Operative Techniques in Sports Medicine最新文献

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.

Cartilage injuries are notoriously difficult to treat and do not heal spontaneously. The available repair methods can be expensive and often provide an inconsistent clinical and biological outcome. The use of autologous or allogeneic particulated cartilage has shown promise in recent years. Chondrocytes can migrate from minced cartilage and facilitate clinical cartilage repair in one-step procedures. Four different techniques have been described in the literature: “The Cartilage Autograft Implantation System” (CAIS) is cartilage biopsies cut into 1- to 2-mm fragments and implanted in cartilage defects embedded in a polymer scaffold. “The DeNovo NT Natural tissue graft” is allogenic particulated juvenile cartilage from donors under the age of 13. The cartilage is cut into 1 mm³ dice and implanted in cartilage defects embedded in fibrin glue. “Autologous minced cartilage” is cartilage biopsies cut into 0.25-0.5 mm³ chips, embedded in fibrin glue and implanted in chondral or osteochondral defects. The technique can be used with or without concomitant bone grafting. In the “augmented autologous minced cartilage” technique, a bioactive component is added to augment the repair process. The different minced cartilage repair techniques have shown a great biological repair potential and provide clinical benefits. The techniques are easily applicable at a low cost, and they provide the surgeon with an alternative to marrow stimulation and chondrocyte expansion and transplantation. The clinical evidence is still limited, and further studies should be performed to establish the clinical efficacy of minced cartilage procedures.