Search

Background: Point-of-care treatment options for medium to large symptomatic articular cartilage defects are limited. Minced cartilage implantation is an encouraging single-stage option, providing fresh viable autologous tissue with minimal morbidity and cost. Purpose: To determine the histological properties of mechanically minced versus minimally manipulated articular cartilage. Study Design: Controlled laboratory study. Methods: Remnant articular cartilage was collected from fresh femoral condylar allografts. Cartilage samples were divided into 4 groups: cartilage explants with or without fibrin glue and mechanically minced cartilage with or without fibrin glue. Samples were cultured for 42 days. Chondrocyte viability was assessed using live/dead assay. Cellular migration and outgrowth were monitored using bright-field microscopy. Extracellular matrix deposition was assessed via histological staining. Proteoglycan content and synthesis were assessed using dimethylmethylene blue assay and radiolabeled 35S-sulfate, respectively. Type II collagen (COL2A1) gene expression was analyzed via polymerase chain reaction. Results: The mean viability of minced cartilage particles (34% ± 14%) was not significantly reduced compared with baseline (46% ± 13%) on day 0 ( P = .90). After culture, no significant difference in the percentage of live cells was appreciated between mechanically minced (58% ± 23%) and explant (73% ± 14%) cartilage in the presence of fibrin glue ( P = .52). The addition of fibrin glue did not significantly affect the viability of cartilage samples. The qualitative assessment revealed comparable cellular migration and outgrowth between groups. Proteoglycan synthesis was not significantly different between groups. Histological analysis findings were positive for COL2A1 in all groups, and matrix formation was appreciated in all groups. COL2A1 expression in minced cartilage (1.72 ± 1.88) was significantly higher than in explant cartilage (0.15 ± 0.07) in the presence of fibrin glue ( P = .01). Conclusion: Mechanically minced articular cartilage remained viable after 42 days of culture in vitro and was comparable with cartilage explants with regard to cellular migration, outgrowth, and extracellular matrix synthesis. Clinical Relevance: Mechanically minced articular cartilage is an encouraging intervention for the treatment of symptomatic cartilage defects. Further translational work is warranted to determine the viability of minced cartilage implantation as a single-stage therapeutic intervention in vivo.

Background:Free bone block (FBB) procedures for anterior shoulder instability have been proposed as an alternative to or bail-out for the Latarjet procedure. However, studies comparing the outcomes of these treatment modalities are limited.Purpose:To systematically review and perform a meta-analysis comparing the clinical outcomes of patients undergoing anterior shoulder stabilization with a Latarjet or FBB procedure.Study Design:Systematic review and meta-analysis; Level of evidence, 4.Methods:PubMed, Embase, and the Cochrane Library databases were systematically searched from inception to 2019 for human-participants studies published in the English language. The search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement including studies reporting clinical outcomes of patients undergoing Latarjet or FBB procedures for anterior shoulder instability with minimum 2-year follow-up. Case reports and technique articles were excluded. Data were synthesized, and a random effects meta-analysis was performed to determine the proportions of recurrent instability, other complications, progression of osteoarthritis, return to sports, and patient-reported outcome (PRO) improvement.Results:A total of 2007 studies were screened; of these, 70 studies met the inclusion criteria and were included in the meta-analysis. These studies reported outcomes on a total of 4540 shoulders, of which 3917 were treated with a Latarjet procedure and 623 were treated with an FBB stabilization procedure. Weighted mean follow-up was 75.8 months (range, 24-420 months) for the Latarjet group and 92.3 months (range, 24-444 months) for the FBB group. No significant differences were found between the Latarjet and the FBB groups in the overall random pooled summary estimate of the rate of recurrent instability (5% vs 3%, respectively; P = .09), other complications (4% vs 5%, respectively; P = .892), progression of osteoarthritis (12% vs 4%, respectively; P = .077), and return to sports (73% vs 88%; respectively, P = .066). American Shoulder and Elbow Surgeons scores improved after both Latarjet and FBB, with a significantly greater increase after FBB procedures (10.44 for Latarjet vs 32.86 for FBB; P = .006). Other recorded PRO scores improved in all studies, with no significant difference between groups.Conclusion:Current evidence supports the safety and efficacy of both the Latarjet and FBB procedures for anterior shoulder stabilization in the presence of glenoid bone loss. We found no significant differences between the procedures in rates of recurrent instability, other complications, osteoarthritis progression, and return to sports. Significant improvement in PROs was demonstrated for both groups. Significant heterogeneity existed between studies on outcomes of the Latarjet and FBB procedures, warranting future high-quality, comparative studies.

