Operative Techniques in Sports Medicine最新文献

Osteoarthritis (OA) refers to a group of mechanically induced joint disorders characterized by an epigenetic nature. It has been defined as a disease of the entire joint. Articular chondrocytes and subchondral osteocytes are constantly subject to stress, strain and load and, if homeostatic and reparative processes are unable to compensate for the destructive processes, the joint environment will suffer and present with structural damage and clinical symptoms. The lack of drugs able to cure patients from OA has resulted in the use of intra-articular infiltrations and surgical procedures among which the implantation of biomimetic scaffolds. Biomimetic scaffolds are innovative materials created with the aim of encouraging bone and cartilage regeneration. The latest generation of scaffolds has been developed with the aim of increasing the healing abilities of the human body's own cells and signaling factors to achieve a superior tissue quality and better clinical outcomes. The present paper presents the in vivo performance of biphasic aragonite scaffolds on knees affected by early OA. The implantation of bioscaffolds has been been evaluated with MRIs, KOOS scores at follow up and histologically. The Agili-C scaffold's analysis has revealed it to be a viable option in the use of patients with mild to moderate OA.

Mini-metal implants are indicated for the treatment of symptomatic focal chondral or osteochondral defects in patients considered too old for biological reconstruction or too young with limited cartilage defects for knee arthroplasty. Precise surgical techniques are required to ensure optimal positioning with recession below the articular cartilage surface. Partial resurfacing for femoral or trochlea surfaces using the HemiCAP and UniCAP implants or the Episealer system has shown good short-term outcomes for middle-aged patients. In some series, however, quantification of tibial articular surface wear was not reported making interpretation of the clinical benefit difficult. When successful, clinical function is high and results appear durable. Favorable outcomes are seen with well-defined indications of: isolated defect, healthy opposing articular cartilage, and >50% volume meniscus. Indications also include patients with failed previous cartilage repair and those facing revision articular cartilage repair. Extended indications may include multiple lesions and the requirement for concomitant osteotomy or ligament reconstruction.

Preserving articular cartilage extends the life span and functional capabilities of a joint, and prevents early joint arthroplasty. Mesenchymal signaling cells (MSCs) induce chondrocytes and stimulate the innate capacity to regenerate and restore damaged cartilage. Preserving the pericellular matrix of chondrocytes boosts the ability of MSC to stimulate chondrocytes. The ability to augment joint homeostasis and induce cartilage regeneration with the use of allogenic MSCs unlocks the possibility of a single stage cell based surgical therapy for medium to large cartilage defects. The results of cell therapy with recycled autologous chondrons mixed with allogeneic (bone-marrow or adipose derived) mesenchymal signaling cells (IMPACT/RECLAIM) after 7 years have supported the safety and clinical efficacy of this treatment. Patients have shown clinically relevant and statistically significant improvement in multiple validated patient reported outcome measures for knee pain and quality of life. Once fully industrialized the single stage approach, compared to conventional 2 stage procedures, should also provide a more economical and logistically friendly treatment option. Low failure rates and similar results compared to the current golden standard reinforce the longevity of this proof of concept. The phase III randomized controlled trial comparing results of the treatment after a non-surgical approach will conclude in 2024. As for now, research supports this unique first in man one stage cartilage repair to be safe, feasible, and have good clinical outcomes when combining recycled cartilage with allogeneic MSCs.

Marrow stimulation is a commonly used surgical adjunct in the treatment of knee cartilage injuries. While initial studies on traditional microfracture demonstrated favorable short-term results, survivorship and clinical outcomes at medium- and long-term follow-up were subsequently shown to be inferior as compared to cell- and graft-based treatment options. As a result, numerous technical modifications and biologic augmentation approaches have been developed with the goal of improving the efficacy and the durability of marrow stimulation procedures. This chapter presents an overview of the basic and clinical science of marrow stimulation, its evolution over the past 25 years, and preliminary outcomes of treatment augmentation with biologic, scaffold, and cartilage-based approaches.

New medical interventions have helped people live longer and healthier lives, which has been accompanied by the expectation of patients remaining active even into their eighth decade and beyond. Unfortunately, advances in the orthopaedic literature for joint preservation have lagged behind. Research into techniques for joint preservation with the goal of delaying arthroplasty have risen to the forefront due to the tremendous physical and economic burden associated with osteoarthritis. One component has been the field of orthobiologics, the class of therapies that utilize biological products to enhance the body's natural healing process. Several potential candidates have emerged and entered the public consciousness, which portends increasing interest into these therapeutics. Among these possibilities include hyaluronic acid, platelet-rich plasma, bone marrow aspirate concentrate, and mesenchymal stem cells (MSC's). Despite concerns regarding the efficacy and cost-benefit ratio, both the basic science and the clinical data have supported their use to varying degrees. Further research remains to provide concrete guidelines for clinicians to provide optimal care for their patients.

While the enthusiasm of stem cells from benchtop and animal study has captured the attention of orthopedic clinicians treating and patients with knee pain, the development of an evidence base has been slow. Appropriate regulatory steps, the development of common language, and emerging mechanisms around stem cells are important. Early clinical trials around varying cell sources are encouraging and foster continued excitement. More comparative trials are needed to clarify the true role of these emerging technologies.

Ever since autologous chondrocyte implantation (ACI) has been introduced, there have been important advancements and progress leading to a more reliable and more standardized application of this technology. While first-generation ACI followed the principle of a cell-suspension being injected under an autologous periosteum patch, second and third generation ACI are characterized by the use of biomaterials, either using a cell-suspension (second generation) or a combination of cells and the biomaterial (third generation). Due to easier handling and improved clinical outcome, third generation ACI has become the gold standard for the use of ACI at this time. The present chapter focuses on the Novocart third generation ACI products. While Novocart 3D uses a collagen membrane and therefore an implantable biomaterial, Novocart Inject is a hydrogel-based ACI product that can be injected into cartilage defects. Both products are currently underway for central European market authorization by the European Medicinal Agency (EMA), additionally, an FDA-approval trial is underway for Novocart 3D. Product characteristics, indications, surgical techniques, and clinical outcomes are summarized in the present chapter.

High tibial osteotomies are challenging procedures that have traditionally implemented two-dimensional planning (2D) for a complex three-dimensional surgery (3D). In an effort to improve the accuracy and precision of the technique, there has been a growing interest in the use of patient specific instrumentation (PSI). The implementation of PSI in osteotomies has demonstrated consistent and reliable results in the correction of the hip-knee-ankle angle, proximal tibial angle, and the posterior tibial slope. Initial clinical studies describing the implementation of this technology have reported superior accuracy in both the coronal and sagittal planes as compared to free-hand techniques. Additionally, these studies reported a fast surgeon learning curve, short operative times, and minimal fluoroscopy exposure. The senior author's preferred closing wedge HTO technique utilizes a patient specific cutting guide with osteotomy fixation provided by an extra-cortical titanium alloy locking plate. This technique is designed to provide reliable and accurate HTOs while minimizing the risk of major complications such as hinge fractures on the contralateral cortex.