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Crawford D.C.,Oregon Health And Science University | DeBerardino T.M.,University of Connecticut Health Center | Williams III R.J.,Sports Medicine and Shoulder Service
Journal of Bone and Joint Surgery - Series A

Background: Despite introduction of autologous chondrocyte therapy for repair of hyaline articular cartilage injury in 1994, microfracture remains a primary standard of care. NeoCart, an autologous cartilage tissue implant, was compared with microfracture in a multisite prospective, randomized trial of a tissue-engineered bioimplant for treating articular cartilage injuries in the knee. Methods: Thirty patients were randomized at a ratio of two to one (two were treated with an autologous cartilage tissue implant [NeoCart] for each patient treated with microfracture) at the time of arthroscopic confirmation of an International Cartilage Repair Society (ICRS) grade-III lesion(s). Microfracture or cartilage biopsy was performed. NeoCart, produced by seeding a type-I collagen matrix scaffold with autogenous chondrocytes and bioreactor treatment, was implanted six weeks following arthroscopic cartilage biopsy. Standard evaluations were performed with validated clinical outcomes measures. Results: Three, six, twelve, and twenty-four-month data are reported. The mean duration of follow-up (and standard deviation) was 26 ± 2 months. There were twenty-one patients in the NeoCart group and nine in the microfracture group. The mean age (40 ± 9 years), body mass index (BMI) (28 ± 4 kg/m 2), duration between the first symptoms and treatment (3 ± 5 years), and lesion size (287 ± 138 mm 2 in the NeoCart group and 252 ± 135 mm 2 in the microfracture group) were similar between the groups. Adverse event rates per procedure did not differ between the treatment arms. The scores on the Short Form-36 (SF-36), Knee Injury and Osteoarthritis Outcome Score (KOOS) activities of daily living (ADL) scale, and International Knee Documentation Committee (IKDC) form improved from baseline (p < 0.05) to two years postoperatively in both treatment groups. In the NeoCart group, improvement, compared with baseline, was significant (p < 0.05) for all measures at six, twelve, and twenty-four months. Improvement in the NeoCart group was significantly greater (p < 0.05) than that in the microfracture group for the KOOS pain score at six, twelve, and twenty-four months; the KOOS symptom score at six months; the IKDC, KOOS sports, and visual analog scale (VAS) pain scores at twelve and twenty-four months; and the KOOS quality of life (QOL) score at twenty-four months. Analysis of covariance (ANCOVA) at one year indicated that the change in the KOOS pain (p = 0.016) and IKDC (p = 0.028) scores from pretreatment levels favored the NeoCart group. Significantly more NeoCart-treated patients (p = 0.0125) had responded to therapy (were therapeutic responders) at six months (43% versus 25% in the microfracture group) and twelve months (76% versus 22% in the microfracture group). This trend continued, as the proportion of NeoCart-treated patients (fifteen of nineteen) who were therapeutic responders at twenty-four months was greater than the proportion of microfracture-treated participants (four of nine) who were therapeutic responders at that time. Conclusions: This randomized study suggests that the safety of autologous cartilage tissue implantation, with use of the NeoCart technique, is similar to that of microfracture surgery and is associated with greater clinical efficacy at two years after treatment. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2012 by The Journal of Bone and Joint Surgery, Incorporated. Source

McCarthy M.M.,Sports Medicine and Shoulder Service | Strickland S.M.,Sports Medicine and Shoulder Service
Current Reviews in Musculoskeletal Medicine

Patellofemoral pain is a frequent and often challenging clinical problem. It affects females more than males and includes many different pathologic entities that result in pain in the anterior aspect of the knee. Diagnosis of the specific cause of pain can be difficult and requires assessment of lower extremity strength, alignment, and range of motion, as well as specific patella alignment, tracking, and mobility. The treatment for patellofemoral pain is usually conservative with anti-inflammatory medications, activity modification, and a specific physical therapy program focusing on strengthening and flexibility. Infrequently, surgical treatment may be indicated after a non-operative program fails. The outcomes of surgical management may include debridement, lateral release, and realignment of the extensor mechanism to unload the patellofemoral articulation are favorable. © 2013 Springer Science+Business Media New York. Source

Voos J.E.,651 College Blvd | Mauro C.S.,University of Pittsburgh | Wente T.,651 College Blvd | Warren R.F.,Sports Medicine and Shoulder Service | Wickiewicz T.L.,Sports Medicine and Shoulder Service
American Journal of Sports Medicine

