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Wang A.,Sir Charles Gairdner Hospital | Wang A.,University of Western Australia | Breidahl W.,Perth Radiological Clinic | Breidahl W.,University of Western Australia | And 5 more authors.
American Journal of Sports Medicine | Year: 2013

Background: Severe chronic lateral epicondylitis (LE) is associated with degenerative tendon changes, extracellular matrix breakdown, and tendon cell loss. On the basis of positive outcomes from preclinical studies, this study is the first clinical trial of autologous tenocyte injection (ATI) on severe tendinopathy associated with chronic LE. Hypothesis: Autologous tenocyte injection is a safe and effective procedure that enables a reduction in pain and improvement in function in resistant LE. Study Design: Case series; Level of evidence, 4. Methods: Patients with severe refractory LE underwent clinical evaluation and magnetic resonance imaging (MRI) before intervention. A patellar tendon needle biopsy was performed under local anesthetic, and tendon cells were expanded by in vitro culture. Tenocytes used for the injection were characterized by flow cytometry and real-time polymerase chain reaction. Autologous tenocytes were injected into the site of tendinopathy identified at the origin of the extensor carpi radialis brevis tendon under ultrasound guidance on a single occasion. Patients underwent serial clinical evaluations and repeat MRI at 12 months after intervention. Results: A total of 20 consecutive patients were included in the study. Three patients withdrew consent after enrollment and before ATI. No adverse event was reported at either biopsy or injection sites. Furthermore, no infection or excessive fibroblastic reaction was found in any patient at the injection site. Clinical evaluation revealed an improvement in mean visual analog scale scores, for a maximum pain score from 5.94 at the initial assessment to 0.76 at 12 months (P<.001). Mean quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and grip strength scores also significantly improved over the 12-month follow-up (QuickDASH score, 45.88 [baseline] to 3.84; grip strength, 20.17 kg [baseline] to 37.38 kg; P < .001). With use of a validated MRI scoring system, the grade of tendinopathy at the common extensor origin improved significantly by 12 months (P < .001). One patient elected to proceed to surgery 3 months after ATI following a reinjury at work. Conclusion: In this study, patients with chronic LE who had previously undergone an unsuccessful full course of nonoperative treatment showed significantly improved clinical function and structural repair at the origin of the common extensor tendon after ATI. This novel treatment is encouraging for the treatment of tendinopathy and warrants further evaluation. © 2013 The Author(s). Source


Ebert J.R.,University of Western Australia | Fallon M.,Perth Radiological Clinic | Zheng M.H.,University of Western Australia | Wood D.J.,University of Western Australia | Ackland T.R.,University of Western Australia
American Journal of Sports Medicine | Year: 2012

Background: While structured postoperative rehabilitation after matrix-induced autologous chondrocyte implantation (MACI) is considered critical, very little has been made available on how best to progressively increase weightbearing and exercise after surgery. Hypothesis: A significant improvement will exist in clinical and magnetic resonance imaging (MRI)based scoring measures to 5 years after surgery. Furthermore, there will be no significant differences in outcomes in MACI patients at 5 years when comparing a traditional and an accelerated postoperative weightbearing regimen. Finally, patient demographics, cartilage defect parameters, and injury/surgery history will be associated with graft outcome. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Clinical and radiological outcomes were studied in 70 patients who underwent MACI to the medial or lateral femoral condyle, in conjunction with either an "accelerated" or a "traditional" approach to postoperative weightbearing rehabilitation. Under the accelerated protocol, patients reached full weightbearing at 8 weeks after surgery, compared with 11 weeks for the traditional group. Clinical measures (Knee Injury and Osteoarthritis Outcome Score [KOOS], Short-Form Health Survey [SF-36], visual analog scale [VAS], 6-minute walk test, and knee range of motion) were assessed before surgery and at 3, 6, 12, and 24 months and 5 years after surgery. High-resolution MRI was undertaken at 3, 12, and 24 months and 5 years after surgery and assessed 8 previously defined pertinent parameters of graft repair as well as a combined MRI composite score. The association between clinical and MRI-based outcomes, patient demographics, chondral defect parameters, and injury/surgery history was investigated. Results: Of the 70 patients recruited, 63 (31 accelerated, 32 traditional) underwent clinical follow-up at 5 years; 58 (29 accelerated, 29 traditional) also underwent radiological assessment. A significant time effect (P ≤ .05) was demonstrated for all clinical and MRI-based scores over the 5-year period. While the VAS demonstrated significantly less frequent pain at 5 years in the accelerated group, there were no other significant differences between the 2 groups. Between 24 months and 5 years, a significant improvement (P ≤ .05) in both groups was observed for the sport and recreation subscale of the KOOS as well as a significant decrease (P ≤ .05) in active knee extension for the traditional group. There were no significant differences (P ≥ .05) in the MRIbased scores between 24 months and 5 years after surgery. Patient age and defect size exhibited significant negative correlations (P ≤ .05) with several MRI-based outcomes at 5 years, while there were no significant correlations (P ≥ .05) between clinical and MRI-based outcomes. At 5 years after surgery, 94% and 95% were satisfied with the ability of MACI to relieve their knee pain and improve their ability to undertake daily activities, respectively. Conclusion: The outcomes of this randomized trial demonstrate a safe and effective accelerated rehabilitation protocol as well as a regimen that provides comparable, if not superior, clinical outcomes to patients throughout the postoperative timeline. © 2012 The Author(s). Source


Counsel P.,Princess Margaret Hospital | Breidahl W.,Perth Radiological Clinic
Seminars in Musculoskeletal Radiology | Year: 2010

