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Congenital dislocation of the patella is a rare condition characterized by lateral dislocation of the patella that is irreducible without surgical correction. Although there is no clear inheritance pattern, it is associated with several congenital syndromes. Patients often demonstrate flexion contracture, loss of active knee extension, increased tibial external rotation, and absent patella in the trochlea. Treatment requires surgical management and is comprised of lateral release, medial stabilization, quadriceps lengthening, and distal realignment. Results are generally favorable after treatment; persistent flexion contracture and redislocation are the most common complications. Further study is needed to define the optimal timing and treatment strategy for this uncommon condition.

When we are looking at the stars, we are in fact looking back in time. This is because it takes years for the light from the stars to reach us. In similar fashion, when we are evaluating data on osteoarthritis after patellofemoral surgery, we need to consider what kind of procedure was performed. Furthermore, it is extremely important to answer the question of whether the patellofemoral instability itself or the surgical procedure is causing the arthritis. Recent evidence suggests that recurrent patellofemoral instability is causing cartilage degeneration and stopping this process via surgical restoration of the anatomy and biomechanics of the patellofemoral joint may significantly reduce the risk of osteoarthritis. Shear loading of the cartilage can be detrimental. An instability event elicits inflammatory markers that are shown to induce arthritis. On the other hand, there is the argument that over-constraint may lead to arthritis owing to an increase in cartilage loading. Another argument is that surgery may not fully restore the patellofemoral anatomy. Appropriate patient selection and continuous evolution of our surgical procedures are key elements toward successful management of patellofemoral instability.

Graft selection in anterior cruciate ligament reconstruction can have a pivotal role in a successful outcome. One of the major concerns with hamstring autograft is the variability of the diameter of each tendon, and grafts with a diameter of less than 8 mm may result in an increased failure rate. The addition of the sartorius tendon as a fifth strand in small-diameter hamstring autografts increases graft strength and diameter. This may improve outcomes in pediatric and revision cases.

In the setting of biological augmentation for meniscus repair, it is extremely important to evaluate all aspects, including effectiveness, costs, potential risks, benefits, and limitations. It seems that everything matters in healing: the aspirate source of the bioactive agents, cell content, presence of stem cells and their type, growth factors, cytokines, biomechanical scaffold, and the quality of the tissue. There are several differences among mesenchymal, adipose, and peripheral blood stem cells, with the cell origin affecting the differentiation potential towards bone, cartilage and ligament. Moreover, different aspirate sources and fibrin clots have different content in cells, growth factors, and cytokines. In this equation, it is not as simple as the more the better. Different doses of growth factors may have different effects in the different cell types. And as this was not complicated enough, synergistic phenomena between cells and between growth factors can play a huge role. Add to that the role of the biomechanical environment, the proper timing of the healing phases and the inherent patient characteristics. There is very, very much to learn, and finally, we acknowledge that not all menisci repairs can always heal.

Posterior cruciate ligament (PCL) reconstruction leads to outcomes less favorable than those of anterior cruciate ligament reconstruction. In recent years, we have seen a surge of publications regarding PCL anatomy, isometry, and reconstruction techniques. PCL reconstruction has been revolutionized with lessons learned from analysis of PCL behavior, such as the distinct role of the posteromedial bundle (PMB) in the biomechanics of the knee at different flexion angles, as well as its co-dominant role with its counterpart, the anterolateral bundle. With the knee in extension, the PMB serves to restrict posterior translation, whereas in knee flexion, the PMB restricts internal rotation. It is rather too early to know whether the biomechanical advantage of double-bundle reconstruction will result in better clinical outcomes in the long term; however, the increased interest and the refinement of both single- and double-bundle reconstruction techniques will certainly advance our knowledge, ultimately translating into better patient outcomes.

PURPOSE OF REVIEW: The purpose of this study was to review the clinical and functional outcomes of meniscus repair in children and adolescents. RECENT FINDINGS: The sequel of meniscal tears and the outcome of meniscus repair have been well studied in adults. However, these topics have received less attention in the pediatric population despite the high prevalence and potentially critical effect on long-term knee function in children. SUMMARY: Meniscus repair has a healing rate ranging from 33 to 100% with less than 40% reoperation rate. Several factors have been suggested to play a role in healing, such as concomitant ACL reconstruction and complexity of the tear. There is a lack of standardization among the utilization of functional outcome and activity level questionnaires across studies; however, most report improved function postoperatively. Other important considerations include bucket handle tears, the discoid meniscus, rehabilitation and return to sports, and alternatives after failed meniscus repair. Based on the favorable outcomes reported, meniscus repair should be attempted in most meniscus tears in children.