Background The purpose of this study was to evaluate mid- and long-term outcomes following the Latarjet procedure for anterior shoulder instability. Methods PubMed, MEDLINE, Embase, and Cochrane libraries were systematically searched, in line with PRISMA guidelines, for studies reporting on outcomes following the Latarjet procedure with minimum five-year follow-up. Outcomes of studies with follow-up between 5 and 10 years were compared to those with minimum follow-up of 10 years. Results Fifteen studies reporting on 1052 Latarjet procedures were included. Recurrent instability occurred in 127 patients, with an overall random summary estimates in studies with a minimum five-year follow-up of 0–18% (I2 = 90%) compared to 5–26% (I2 = 59%) for studies with a minimum 10-year follow-up. Overall rates for return to sports, non-instability related complications, and progression of arthritis estimated at 65–100% (I2 = 87%), 0–20% (I2 = 85%), and 8–42% (I2 = 89%) for the minimum five-year follow-up studies and 62–93% (I2 = 86%), 0–9% (I2 = 28%), and 9–71% (I2 = 91%) for the minimum 10-year follow-up studies, respectively. All studies reported good-to-excellent mean PRO scores at final follow-up. Conclusions The Latarjet is a safe and effective procedure for patients with shoulder instability. The majority of patients return to sport, though at long-term follow-up, a trend towards an increased incidence of recurrent instability is appreciated, while a significant number may demonstrate arthritis progression.

Cartilage defects in the knee are being diagnosed with increased frequency and are treated with a variety of techniques. The aim of any cartilage repair procedure is to generate the highest tissue quality, which might correlate with improved clinical outcomes, return-to-sport, and long-term durability. Minced cartilage implantation (MCI) is a relatively simple and cost-effective technique to transplant autologous cartilage fragments in a single-step procedure. Minced cartilage has a strong biologic potential since autologous, activated non-dedifferentiated chondrocytes are utilized. It can be used both for small and large cartilage lesions, as well as for osteochondral lesions. As it is purely an autologous and homologous approach, it lacks a significant regulatory oversight process and can be clinically adopted without such limitations. The aim of this narrative review is to provide an overview of the current evidence supporting autologous minced cartilage implantation.

Background: Immediate postoperative pain relief following arthroscopic partial meniscectomy remains a critical contributor to improved patient experience, early recovery of range of motion, and enhanced rehabilitation. Purpose: To evaluate the effect of intra-articular versus extra-articular bupivacaine on pain intensity and analgesic intake after arthroscopic partial meniscectomy. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This was a prospective double-blind, randomized clinical trial. All patients included underwent arthroscopic partial meniscectomy under general anesthesia. Patients were randomized into 2 groups, with 20 patients in each group. At the conclusion of the arthroscopic procedure, the intra-articular group received 10 mL 0.5% bupivacaine introduced intra-articularly and 10 mL isotonic saline 0.9% infiltrated subcutaneously around the portals. The extra-articular group received the isotonic saline intra-articularly and the bupivacaine around the portals. The primary outcome was the visual analog scale (VAS) for pain. Assessments were performed 0 to 0.5, 1 to 2, 2 to 4, and at 24 and 48 hours postoperatively. In addition, analgesic and narcotic consumption was monitored. Results: There were no differences between the groups in terms of patient demographics. VAS scores for the intra-articular group were 6, 8, 3.25, 4.3, and 4.5 at 0 to 0.5, 1 to 2, 2 to 4, 24, and 48 hours postoperatively, respectively. VAS scores for the extra-articular group were 3.8, 5, 2.9, 5.2, and 5.25, respectively. No statistically significant differences were observed between the 2 groups regarding pain intensity at all time points. There was also no statistically significant difference in analgesic consumption. Dipyrone was the preferred drug by patients from the intra-articular group, while the extra-articular group preferred to use opioids and nonsteroidal anti-inflammatory drugs. Conclusion: There were no differences in pain severity and analgesic intake between intra- or extra-articular bupivacaine administration after arthroscopic partial meniscectomy.

