Anterior capsular reconstruction with acellular dermal allograft for subscapularis deficiency: a report of two cases

Anterior glenohumeral instability with an irreparable subscapularis tear is a challenging problem for the orthopedic shoulder surgeon. Current techniques, including tendon transfers, yield inconsistent results with high rates of recurrent instability. Acellular dermal allografting has been used in young patients with massive superior rotator cuff tears with early success, but acellular dermal allografting is comparatively unstudied in anterior deficiency. We present two cases of anterior capsular reconstruction with an acellular dermal allograft in patients ages 66 and 58 years with irreparable subscapularis tendon tears. Follow-up for both patients exceeded 4 years, with forward flexion >140°, external rotation exceeding 60°, a Single Assessment Numeric Evaluation score >90 points, a visual analog scale score of 0 points, and an American Shoulder and Elbow Score of 98 points. In conclusion, acellular dermal allografting can be used to reconstruct the anterior capsule in patients with massive irreparable subscapularis tears, similar to its use in superior capsular reconstruction in patients with massive posterosuperior rotator cuff tears

An Expert Consensus Statement on the Management of Large Chondral and Osteochondral Defects in the Patellofemoral Joint

© The Author(s) 2020. Background: Cartilage lesions of the patellofemoral joint constitute a frequent abnormality. Patellofemoral conditions are challenging to treat because of complex biomechanics and morphology. Purpose: To develop a consensus statement on the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint using a modified Delphi technique. Study Design: Consensus statement. Methods: A working group of 4 persons generated a list of statements related to the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint to form the basis of an initial survey for rating by a group of experts. The Metrics of Osteochondral Allografts (MOCA) expert group (composed of 28 high-volume cartilage experts) was surveyed on 3 occasions to establish a consensus on the statements. In addition to assessing agreement for each included statement, experts were invited to propose additional statements for inclusion or to suggest modifications of existing statements with each round. Predefined criteria were used to refine statement lists after each survey round. Statements reaching a consensus in round 3 were included within the final consensus document. Results: A total of 28 experts (100% response rate) completed 3 rounds of surveys. After 3 rounds, 36 statements achieved a consensus, with over 75% agreement and less than 20% disagreement. A consensus was reached in 100.00% of the statements relating to functional anatomy of the patellofemoral joint, 88.24% relating to surgical indications, 100.00% relating to surgical technical aspects, and 100.00% relating to rehabilitation, with an overall consensus of 95.5%. Conclusion: This study established a strong expert consensus document relating to the functional anatomy, surgical indications, donor graft considerations for osteochondral allografts, surgical technical aspects, and rehabilitation concepts for the management of large chondral and osteochondral defects in the patellofemoral joint. Further research is required to clinically validate the established consensus statements and better understand the precise indications for surgery as well as which techniques and graft processing/preparation methods should be used based on patient- and lesion-specific factors

Carbon Dioxide Insufflation of the Knee in the Treatment of Full-Thickness Chondral Defects With Micronized Human Articular Cartilage

BioCartilage (BC) is dehydrated, minced human hyaline articular cartilage that was developed as an adjunct to microfracture surgery to help stimulate the bone marrow and stem cells to form hyaline-like tissue in full-thickness chondral defects. The minced pieces of BC require a dry environment for application and can easily be disrupted by residual moisture of saline solution in the surrounding tissues. We present a technique of carbon dioxide insufflation during knee arthroscopy as a means of maintaining a dry environment for preparation of the bony bed during BC augmentation of microfracture surgery. This technique is safe and provides more than adequate visualization, as well as a dry environment, to make the arthroscopic application of BC significantly more efficient

Arthroscopic Superior Capsule Reconstruction with a Doubled-Over (6 mm) Dermal Allograft

Superior capsule reconstruction has gained popularity as a treatment option for massive rotator cuff tears. The initial graft described was a tensor fascia lata. In the United States, acellular dermal matrix or dermal allograft has gained popularity. The results from published reports have been promising, but graft tear on postoperative imaging has been reported in several studies. Strives are being made to reduce the graft tear rate. One such way is to increase the thickness of the graft. Biomechanical studies have shown that thicker and stiffer grafts perform better in restoring superior stability. We present a technique of doubling a commercially available 3 mm dermal allograft and making it into a 6 mm graft for superior capsule reconstruction

Cryopreserved, Viable Osteochondral Allograft for the Treatment of a Full-Thickness Cartilage Defect of the Glenoid

Glenoid chondral injuries constitute challenging injuries to treat because of the limited access and the limited options and evidence available for their resolution. The purpose of this Technical Note is to describe the procedure, pearls, and pitfalls of implantation of a cryopreserved osteochondral allograft (Cartiform) for the treatment of full-thickness cartilage defects of the shoulder. Cartiform is a cryopreserved osteochondral allograft composed of chondrocytes, chondrogenic growth factors, and extracellular matrix proteins that can be implanted through a single-stage procedure

Ulnar Collateral Ligament Reconstruction of the Elbow With Double Suspensory Fixation

Ulnar collateral ligament reconstruction of the elbow has evolved substantially since its introduction in 1974. Numerous variations of the surgery have been introduced, including modifications in tunnel creation, graft tensioning, and fixation. These changes have aimed to improve overall quality of the reconstruction; however, even the most commonly used techniques still present many challenges. We describe a technique for ulnar collateral ligament (UCL) reconstruction using bisuspensory button fixation and a single tunnel on both the ulnar and humeral sides. This technique avoids many of the most common complications and methods of failure of UCL reconstruction, provides immediate strong graft fixation, and offers the surgeon a technically less demanding procedure