Background: Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients. Purpose: To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance. Study Design: Systematic review; Level of evidence, 4. Methods: This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted. Results: A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD) >10 mm postoperatively, including 9 patients (0.5%) with LLD >20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity ≥5°, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity. Conclusion: This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment. Registration: CRD42019136059 (PROSPERO)

BACKGROUND CONTEXT Add-on phenomenon following posterior surgery for Lenke 1A curves has been studied and lowest instrumented vertebra (LIV) selection, skeletal immaturity, and L4 right vertebral tilt have been identified as risk factors. To minimize the risk, LIV has been recommended to be set at the last substantially touched vertebra (LSTV); however, add-on phenomenon has been observed even when LIV was set at LSTV and immediate postop X-rays showed minimal residual curve. To study the possible causes in this scenario, we can keep LIV consistently at or immediately adjacent to LSTV and compare characteristics between curves with and curves without add-on phenomenon. PURPOSE To study risk factors for add-on phenomenon while keeping LIV consistently at or immediately adjacent to LSTV. STUDY DESIGN/SETTING Case control study, single institution. PATIENT SAMPLE We identified 21 consecutive patients who had Lenke 1A curves, preop upper thoracic bending X-rays, and minimum of 2 year follow-up from patients who underwent posterior scoliosis surgery at a single institution from 2006 to 2017. METHODS We used billing records to identify patients who underwent posterior scoliosis surgery from 2006 to 2017 at a single institution. From the 21 patients who met our criteria, we obtained age at presentation and at time of surgery from medical records. The main thoracic curve (MT), proximal thoracic curve (PT), and PT bend out Cobb angle, % PT correction on bend out = (PT - PT on bend out)/PT, Risser stage, and L4 tilt were determined from preop X-rays. Upper instrumented vertebra (UIV) was either T3 or T4. LIV was at or immediately adjacent LSTV such that if LSTV was: a) T12, LIV was primarily L1 (LSTV+1); b) L1, LIV was L1; c) L2, LIV was L1 if L1 was neutral on bending xrays (LSTV-1) and L2 if not (LSTV); d) L3, LIV was L2 (LSTV -1). Residual curve, lowest instrumented vertebra adjacent disc angle (LIVDA), and lumbar curve were measured in first (avg 2 months) and last follow-up (avg. 40 months). Add-on phenomenon was defined as (1) an increase in the residual Cobb angle of at least 10°, (2) an increase in the lumbar curve of 5 ° (3) increase in LIVDA of greater than 5 °. RESULTS The residual curve progressed more than 10 ° in 3 patients between two follow-ups, 1/3 of whom had progression of LIVDA of greater than 5 ° and 2/3 of whom had progression of the lumbar curve of more than 5 °. These 3 patients were the add-on group (AG). None of the other 18 patients met any of the criteria for add-on phenomenon and were the non-add-on group (nAG). There were no significant differences between the two groups in the age at the time of presentation or surgery, Risser stage, preoperative MT and PT. One out of 3 patients in AG and 10/18 patients in nAG had L4 tilt to the right (p=0.59). LIV=LSTV-1 did not appear to be a risk factor (p=0.38); all 8 of those patients were in the nAG while 3 patients in AG had LIV either at LSTV or LSTV+1. PT bend out Cobb angles were statistically larger (25.7o +/- 2.1o, range 24 to 28, versus 10.8o +/- 5.5 °, range 0 to 21, p=0.0002) and the % PT correction with bend out was statistically lower (5.0 +/- 2.7%, range 3 to 8, versus 53 +/- 19%, range 25 to 100, p=0.0004) in the AG compared to the nAG. CONCLUSIONS We demonstrated an association between add-on phenomenon and limited correction of PT on bend out in Lenke 1A curves where the LIV was primarily at or immediately adjacent to LSTV. If % PT correction with bend out is less than 10%, the surgeon may consider treating the curve as a Lenke 2A curve and set UIV at T1 or T2. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Dermis-isolated adult stem (DIAS) cells, abundantly available, are attractive for regenerative medicine. Strategies have been devised to isolate and to chondroinduce DIAS cells from various animals. This study aimed to characterize DIAS cells from human abdominal skin (human dermis-isolated adult stem [hDIAS] cells) and to compare and to refine various chondroinduction regimens to form functional neocartilage constructs. The stemness of hDIAS cells was verified (Phase I), three chondroinduction pretreatments were compared (Phase II), and, from these, one regimen was carried forward for refinement in Phase III for improving the mechanical properties of hDIAS cell-derived constructs. Multilineage differentiation and mesenchymal stem cell markers were observed. Among various chondroinduction pretreatments, the nodule formation pretreatment yielded constructs at least 72% larger in diameter, with higher glycosaminoglycan (GAG) content by 44%, compared with other pretreatments. Furthermore, it was found that culturing cells on nontissue culture-treated surfaces yielded constructs (1) on par with constructs derived from aggrecan-coated surfaces and (2) with superior mechanical properties than constructs derived from cells cultured on tissue culture-treated surfaces. After the nodule formation pretreatment, combined supplementation of TGF-β1, IGF-I, and fetal bovine serum significantly enhanced aggregate modulus and shear modulus by 75% and 69%, respectively, over the supplementation by TGF-β1 alone. In summary, human skin-derived DIAS cells are responsive to chondroinduction for forming neocartilage. Furthermore, the mechanical properties of the resultant human constructs can be improved by treatments shown to be efficacious in animal models. Advances made toward tissue-engineering cartilage using animal cells were shown to be applicable to hDIAS cells for cartilage repair and regeneration.