Objectives: To develop machine learning algorithms to predict failure of surgical procedures that address cartilage defects of the knee and detect the most valuable variables associated with failure. Methods: A single institution prospectively collected database of cartilage procedures was queried for procedures performed between 2000 and 2018. Failure was defined as revision cartilage surgery and/or knee arthroplasty. One hundred and one preoperative and intraoperative features were evaluated as potential predictors. The dataset was randomly divided into training (70%) and independent testing (30%) sets. Four machine learning algorithms were trained and internally validated. Algorithm performance was assessed using area under curve (AUC) and the Brier score. Local Interpretable Model-agnostic Explanations (LIME) was utilized to assess the optimized algorithm fidelity. Results: A total of 1091 patients who underwent surgical procedures addressing cartilage defects in the knee with a minimum of 2-years of follow-up were included. The mean follow-up was 3.5 ± 2.8 years. The mean age was 40.5 ± 15 years. There were 205 (18.8%) patients who failed at final follow-up. The Random Forest algorithm was found to be the best performing algorithm, with an AUC of 0.765 and a Brier score of 0.135. The 10 most important features for predicting failure following surgical procedures addressing cartilage defects of the knee were: symptom duration, age, body mass index (BMI), lesion grade, total lesion area (sum of all lesion areas), number of previous surgeries, number of lesions in the knee, gender, athletic level, and traumatic etiology. LIME analysis allowed for assessment of the optimized algorithm fidelity, as well as provided a patient-specific comparison for the risk of failure of an individual patient being assigned various types of cartilage procedures. Conclusions: Machine learning algorithms were accurate in predicting the risk of failure following cartilage procedures of the knee, with the most important features being symptom duration, age, BMI, lesion grade, and total lesion area. Machine learning algorithms may be used to compare the risk of failure of specific patient-procedure combinations in the treatment of cartilage defects of the knee. Integrated human and machine learning decision-making may improve patient selection and bring about the new era of patient-tailored evidence-based clinical care. [Table: see text][Table: see text][Figure: see text][Figure: see text]

This 2020 NBA Orthobiologics Consensus Statement provides a concise summary of available literature and practical clinical guidelines for team physicians and players. We recognize that orthobiologic injections are a generally safe treatment modality with a significant potential to reduce pain and expedite early return to play in specific musculoskeletal injuries. The use of orthobiologics in sports medicine to safely reduce time loss and reinjury is of considerable interest, especially as it relates to the potential effect on a professional athlete. While these novel substances have potential to enhance healing and regeneration of injured tissues, there is a lack of robust data to support their regular use at this time. There are no absolutes when considering the implementation of orthobiologics, and unbiased clinical judgment with an emphasis on player safety should always prevail. Current best evidence supports the following: Key Points There is support for the use of leukocyte-poor platelet-rich plasma in the treatment of knee osteoarthritis. There is support for consideration of using leukocyte-rich platelet-rich plasma for patellar tendinopathy. The efficacy of using mesenchymal stromal cell injections in the management of joint and soft tissue injuries remains unproven at this time. There are very few data to suggest that current cell therapy treatments lead to any true functional tissue regeneration. Meticulous and sterile preparation guidelines must be followed to minimize the risk for infection and adverse events if these treatments are pursued. Given the high variability in orthobiologic formulations, team physicians must stay up-to-date with the most recent peer-reviewed literature and orthobiologic preparation protocols for specific injuries. Evidence-based treatment algorithms are necessary to identify the optimal orthobiologic formulations for specific tissues and injuries in athletes. Changes in the regulatory environment and improved standardization are required given the exponential increase in utilization as novel techniques and substances are introduced into clinical practice.

Objectives: In the meniscal deficient patient, meniscal allograft transplantation (MAT) has demonstrated promising early- and mid-term outcomes. Despite exhibiting improvement when compared to baseline values, outcomes at long-term follow-up have been shown to gradually decline secondary to graft failure and osteoarthritic development. However, it remains largely unknown if patient reported outcome measures (PROM) at long-term follow-up continue to meet thresholds for clinically significant outcome (CSO) measures such as minimum clinically important difference (MCID) and patient acceptable symptomatic state (PASS). The purpose of this investigation was to analyze CSOs after MAT at a minimum 5-year follow-up, while evaluating graft survival and overall patient satisfaction. Methods: A retrospective review of a prospectively collected, single-institution database spanning from 1999-2016 was performed to identify patients who underwent MAT using the bridge-in-slot technique and completed baseline PROMs with a minimum of 5-year follow-up. Baseline patient and surgical characteristics were collected. Preoperative and final follow-up PROMs were analyzed to determine whether patients met established MCID and PASS thresholds for International Knee Documentation Committee (IKDC; 9.9 and 36.0, respectively) and Lysholm (12.3 and 66.5, respectively) scores. Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales were also collected, though not analyzed for CSO attainment. Failure was defined as revision MAT, conversion to unilateral or total knee arthroplasty, and macroscopic graft failure during second-look arthroscopy. Results: A total of 275 underwent MAT, of which 34% (n=95/275) completed PROMs with a minimum of 5-year follow-up (mean follow up, 8.5 ± 3.2 years [range, 5.0 – 16.8]). Mean patient age was 29.5 ± 9.9 years, with a mean symptom duration of 5.3 ± 5.5 years (Table 1). The majority of patients received concomitant procedures at the time of index MAT, including osteochondral allograft transplantation (43.1%) and anterior cruciate ligament reconstruction (20.0%) (Table 2). Mean PROMs at final follow-up significantly improved when compared to preoperative values for IKDC, Lysholm, and KOOS subscales (all P < .01; Figure 1). MCID and PASS for the IKDC survey were met by 77.8% and 38.8% of patients at final follow up, respectively. MCID for Lysholm score was achieved by 69.2% of patients, while only 2.6% met PASS (Table 3). Failure was reported in 20% (n=19/95) of patients, occurring at a mean 3.8 ± 3.0 years following surgery (Figure 2). Overall, 91% of patients with an intact meniscal allograft reported being satisfied at final follow-up. Conclusions: At a minimum of 5-year follow-up, significant improvements in PROMs were appreciated when compared to preoperative values. MCID was achieved in a total of 77.8% of patients for IKDC and 69.2% for Lysholm. PASS thresholds were met by 38.8% of patients for IKDC and 2.6% of patients for Lysholm. Failure was reported in 20% of patients. Further investigations analyzing variables associated with the success and failure to meet CSO in patients undergoing MAT with long-term follow up are warranted. [Figure: see text][Figure: see text][Table: see text]