The optimal treatment of posterior cruciate ligament ruptures remains controversial despite numerous recent basic science advances on the topic. The current literature on the anatomy, biomechanics, and clinical outcomes of posterior cruciate ligament reconstruction is reviewed. Recent studies have quantified the anatomic location and biomechanical contribution of each of the 2 posterior cruciate ligament bundles on tunnel placement and knee kinematics during reconstruction. Additional laboratory and cadaveric studies have suggested double-bundle reconstructions of the posterior cruciate ligament may better restore normal knee kinematics than single-bundle reconstructions although clinical outcomes have not revealed such a difference. Tibial inlay posterior cruciate ligament reconstructions (either open or arthroscopic) are preferred by many authors to avoid the "killer turn" and graft laxity with cyclic loading. Posterior cruciate ligament reconstruction improves subjective patient outcomes and return to sport although stability and knee kinematics may not return to normal. © 2012 The Author(s). Source

Taylor S.A.,Sports Medicine and Shoulder Service | Rodeo S.A.,Sports Medicine and Shoulder Service
Current Reviews in Musculoskeletal Medicine

Meniscal tears are relatively common injuries sustained by athletes and non-athletes alike and have far reaching functional and financial implications. Studies have clearly demonstrated the important biomechanical role played by the meniscus. Long-term follow-up studies of post-menisectomy patients show a predisposition toward the development of degenerative arthritic changes. As such, substantial efforts have been made by researchers and clinicians to understand the cellular and molecular basis of meniscal healing. Proinflammatory cytokines have been shown to have a catabolic effect on meniscal healing. In vitro and some limited in vivo studies have shown a proliferative and anabolic response to various growth factors. Surgical techniques that have been developed to stimulate a healing response include mechanical abrasion, fibrin clot application, growth factor application, and attempts at meniscal neovascularization. This article discusses various augmentation techniques for meniscal repair and reviews the current literature with regard to fibrin clot, platelet rich plasma, proinflammatory cytokines, and application of growth factors. © 2013 Springer Science+Business Media New York. Source

Bedi A.,Sports Medicine and Shoulder Service | Raphael B.,Sports Medicine and Shoulder Service | Maderazo A.,Imaging Hospital for Special Surgery | Pavlov H.,Imaging Hospital for Special Surgery | Williams III R.J.,Sports Medicine and Shoulder Service
Arthroscopy - Journal of Arthroscopic and Related Surgery

Purpose: To compare the obliquity and length of femoral tunnels prepared with transtibial versus anteromedial portal drilling for anterior cruciate ligament (ACL) reconstruction and identify potential risks associated with the anteromedial portal reaming technique. Methods: We used 18 human cadaveric knees (9 matched pairs) without ACL injury or pre-existing arthritis for the study. Femoral tunnels for ACL reconstruction were prepared by either a transtibial (n = 6) or anteromedial portal (n = 12) technique. For the anteromedial portal technique, a guidewire was advanced through the medial portal in varying degrees of knee flexion (100° [n = 4], 110° [n = 4], or 120° [n = 4]) as measured with a goniometer. By use of a 6-mm femoral offset guide, two 6-mm femoral tunnels were reamed with the guide placed (1) as far posterior and lateral in the notch as possible and (2) as far medial and vertical in the notch as possible to define the range of maximal and minimal achievable coronal obliquity for each technique. All knees were imaged with high-resolution, 3-dimensional fluoroscopy to define (1) coronal tunnel obliquity relative to the lateral tibial plateau, (2) sagittal tunnel obliquity relative to the long axis of the femur, (3) intraosseous tunnel length, and (4) the presence of posterior cortical wall blowout. Data analysis was performed with a paired t-test and repeated-measures analysis of variance, with P < .05 defined as significant. Results: Preparation of a vertical tunnel was possible with both transtibial and anteromedial portal drilling. The maximal achievable coronal obliquity, however, was significantly better with an anteromedial portal compared with transtibial drilling. However, 7 of 36 tunnels (19.4%) showed violation of the posterior tunnel wall, and all of these cases occurred with the anteromedial portal drilling technique. In addition, 1 of 6 oblique femoral tunnels (16.7%) drilled with the transtibial technique and 5 of 12 oblique femoral tunnels (41.7%) drilled with the anteromedial portal had an intraosseous length less than 25 mm. Increasing knee flexion with anteromedial portal drilling was associated with a significant reduction in tunnel length, increase in coronal obliquity, increase in sagittal obliquity, and increased risk of posterior wall blowout (P < .05). Conclusions: The anteromedial portal technique allows for slightly greater femoral tunnel obliquity compared with transtibial drilling. However, there is a substantially increased risk of critically short tunnels (<25 mm) and posterior tunnel wall blowout when a conventional offset guide is used. Increasing knee flexion with anteromedial portal drilling allows for greater coronal obliquity of the femoral tunnel but is accompanied by a greater risk of critically short tunnels and posterior wall compromise. Clinical Relevance: Our findings provide insight into the potential risks and advantages of a transtibial versus an anteromedial femoral tunnel drilling technique in ACL reconstruction. © 2010 Arthroscopy Association of North America. Source

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