Objective The aim of this study was to determine the incidence of hand disorders in a general rural area, record the demographic characteristics for each condition, and evaluate the tendencies overtime in the incidence of these conditions. Methods Using nationwide census data, we identified a health network system serving a geographic area with stable population. Subsequently, we retrospectively analyzed all the patient records (n=731 patients) with hand disorders documented between 2001 and 2015. We performed a retrospective review and collected demographic data for the patients and disorders treated surgically. We calculated the incidence of these conditions based on the census data and performed qualitative and categorical analysis with different demographic and disease-related variables. Results We reviewed surgically treated 204 male and 527 female patients with hand disorders. The mean annual incidence was 222.5 cases per 100,000 individuals per year. More than 55% of the patients were between 50 and 69 years old. Trigger finger (TF) accounted for approximately 42% of patients, followed by 35% with carpal tunnel syndrome (CTS). TF and CTS were related to hand dominance, and right hand was affected in 53.4% of the patients. Conclusion Hand disorders in a rural area seem to correlate with the occupational sector activities, such as farming and agriculture. CTS was the most common disorder in the past; however, the dramatic increase in the incidence rate of TF made it the most common hand disorder in the last decade. Incidence rates in both males and females showed an increasing trend.

Anterior vertebral tethering (AVT) is a relatively recent alternative to posterior spinal fusion for progressive curves in growing patients with idiopathic scoliosis. AVT uses a thoracoscopic approach to minimize trauma to the thoracic wall and chest cavity. There are limited technical descriptions of this method. Patients benefit from proficiency and reproducibility to allow for appropriate spinal curve correction over time. This Technical Note outlines the steps of the thoracoscopic approach to AVT and reviews the current indications for AVT over posterior spinal fusion, as well as the most recently published clinical outcomes of this procedure., Technique Video Video 1 Anterior vertebral body tethering surgery using a thoracoscopic approach to minimize thoracic wall and chest cavity trauma. The patient is placed in the lateral decubitus position with the convex side of the scoliotic curve upward. After positioning of the portals, the thoracoscope is introduced into the middle portal. First, a hooked electrocautery device is used to open the spinal pleura, exposing the segmental vessels of each vertebra to be instrumented. An Aquamantys device and electrocautery are then used in combination to achieve coagulation and division of the segmental vessels. The anchors are placed transversely into each vertebral body, starting with the most inferior body to be tethered. For each anchor, biplanar fluoroscopy is used to create the anchor tract. A depth reading on the pedicle probe is used to determine anchor length. With the probe removed, a 6.5-mm-diameter tether anchor is advanced along this trajectory, guided by anteroposterior fluoroscopy, until the anchor head contacts the vertebral body or until the tip of the anchor projects 2 to 3 mm from the contralateral cortex. A motor evoked potential is then obtained, and this procedure is repeated for each vertebral level to be tethered. After all anchors have been placed, the flexible polyethylene terephthalate tether is introduced into the chest cavity through the most caudal portal. A marking is made on the tether 2 cm from its end so that it is easy to visualize that the tether is adequately positioned with 2 cm of excess from the cephalad anchor. A set screw is placed within the cephalad anchor, and the set screw is torqued; the counter-torque tower and torque screwdriver are used for this. The tether is fed through the anchor caudal to that one; the counter-torque tower and tensioning device are placed at this level, and the set screw is loosely applied. The tether is tensioned between these spinal levels to an appropriate amount, and the set screw is tightened to the same torque as described previously. This procedure is repeated for each anchor, with the highest amount of tensioning provided at the curvature apex. This tension is decreased at the construct ends. After the last set screw is tightened, the excess tether is cut 2 cm from the caudal anchor. A radiograph is obtained to determine immediate scoliotic curvature correction.

