Operative Techniques in Sports Medicine最新文献

Massive irreparable rotator cuff tears (MIRCT) is a difficult clinical problem to treat in young, active individuals with minimal arthritis. Tendon transfers allow for donation of muscle units that can power the shoulder and restore kinematics. Posterosuperior rotator cuff deficiency can be treated with either a latissimus dorsi tendon or lower trapezius tendon transfer. The authors preferred method for treating irreparable supraspinatus and infraspinatus tears is with an arthroscopic assisted lower trapezius tendon transfer. The advantage of the lower trapezius tendon is that its vector is directly in line with the infraspinatus tendon allowing for better external rotation and abduction moment arms. The tendon is harvested from the spine of the scapula and augmented with an Achilles tendon allograft for length which is then secured at the footprint of the rotator cuff. Anterosuperior rotator cuff deficiency can be treated with a pectoralis major tendon or anterior latissimus tendon transfer. For subscapularis deficiency, our preferred method is an open versus arthroscopic latissimus tendon transfer. The tendon is harvested in the posterior axilla and augmented with an Achilles tendon allograft at the tendon interface to provide bulk. The tendon is passed arthroscopically to the anterior humerus and secured at the lesser tuberosity. Tendon transfers are a safe, reliable and reproducible technique when treating MIRCTs.

Massive rotator cuff tears provide a significant challenge to the orthopedic surgeon. A complete and anatomical tendon restoration without significant tension is the goal of treatment, but oftentimes the chronicity of the presentation makes it difficult. The treating surgeon must approach these cases in a methodical and organized manner. Visualization and recognition of the tear pattern, followed by appropriate soft tissue releases, and finally thoughtful suture management are the keys to optimizing surgical success and ultimately clinical outcomes. When the tendon cannot be anatomically restored to the native footprint, alternative options can be used with varying success. These alternatives include medialization of the footprint, partial repair, margin convergence, and patch augmentation, among others. We will provide some tips and tricks which we have found most useful to successfully complete these often-difficult cases. For tears that cannot be repaired or if a repair would be contraindicated or ill-advised, other options such as superior capsular reconstruction, tendon transfers, and reverse total shoulder arthroplasty are considerations that are beyond the scope of this manuscript.

The NeoCart implant (Histogenics Corporation, Waltham, MA; Ocugen Inc., Malvern, PA) is a cell-based therapeutic for the restoration of articular cartilage defects. The implant is composed of a type I collagen scaffold, inoculated with expanded autologous chondrocytes, and preconditioned under hydrostatic loading and low oxygen tension. The process was designed to create an autogenous chondrogenic construct for application during a surgical biologic reconstruction procedure for patients with symptomatic cartilage disease. Favorable pre-clinical basic science and animal studies characterizing the regenerative potential of NeoCart led to application for United States Food and Drug Administration (FDA) approval as the first autologous tissue therapeutic for articular cartilage restoration, beginning with a Phase I safety trial in 2003.

Deemed safe in Phase I and efficacious in Phase II relative to “standard of care” microfracture, a Phase III randomized controlled superiority trial versus microfracture was authorized by FDA in 2010. The primary outcome measure of a statistically significant difference in the number of responders to treatment versus control based on meeting a dual-criteria threshold of >20-point and >12-point improvement in International Knee Documentation Committee and Knee Injury and Osteoarthritis Outcome Score pain domain scores, respectively, was established. The 1-year protocol assessment metric for superiority was narrowly missed, which led to termination of the trial in 2019. Ultimately, the therapy was not approved for use by the FDA. The history of this case example: quelching a biologically safe and effective therapeutic, highlights hurdles in the complex process of bringing scientifically sound products to patients through regulatory processes in the United States.

Focal resurfacing implants for the treatment of symptomatic chondral lesions in the knee have gained popularity in recent years, as surgeons explore potential solutions for challenging conditions in young active patients. Here, we provide an overview of the BioPoly resurfacing implant, a novel self-lubricating device with characteristics similar to synthetic cartilage. The basic science of the product, patient selection, surgical technique, and early outcome data will be discussed.