Objectives: Meniscal allograft transplantation (MAT) is a surgical treatment option for patients with meniscus deficiencies. Prior studies have defined clinically significant outcomes such as minimal clinical important difference (MCID) and patient acceptable symptomatic state (PASS) for commonly administered patient reported outcome measures (PROMs) after MAT. The purpose of this study was to determine the time to achieving MCID and PASS and to identify any risk factors affecting achievement in patients undergoing MAT. Methods: A prospectively maintained MAT registry was retrospectively reviewed from April 2014-May 2020. Patients who underwent revision MAT or did not complete preoperative PROMs were excluded. International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were administered preoperatively and at 6-months, 1-year, and 2-years postoperatively. Previously defined MCID and PASS thresholds were utilized and Kaplan-Meier survival curve analysis with interval censoring was used to calculate the cumulative percentages of MCID, and PASS achievement at each follow-up time interval (5-7, 11-13, and 23-25 months). Results: Eighty-four patients (mean age: 28.2±9.7) were included. Time to MCID and PASS is presented in Table 1. Previously reported PASS values for KOOS Pain, Symptoms, and Sport did not reach an AUC>0.70 and thus were not included in analysis. Worker’s compensation status was found to delay time to achieving MCID for all PROs (HR=0.238-0.305, P=0.008-0.020) and PASS for KOOS Symptoms (HR=0.171, P = 0.026) and IKDC (HR=1.88, PConclusions: This study defined the time to achieving MCID and PASS on IKDC and KOOS subscores for patients undergoing MAT. Worker’s compensation status, BMI, and the presence of focal chondral defects may prolong time to achievement of MCID and PASS after MAT. [Table: see text][Table: see text][Table: see text]

Background: The physical examination of overweight patients can require specific adaptations. Orthopaedic literature on the impact of body mass index (BMI) on the physical examination of the shoulder is virtually nonexistent. Purpose: To assess whether BMI affects the sensitivity and specificity of common shoulder tests, using arthroscopy as a gold standard. We also examined the effects of BMI on the sensitivity and specificity of magnetic resonance imaging (MRI) of the shoulder for reference. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: We analyzed the data of 116 consecutive patients who underwent shoulder arthroscopy for the treatment of rotator cuff tears, Bankart lesions, and superior labral anterior-posterior (SLAP) lesions. Preoperative BMI, physical examination of the shoulder findings, and MRI findings were extracted. Contingency tables and receiver operating characteristic curves were used to evaluate the sensitivity and specificity of provocative tests of the shoulder and MRI as well as their relationship to BMI. Results: The sensitivity and specificity of the Jobe supraspinatus test were 77.8% and 72.7% in patients with BMI ≤25, 82.6% and 70.6% in those with 25 < BMI ≤ 30, and 81.3% and 55.6% in those with BMI >30, respectively ( P < .001). The apprehension and relocation tests demonstrated higher sensitivity and specificity for the overweight patients (25 < BMI ≤ 30) compared with the other BMI groups, with a sensitivity and specificity of 83.3% and 100% for the apprehension test and a sensitivity and specificity of 75% and 100% for the relocation test, respectively. The O’Brien, Speed, and Ebinger tests for SLAP tears had low accuracy and did not yield statistically significant results. MRI interpretation was found to be influenced by BMI in obese patients, especially when SLAP lesions were assessed. Conclusion: Counterintuitively, tests for shoulder instability had greater specificity in overweight patients and should be encouraged, particularly in obese patients, in whom the specificity of shoulder MRI for the detection of a Bankart lesion is lower. The Jobe test was more sensitive but less specific in overweight patients. These findings may assist care providers in improving the interpretation of the shoulder examination of overweight patients and consequently lead to better treatment-related decisions.