Tissue engineering aims to create implantable biomaterials for the repair and regeneration of damaged tissues. In vitro tissue engineering is generally based on static culture, which limits access to nutrients and lacks mechanical signaling. Using shear stress is controversial because in some cases it can lead to cell death while in others it promotes tissue regeneration. To understand how shear stress works and how it may be used to improve neotissue function, a series of studies were performed. First, a tunable device was designed to determine optimal levels of shear stress for neotissue formation. Then, computational fluid dynamics modeling showed the device applies fluid-induced shear (FIS) stress spanning three orders of magnitude on tissue-engineered cartilage (neocartilage). A beneficial window of FIS stress was subsequently identified, resulting in up to 3.6-fold improvements in mechanical properties of neocartilage in vitro. In vivo, neocartilage matured as evidenced by the doubling of collagen content toward native values. Translation of FIS stress to human derived neocartilage was then demonstrated, yielding analogous improvements in mechanical properties, such as 168% increase in tensile modulus. To gain an understanding of the beneficial roles of FIS stress, a mechanistic study was performed revealing a mechanically gated complex on the primary cilia of chondrocytes that is activated by FIS stress. This series of studies places FIS stress into the arena as a meaningful mechanical stimulation strategy for creating robust and translatable neotissues, and demonstrates the ease of incorporating FIS stress in tissue culture.

As our vocabulary grows to include exotic terms promising treatment options for osteoarthritis and cartilage treatment, our adherence to the scientific method and quest for unbiased data remain critical. Only by following this path will biologics like exosomes remain more than theoretical comets of hope. Exosomes are extracellular vesicles that are released from all body cells. In orthopaedics, exosomes may be part of cell-to-cell communication systems mediating osteoarthritis, fracture healing, and cartilage repair. Recent research has combined mesenchymal stem cell exosomes and hyaluronic acid in a rabbit cartilage repair model. Currently, there are limitations in the translation of these methods into human trials.

Background Massive rotator cuff surgical management can be challenging. Controversy exists in the literature regarding the potential benefit of full head coverage for arthroscopic rotator cuff repair. The purpose of this study was to compare re-tear rate and clinical outcome of arthroscopic repair of massive rotator cuff tears in relation to the achievement of full humeral head footprint coverage or not. Hypothesis We hypothesized that there will be no difference in re-tear rate and clinical outcomes between full and partial coverage rotator cuff repairs. Patients and methods A retrospective analysis of all adult patients with a massive rotator cuff tear who underwent arthroscopic repair with a minimum five years follow-up was performed. Outcomes analyzed included re-tear rate, the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, and the Penn Shoulder Score. Correlation and subgroup analyses were performed in order to evaluate whether age, symptom duration, tear size, coverage percentage, and fatty infiltration had any effect in outcome. Results The average ASES score was 76.3 ± 25.2, and average Penn Shoulder Score was 75.8 ± 23.1 at 7.9 years mean follow-up in 27 patients analyzed. Re-tear rate was similar between full and partial footprint coverage repair with 2 versus 4 failures, respectively (p = 0.64). ASES and Penn Shoulder scores were 84.2 and 83.7 for full rotator cuff repair versus 70.6 and 71.1, for partial coverage repair (p = 0.20 and p = 0.22, respectively). The percentage of head coverage and the tear size were both found to be significantly correlated with outcome, with coefficient of determination R2 of 0.40 and 0.217, respectively, while a global fatty degeneration index GFDI Discussion No difference in failure rate and functional outcome was detected between full and partial coverage rotator cuff repair. The size of the tear and fatty infiltration were inversely correlated with functional score while the percentage of coverage achieved was positively correlated with favorable outcome. Level of Evidence III; retrospective comparative study.

From imaging interpretation and health monitoring to drug development, the role of artificial intelligence (AI) in medicine has increased. But AI is not ready to replace humans when it comes to the diagnosis of sports medicine conditions. Rather, in highly specialized fields such as sports medicine, when it comes to interpretation of diagnostic studies such as magnetic resonance imaging scans (that are more sophisticated than simple radiographs), experts outperform AI systems at present. Key features of clinical practice, such as the physical examination, in-person consultation, and ultimately, decision making, cannot be easily replaced. As every novel "smart" tool is incorporated into our lives, we need to be ready to embrace its use, but we also ought to be critical of its implementation and seek transparency at every step of the process. We cannot afford to see AI as an antagonistic element in our practices but rather as a valuable assistant that could someday improve diagnostic accuracy.

The use of platelet-rich plasma in knee osteoarthritis is still controversial, and meta-analysis shows that platelet-rich plasma can be effective and safe for nonoperative management of knee osteoarthritis. Randomized controlled trials (RCTs) are essential tools for evaluating the effectiveness and safety of new therapeutic interventions. Meta-analysis of these RCTs is critical to try to approximate the truth but also reminds us that sometimes, "value does not necessarily derive from quantity but rather from quality." Given the fact that approximately 92.8% of published abstracts of RCTs report at least 1 significant outcome (indicated as at least P.05), there is a notion that significant outcomes are most likely to become published, suggesting a potential publication bias. Therefore, additional studies repeating the significant outcomes are sometimes necessary.