Muscle injuries of the lower leg are a common cause for time off from sports, and may also be a cause of disability in nonathletes who have a running or pushing off injury as part of their activities of daily living. Most injuries can be managed without imaging, but in selected cases advanced imaging techniques can demonstrate the exact site and extent of the injury and potentially modify rehabilitation and return to sports. In experienced hands ultrasonography can identify the location of muscle injuries as well as aid in hematoma aspiration. It is useful for excluding differential diagnoses such as deep vein thrombosis or Baker's cyst and may be superior for investigating certain conditions such as muscle hernia. Magnetic resonance imaging is more sensitive for injury to deeper muscles and dual injuries and is generally the modality of choice in elite athletes. © 2010 Thieme Medical Publishers, Inc. Source


Ebert J.R.,University of Western Australia | Smith A.,Curtin University Australia | Fallon M.,Perth Radiological Clinic | Wood D.J.,University of Western Australia | Ackland T.R.,University of Western Australia
American Journal of Sports Medicine | Year: 2014

Background: Matrix-induced autologous chondrocyte implantation (MACI) is an established technique for the repair of knee chondral defects, although the correlation between clinical and radiological outcomes after surgery is poorly understood.Purpose: To determine the correlation between clinical and radiological outcomes throughout the postoperative timeline to 5 years after MACI.Study Design: Cohort study (diagnosis); Level of evidence, 3.Methods: This retrospective study was undertaken in 83 patients (53 male, 30 female) with complete clinical and radiological follow-up at 1, 2, and 5 years after MACI. The mean age of patients was 38.9 years (range, 13-62 years), with a mean body mass index (BMI) of 26.6 kg/m2(range, 16.8-34.8 kg/m2), mean defect size of 3.3 cm2(range, 1-9 cm2), and mean preoperative duration of symptoms of 9.2 years (range, 1-46 years). Patients indicated for MACI in this follow-up were 13 to 65 years of age, although they were excluded if they had a BMI >35 kg/m2, had undergone prior extensive meniscectomy, or had ongoing progressive inflammatory arthritis. Patients were assessed clinically using the Knee Injury and Osteoarthritis Outcome Score (KOOS). Magnetic resonance imaging (MRI) was used to evaluate the graft using a 1.5-T or 3-T clinical scanner; the MRI assessment included 8 parameters of graft repair (infill, signal intensity, border integration, surface contour, structure, subchondral lamina, subchondral bone, and effusion) based on the magnetic resonance observation of cartilage repair tissue (MOCART) score as well as an MRI composite score. The degree of an association between the MRI parameters and the KOOS subscales at each postoperative time point was assessed with the Spearman correlation coefficient (SCC), and significance was determined at P<.05. Ethics approval was obtained from the appropriate hospital and university Human Research Ethics Committees, and informed consent was gathered from all patients.Results: The only MRI parameter displaying consistent evidence of an association with the KOOS subscales was effusion, with a pattern of increasing strength of correlations over time and statistically significant associations at 5 years with KOOS-Pain (SCC, 0.25; P=.020), KOOS-Activities of Daily Living (SCC, 0.26; P=.018), and KOOS-Sport (SCC, 0.32; P=.003). Apart from a significant correlation between subchondral lamina and KOOS-Sport at 1 year (SCC, 0.27; P=.016), no further significant findings were observed.ab Conclusion: Apart from some consistent evidence of an association between the KOOS and effusion, this analysis demonstrated a limited correlative capacity between clinical and radiological outcomes up to 5 years after surgery. © 2014 The Author. Source


Ebert J.R.,University of Western Australia | Smith A.,Curtin University Australia | Fallon M.,Perth Radiological Clinic | Wood D.J.,University of Western Australia | Ackland T.R.,University of Western Australia
American Journal of Sports Medicine | Year: 2014

Background: Matrix-induced autologous chondrocyte implantation (MACI) is an established technique for the repair of knee chondral defects. While a number of factors may affect the clinical outcome, little is known about the influence of subchondral bone abnormalities at the time of surgery on pain and graft outcomes after MACI.Purpose: To investigate the association between subchondral bone marrow edema within 3 months before MACI surgery on preoperative and postoperative reported pain and symptoms as well as postoperative graft outcomes.Study Design: Cohort study; Level of evidence, 3.Methods: This retrospective study was undertaken in 56 patients undergoing MACI with clinical and radiological assessments before surgery and at 3, 12, 24, and 60 months after surgery. Patients were assessed using the Pain and Symptoms subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS). High-resolution magnetic resonance imaging (MRI) was used to evaluate the severity of preoperative subchondral bone marrow edema, while graft infill and an MRI composite graft score were evaluated after surgery via the magnetic resonance observation of cartilage repair tissue (MOCART) scoring system. Linear regression utilizing generalized estimating equations was used to investigate the association between preoperative subchondral bone marrow edema scores and preoperative and postoperative KOOS subscores as well as postoperative MRI-based scores of graft repair.Results: The degree of preoperative subchondral bone marrow edema was not significantly associated with postoperative outcomes, whereby there was no evidence of a difference between edema subgroups over all time points for the KOOS-Pain subscore (P = .644), KOOS-Symptoms subscore (P = .475), or MRI composite score (P = .685) after adjustment for potential confounders of age, body mass index, defect size, and defect location.Conclusion: No association was demonstrated between the severity of preoperative subchondral bone marrow edema with postoperative patient-reported knee pain or symptoms or postoperative graft repair assessed via MRI. ©2013 The Author(s). Source

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