found (-3.9° ± 1.12° versus -2.0° ± 0.91°, respectively [p = 0.034]), but this was not clinically significant. There was no significant difference in any of the outcomes at one year. There was a significant difference in implant malpositioning between the eversion group and the subluxation group, with an increased percentage of lateral tibial overhang in the subluxation group (0.45 ± 0.39 versus 1.84 ± 0.82, respectively [p = 0.005]), but this did not correlate with functional outcome. There was no significant difference in alignment between the two groups (178.29° ± 0.84° versus 178.18° ± 0.78°). At one year after surgery, there was no difference between the two groups in Insall-Salvati ratio (1.15 ± 0.06 versus 1.12 ± 0.06) although there was a correlation between the percentage reduction in the ratio and functional outcome. There were two partial divisions of the patella tendon in the subluxation group, but no patella-related complications in the eversion group. CONCLUSIONS: The results of this trial showed that retracting rather than everting the patella during total knee arthroplasty resulted in no significant clinical benefit in the early to medium term. We observed no increase in patellar tendon shortening as a result of eversion rather than subluxation. Our findings did suggest that, with subluxation, there may be an increased risk of damage to the patellar tendon and reduced visualization of the lateral compartment, leading to an increase in implant malpositioning with lateral tibial overhang.

Gluteal tendon repair augmented with a synthetic ligament: surgical technique and a case series.

We describe an augmented surgical repair technique for gluteus minimus and medius tears, along with a supportive case series. A consecutive series of 22 patients presenting with clinical and radiological findings consistent with hip abductor tears, who had undergone failed prior conservative treatments, were prospectively recruited. Patients underwent open bursectomy, Y-iliotibial release, debridement of the diseased tendon, decortication of the trochanteric foot-plate and reattachment augmented with a LARS ligament through a trans-osseous tunnel, together with suture anchors. All patients were assessed pre- and postoperatively to 12 months with the Oxford Hip Score (OHS), the Short-Form Health Survey (SF-36) and a Visual Analogue Pain Scale (VAS), while a satisfaction scale was employed at 12 months. A statistically significant improvement (p<0.05) was observed for all patient reported outcome measures, while all patients were at least 'satisfied' with the procedure at 12 months. One patient reported some lateral hip discomfort at 10 months, and removal of the LARS interference screw provided immediate relief. One patient had a urological catheter-related complication. With no other complications and no clinical failures of the repair, we believe the technique to be safe and reliable, whilst reducing the incidence of re-tears as reported in the existing literature.

Arthroscopic Delivery of Matrix-Induced Autologous Chondrocyte Implant: International Experience and Technique Recommendations.

OBJECTIVE: To identify consensus recommendations for the arthroscopic delivery of the matrix-induced autologous chondrocyte implant. DESIGN: An invited panel was assembled on November 20 and 21, 2009 as an international advisory board in Zurich, Switzerland, to discuss and identify best practices for the arthroscopic delivery of matrix-induced autologous chondrocyte implantation. RESULTS: Arthroscopic matrix-induced autologous chondrocyte implantation is suitable for patients 18 to 55 years of age who have symptomatic, contained chondral lesions of the knee with normal or corrected alignment and stability. This technical note describes consensus recommendations of the international advisory board for the technique of arthroscopic delivery of the matrix-induced autologous chondrocyte implant. CONCLUSIONS: Matrix-induced autologous chondrocyte implantation can be further improved by arthroscopic delivery that does not require special instrumentation. In principle, arthroscopic versus open procedures of delivery of the matrix-induced autologous chondrocyte implant are less invasive and may potentially result in less postoperative pain, less surgical site morbidity, and faster surgical recovery. Long-term studies are needed to confirm these assumptions as well as the efficacy and safety of this arthroscopic approach.

Functional outcome of matrix-associated autologous chondrocyte implantation in the ankle.

BACKGROUND: The technique of Matrix-associated autologous chondrocyte implantation (MACI) is well established with satisfactory outcomes up to 5 years in the knee. Fewer series describe the outcomes of this technique in the ankle. We present the functional outcomes of the technique for a single surgeon series in a general hospital setting. MATERIALS AND METHODS: Twenty-seven patients, mean age 41, were reviewed at 3.7 (range, 1 to 5) years. Patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale, Tegener activity score and University of California lower extremity activity scale. MRI findings were also reviewed. RESULTS: While most patients report a significant improvement in symptoms with full return to activities of daily living, 36% of those under 40 and 78% of those over 40 reported restricted recreational activity. Of the patients under 40 years of age, 86% were able to run compared with 23% of those over 40. Of patients over 40, 64% continued to have moderate or severe pain. CONCLUSION: Careful preoperative counseling is required for patients of all ages regarding likely outcomes. In patients over 40, the procedure is unlikely to give good pain relief and alternative options should be considered.