Cartilage disorders, including focal cartilage lesions, are among the most common clinical problems in orthopedic practice. Left untreated, large focal lesions may result in progression to osteoarthritis, with tremendous impact on the quality of life of affected individuals. Current management strategies have shown only a modest degree of success, while several upcoming interventions signify better outcomes in the future. Among these, stem cell therapies have been suggested as a promising new era for cartilage disorders. Certain characteristics of the stem cells, such as their potential to differentiate but also to support healing made them a fruitful candidate for lesions in cartilage, a tissue with poor healing capacity. The aim of this editorial is to provide an update on the recent advancements in the field of stem cell therapy for the management of focal cartilage defects. Our goal is to present recent basic science advances and to present the potential of the use of stem cells in novel clinical interventions towards enhancement of the treatment armamentarium for cartilage lesions. Furthermore, we highlight some thoughts for the future of cartilage regeneration and repair and to explore future perspectives for the next steps in the field.

Purpose We performed virtual feasibility and in-vivo validation studies to test whether the use of a kinematic tibial template (KTT) assists the surgeon in accurately locating the orientation of the F-E of the knee with low bias and high precision. Methods With use of 166 3-dimensional bone models of normal knees, we designed seven KTTs that located the orientation of the F-E plane of the knee when best-fit within the cortical edge of the tibial resection. The virtual feasibility study asked 11 evaluators with different levels of surgical experience to use software and select, orient, and best-fit the KTT within the tibial resection of each bone model. The in-vivo validation study analyzed tibial component rotation on postoperative CT scans of 118 consecutive patients after one surgeon set the I-E rotation of the tibial component with a KTT when performing kinematically-aligned TKA. Bias and precision were computed as the mean and standard deviation of the differences between the A-P axis of the KTT and the F-E plane of the knee. Results For the virtual feasibility study, the bias was 0.7° external and the precision was ± 4.6° for 1826 KTT fittings, which were not affected by the level of surgical experience. For the in-vivo validation study, the bias was 0.1° external and the precision was ± 3.9°. Conclusions The virtual feasibility and in-vivo validation studies suggest a KTT can assist the surgeon in accurately setting the I-E rotation of the tibial component parallel to the F-E plane of the knee when performing kinematically-aligned TKA.

Chondral lesions frequently occur in different topographic locations of the knee. This study evaluated the functional properties among the articulating surfaces of the tibiofemoral and patellofemoral joints, and whether neo-cartilage engineered using chondrocytes from different knee locations would reflect these differences. The biomechanical properties of bovine cartilage isolated from eight locations within the tibiofemoral (medial and lateral condyle, medial and lateral tibial plateau) and patellofemoral joints (medial and lateral trochlea, medial and lateral patella) were examined. Tensile Young's moduli (tensile moduli) and aggregate moduli of the medial condyle were lower than those of the medial tibial plateau (6.11 ± 0.89 MPa vs. 7.19 ± 1.05 MPa, p = 0.04 and 354.4 ± 38.3 kPa vs. 419.4 ± 31.3 kPa, p = 0.002, respectively). Patella tensile and compressive moduli were lower than the trochlea (4.79 ± 2.01 MPa vs. 6.91 ± 2.46 MPa, p = 0.01 and 337.4 ± 37.2 kPa vs. 389.1 ± 38.3 kPa, p = 0.0005, respectively). Furthermore, chondrocytes from the above locations were used to engineer neo-cartilage, and its respective properties were evaluated. In neo-cartilage, medial condyle tensile and aggregate moduli were lower than in the medial tibial plateau (0.96 ± 0.23 MPa vs. 1.31 ± 0.31 MPa, p = 0.02, and 115.8 ± 26.0 kPa vs. 160.8 ± 18.8 kPa, p = 0.001, respectively). Compared to trochlear chondrocytes, neo-cartilage formed from patellar chondrocytes exhibited lower tensile and compressive moduli (1.16 ± 0.27 MPa vs. 0.74 ± 0.25 MPa, p

It was thought that the meniscus together with articular cartilage would be among the first tissues to successfully engineer. However, despite extensive research in the field, this path was proven not to be easy. Tissue engineering of musculoskeletal tissues remains promising, and several advancements have further identified the role of biological treatments in meniscus repair and regeneration. To move forward, and advance from being promising to being forthcoming, an important step would be to improve the quality of presented studies. This editorial commentary proposes a checklist of necessary reported data for tissue engineering studies: macroscopic and histologic appearance, tissue composition, mechanical properties, and translational data.

Controlled biomechanical studies, generally in vitro (and often ex vivo), may represent a first step in evaluation of a new arthroscopic or orthopedic implant or technique. The purpose and methods of biomechanical studies must be thoughtfully considered to achieve results translatable to a clinically relevant conclusion. A limitation is that with the exception of animal studies or rare human investigations, most biomechanical studies actually only investigate mechanics and do not study biological healing. We review tips and pearls for performing quality biomechanical investigations.

Multiple alternatives to reverse total shoulder arthroplasty exist for the management of massive rotator cuff tears. Surgeons should understand the current indications for and outcomes of alternatives to reverse total shoulder arthroplasty for the management of massive rotator cuff tears. Successful rotator cuff repair involves two major challenges: the creation of forceful mechanical integrity of the repair and the creation of a biologic environment that enhances tissue healing. Given the latest advancements in grafts and biologic enhancement, arthroscopic repair appears to be an effective and reasonable alternative for the management of massive rotator cuff tears.

Injuries to articular cartilage and menisci can lead to cartilage degeneration that ultimately results in arthritis. Different forms of arthritis affect ~50 million people in the USA alone, and it is therefore crucial to identify methods that will halt or slow the progression to arthritis, starting with the initiating events of cartilage and meniscus defects. The surgical approaches in current use have a limited capacity for tissue regeneration and yield only short-term relief of symptoms. Tissue engineering approaches are emerging as alternatives to current surgical methods for cartilage and meniscus repair. Several cell-based and tissue-engineered products are currently in clinical trials for cartilage lesions and meniscal tears, opening new avenues for cartilage and meniscus regeneration. This Review provides a summary of surgical techniques, including tissue-engineered products, that are currently in clinical use, as well as a discussion of state-of-the-art tissue engineering strategies and technologies that are being developed for use in articular cartilage and meniscus repair and regeneration. The obstacles to clinical translation of these strategies are also included to inform the development of innovative tissue engineering approaches.

The realization of the presence of an inflammatory component in cartilage degeneration together with the promising application of platelet-rich plasma and amnion as “healing agents” opened a new window of opportunity for biological treatments in osteoarthritis. If the goal is to delay or even cease the degenerative process, then treating the cause rather than the symptom is a key factor for this biological intervention to be successful. As new biological agents arise, there are 3 crucial milestones that need to be met in laboratory and clinical studies: safety, reasonable cost, and improved effectiveness in comparison with alternatives.

Background Discoid meniscus (DM) is a congenital variant that typically affects the lateral meniscus of the knee. Despite the presence of multiple classification systems for DM, no system has demonstrated utility in treatment planning. We performed a retrospective review of discoid menisci that underwent surgical intervention at our institution to assess for discoid meniscus characteristics associated with surgical treatment with or without repair. Next, we propose a new method of classifying lateral discoid meniscus and demonstrate its efficacy in predicting surgical treatment. Methods We searched the orthopedic database at our institution for patients who underwent surgical treatment for lateral discoid meniscus between 1991 and 2017. Clinical records were reviewed to determine the type of DM surgery performed (surgery with or without repair) as well as DM morphology, stability, tear presence, tear location, and tear type. Univariate associations between DM characteristics and surgery type were calculated and multivariable logistic regression models of surgery type were created. Based on the univariate analysis and logistic regression models, we propose a new classification system for discoid meniscus. Results There were 434 knees with discoid lateral menisci that received surgical treatment at our institution between 1991 and 2017. In univariate analysis, unstable menisci (93%, pConclusions/Significance Lateral discoid menisci stability and tear location were associated with surgical treatment type in both univariate analysis and logistic regression models (Table 1). Based on our results and clinical relevance, we propose a classification system for DM with utility in surgical treatment planning. Menisci are classified by stability (Stable (S0), Unstable (S1)), morphology (Incomplete (M0), Complete (M1)), and Tear (No tear (T0), Central tear (T1), or Peripheral tear (T2)) (Figure 1). Tables and Figures [Table: see text][Figure: see text]

Most common sites affected by metastatic disease in general: Lung. Liver. Bone. Most common bones affected by metastatic disease: Spine (70%). Pelvis (40%). Proximal femur (25%). Humerus. Most common site affected: Thoracic spine. Most common site of fracture secondary to metastasis: Proximal femur. Most common tumors metastasized to bones: Prostate (32%)—90% osteoblastic lesions. Breast (22%)—60% osteoblastic, 40% osteolytic lesions. Kidney (16%)—Mainly osteolytic. Lung—Mainly osteolytic. Thyroid—Mainly osteolytic. Multiple metastatic bone lesions typically present. Vascular spread through: Batson’s vertebral plexus: responsible for metastases to axial structure (skull, vertebral bodies, pelvis, proximal limbs). Arterial tree metastases: responsible for metastases to distal extremities (mainly in lung and renal cancer). Most common and dominant symptom: Pain—more than 3/4 of patients. Mechanical due to bone destruction or. Tumorigenic—worst at night. Other symptoms. Pathological fracture (8–30% at presentation). Malignant hypercalcemia symptoms—confusion, muscle weakness, polyuria and polydipsia, nausea/vomiting. Neurologic abnormalities (due to compression of the spinal cord in case of disease to the spine).

The pelvis is formed by the two innominate bones that articulate posteriorly at the sacrum and anteriorly at the pubic symphysis. These attachments form the pelvic girdle, which links the axial skeleton to the lower extremities of the body. Each innominate bone is formed by the fusion of the ischium, ilium, and ischium that occurs during puberty. The fusion of these three bones forms cup-shaped, anteverted (15°) acetabulum that articulates with the head of the femur to form the diarthrodial hip joint.

Articular cartilage is mainly hyaline articular cartilage. It is an avascular and aneural tissue; thus its potential for healing is limited—if not nonexistent.

Recent trauma or surgery. IV drug use. Immunocompromise. Diabetes mellitus. Peripheral vascular disease. Peripheral neuropathy.

Structural support for body and protection of internal organs. Provision of levers for muscles, allowing for movement. Storage of minerals/lipids and regulation of mineral homeostasis and pH balance. Production of blood cells.

Physeal-sparing anterior cruciate ligament reconstruction with the use of iliotibial band autograft in skeletally immature patients is associated with excellent functional outcome scores in a population with high activity level. Furthermore, the risk of growth disturbance is minimal, which is of paramount importance in the skeletally immature patient. This chapter focuses on the preoperative, intraoperative, and postoperative complications associated with this technique.

Background Massive rotator cuff surgical management can be challenging. Controversy exists in the literature regarding the potential benefit of full head coverage for arthroscopic rotator cuff repair. The purpose of this study was to compare re-tear rate and clinical outcome of arthroscopic repair of massive rotator cuff tears in relation to the achievement of full humeral head footprint coverage or not. Hypothesis We hypothesized that there will be no difference in re-tear rate and clinical outcomes between full and partial coverage rotator cuff repairs. Patients and Methods A retrospective analysis of all adult patients with a massive rotator cuff tear who underwent arthroscopic repair with a minimum five years follow-up was performed. Outcomes analyzed included re-tear rate, the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, and the Penn Shoulder Score. Correlation and subgroup analyses were performed in order to evaluate whether age, symptom duration, tear size, coverage percentage, and fatty infiltration had any effect in outcome. Results The average ASES score was 76.3 ± 25.2, and average Penn Shoulder Score was 75.8 ± 23.1 at 7.9 years mean follow-up in 27 patients analyzed. Re-tear rate was similar between full and partial footprint coverage repair with 2 versus 4 failures, respectively (p = 0.64). ASES and Penn Shoulder scores were 84.2 and 83.7 for full rotator cuff repair versus 70.6 and 71.1, for partial coverage repair (p = 0.20 and p = 0.22, respectively). The percentage of head coverage and the tear size were both found to be significantly correlated with outcome, with coefficient of determination R2 of 0.40 and 0.217, respectively, while a global fatty degeneration index GFDI Discussion No difference in failure rate and functional outcome was detected between full and partial coverage rotator cuff repair. The size of the tear and fatty infiltration were inversely correlated with functional score while the percentage of coverage achieved was positively correlated with favorable outcome. Level of evidence III; retrospective comparative study.

Summary Although the knee joint and temporomandibular joint (TMJ) experience similar incidence of cartilage ailments, the knee orthopedics field has greater funding and more effective end-stage treatment options. Translational research has resulted in the development of tissue-engineered products for knee cartilage repair, but the same is not true for TMJ cartilages. Here, we examine the anatomy and pathology of the joints, compare current treatments and products for cartilage afflictions, and explore ways to accelerate the TMJ field. We examine disparities, such as a 6-fold higher article count and 2,000-fold higher total joint replacement frequency in the knee compared to the TMJ, despite similarities in osteoarthritis incidence. Using knee orthopedics as a template, basic and translational research will drive the development and implementation of clinical products for the TMJ. With more funding opportunities, training programs, and federal guidance, millions of people afflicted with TMJ disorders could benefit from novel, life-changing therapeutics., Graphical abstract, In this review, Bielajew et al. describe the stark quantitative differences in the knee orthopedics and temporomandibular joint (TMJ) fields, despite similarities in disease incidence. The authors call on researchers and clinicians to use knee orthopedics as a template to improve product development and end-stage outcomes for people with TMJ disorders.

Background Hallux valgus is an increasingly common deformity in young female athletes that constricts their daily athletic activities and influences foot cosmesis. The aim of this study was to evaluate the outcome of modified Chevron osteotomy for hallux valgus deformity in this specific population. Methods Forty-two cases of modified Chevron osteotomies were carried out in 33 patients with mild to moderate hallux valgus deformity. Each participant was evaluated for AOFAS score, pain, range of motion, cosmetic and radiological outcome. Results Mean AOFAS score improved to 96.3 ( p p =0.138). The cosmetic result was excellent/good in 40 cases (95%). Mean metatarsophalangeal and intermetatarsal angles were decreased from 29.8° and 14.2° preoperatively to 12.2° and 8.1° postoperatively ( p p Conclusions Modified Chevron osteotomy could offer substantial correction of hallux valgus deformity in young female athletes, with excellent clinical outcome.

Objectives A variety of surgical options exist to treat the challenging problem of recurrent patellar instability in children and adolescents. The goal of the current study is to describe a novel combined reconstruction technique of both the medial patellofemoral ligament (MPFL) and the medial quadriceps tendon-femoral ligament (MQTFL) and report patient outcomes of a single-surgeon series. Methods All patients studied underwent simultaneous MPFL and MQTFL reconstruction for patellar instability using gracilis allograft. Demographic, clinical, and radiographic data were collected. Subjective outcomes were assessed for a minimum of 1 year postoperatively. Results Twenty-five patients (27 knees), including 15 female and 10 male individuals with an average age of 15.0±2.2 years (range, 10.3 to 18.9), were included. Prior ipsilateral patellofemoral surgery had been performed in 6 of 25 (24%) patients. Simultaneous hemiepiphysiodesis for valgus deformity at the time of combined reconstruction was performed in 5 of 25 (20%) patients. Preoperative imaging showed a mean tibial tubercle-trochlear groove of 17.2±3.8, Caton-Deschamps Index (CDI) of 1.13±0.16, and trochlear dysplasia Dejour A/B [22/26 (85%)] or Dejour C/D [4/26 (15%)]. A total of 18 patients (19 knees, 72%) returned outcomes questionnaires at a mean 2.0±0.5 years after surgery. Mean Kujala, Pedi-IKDC, and Lysholm scores were 85.9±13.9, 81.5±15.2, and 84.3±13.5, respectively. Later revision procedure (tibial tubercle osteotomy) for recurrent patellar instability was required in 2 of 25 patients (8%) patients, and another patient reported persistent instability not requiring revision. Return to sports was possible in 10 of 13 self-reported athletes (77%) at a mean of 5.8±3.9 months (range, 2 to 15). Conclusions The present study describes a combined MPFL-MQTFL reconstruction technique with favorable short-term results. Although particularly useful in the skeletally immature patient where tibial tubercle osteotomy should be avoided and patellar fixation minimized, combined reconstruction may potentially be appropriate for older patients with patellofemoral instability as well. This technique more closely recreates the native anatomy of both the MPFL and MQTFL, may decrease the risk of patellar fracture, and can be useful in the revision setting. Level of evidence Level IV.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects (benefits and harms) of the use of allograft versus autograft for the reconstruction of anterior cruciate ligament rupture in adults.

How long should a trial of conservative treatment of posterior cruciate ligament injuries continue before surgical intervention? A recent study demonstrates that time from injury to surgery could be negatively correlated with graft maturation and remnant preservation. Considering the improvements in arthroscopic posterior cruciate ligament reconstruction outcomes, early intervention could be considered in high functional demand patients with high grades of instability. Yet it remains to be seen whether graft maturation and remnant preservation result in improved clinical outcomes regardless of the time to surgical intervention.

© 2018 by Annual Reviews. All rights reserved. The zygapophysial joint, a diarthrodial joint commonly referred to as the facet joint, plays a pivotal role in back pain, a condition that has been a leading cause of global disability since 1990. Along with the intervertebral disc, the facet joint supports spinal motion and aids in spinal stability. Highly susceptible to early development of osteoarthritis, the facet is responsible for a significant amount of pain in the low-back, mid-back, and neck regions. Current noninvasive treatments cannot offer long-term pain relief, while invasive treatments can relieve pain but fail to preserve joint functionality. This review presents an overview of the facet in terms of its anatomy, functional properties, problems, and current management strategies. Furthermore, this review introduces the potential for regeneration of the facet and particular engineering strategies that could be employed as a long-term treatment.

Bone marrow aspirate concentrates have become a popular therapeutic approach for several musculoskeletal conditions. A plethora of different preparations exist that make difficult to evaluate their clinical outcome and, thus, to make safe conclusions for their effectiveness. The first step for this assessment is comprehensive and reliable reporting of all the important variables that would allow characterization of their content and properties. This is critical for the understanding of their mechanism of action and the identification of the proper indications based on patient and disorder characteristics that could potentially lead to their effective application in clinical scenarios.