Assessment of rotatory laxity in anterior cruciate ligament-deficient knees using magnetic resonance imaging with Porto-knee testing device

Purpose Objective evaluation of both antero-posterior translation and rotatory laxity of the knee remains a target to be accomplished. This is true for both preoperative planning and postoperative assessment of different ACL reconstruction emerging techniques. The ideal measurement tool should be simple, accurate and reproducible, while enabling to assess both ‘‘anatomy’’ and ‘‘function’’ during the same examination. The purpose of this study is to evaluate the clinical effectiveness of a new in-housedeveloped testing device, the so-called Porto-knee testing device (PKTD). The PKTD is aimed to be used on the evaluation of both antero-posterior and rotatory laxity of the knee during MRI exams. Methods Between 2008 and 2010, 33 patients with ACLdeficient knees were enrolled for the purpose of this study. All patients were evaluated in the office and under anesthesia with Lachman test, lateral pivot-shift test and anterior drawer test. All cases were studied preoperatively with KT-1000 and MRI with PKTD, and examinations performed by independent observers blinded for clinical evaluation. During MRI, we have used a PKTD that applies antero-posterior translation and permits free tibial rotation through a standardized pressure (46.7 kPa) in the proximal posterior region of the leg. Measurements were taken for both knees and comparing side-to-side. Five patients with partial ruptures were excluded from the group of 33. Results For the 28 remaining patients, 3 women and 25 men, with mean age of 33.4 ± 9.4 years, 13 left and 15 right knees were tested. No significant correlation was noticed for Lachman test and PKTD results (n.s.). Pivot-shift had a strong positive correlation with the difference in anterior translation registered in lateral and medial tibia plateaus of injured knees (cor. coefficient = 0.80; p\0.05), and with the difference in this parameter as compared to side-to-side (cor. coefficient = 0.83; p\0.05). Considering the KT-1000 difference between injured and healthy knees, a very strong positive correlation was found for side-to-side difference in medial (cor. coeffi- cient = 0.73; p\0.05) and lateral (cor. coefficient = 0.5; p\0.05) tibial plateau displacement using PKTD. Conclusion The PKTD proved to be a reliable tool in assessment of antero-posterior translation (comparing with KT-1000) and rotatory laxity (compared with lateral pivotshift under anesthesia) of the ACL-deficient knee during MRI examinatio

Osteochondral transplantation using autografts from the upper tibio-fibular joint for the treatment of knee cartilage lesions

Purpose Treatment of large cartilage lesions of the knee in weight-bearing areas is still a controversy and challenging topic. Autologous osteochondral mosaicplasty has proven to be a valid option for treatment but donor site morbidity with most frequently used autografts remains a source of concern. This study aims to assess clinical results and safety profile of autologous osteochondral graft from the upper tibio-fibular joint applied to reconstruct symptomatic osteochondral lesions of the knee. Methods Thirty-one patients (22 men and 9 women) with grade 4 cartilage lesions in the knee were operated by mosaicplasty technique using autologous osteochondral graft from the upper tibio-fibular joint, between 1998 and 2006. Clinical assessment included visual analog scale (VAS) for pain and Lysholm score. All patients were evaluated by MRI pre- and post-operatively regarding joint congruency as good, fair (inferior to 1 mm incongruence), and poor (incongruence higher than 1 mm registered in any frame). Donor zone status was evaluated according to specific protocol considering upper tibio-fibular joint instability, pain, neurological complications, lateral collateral ligament insufficiency, or ankle complaints. Results Mean age at surgery was 30.1 years (SD 12.2). In respect to lesion sites, 22 were located in weight-bearing area of medial femoral condyle, 7 in lateral femoral condyle, 1 in trochlea, and 1 in patella. Mean follow-up was 110.1 months (SD 23.2). Mean area of lesion was 3.3 cm 2 (SD 1.7), and a variable number of cylinders were used, mean 2.5 (SD 1.3). Mean VAS score improved from 47.1 (SD 10.1) to 20.0 (SD 11.5); p = 0.00. Similarly, mean Lysholm score increased from 45.7 (SD 4.5) to 85.3 (SD 7.0); p = 0.00. The level of patient satisfaction was evaluated, and 28 patients declared to be satisfied/very satisfied and would do surgery again, while 3 declared as unsatisfied with the procedure and would not submit to surgery again. These three patients had lower clinical scores and kept complaints related to the original problem but unrelated to donor zone. MRI score significantly improved at 18–24 months comparing with pre-operative (p = 0.004). No radiographic or clinical complications related to donor zone with implication in activity were registered. Conclusions This work corroborates that mosaicplasty technique using autologous osteochondral graft from the upper tibio-fibular joint is effective to treat osteochondral defects in the knee joint. No relevant complications related to donor zone were registered

Complex Elbow Dislocations

Complex Elbow DislocationsSports practice has become common in all ages, and the number of persons practicing extreme sports has been rapidly increasing. High-risk activities have raised the number and severity of (elbow) lesions that can cause severe disability. Diagnosis of acute elbow dislocation is usually clinically evident, and reduction should be performed expeditiously. On-field reduction should be performed if an experienced health technician is present. Most of the times, the radiographic evaluation is performed first and usually allows identifying an associated fracture that defines a complex dislocation. Postreduction radiographic control is essential, and frequently CT scan or MRI can complete the information needed to fully understand the lesion and plan the treatment. Fractures associated with elbow dislocation are frequent, but fortunately most of them are impacted fractures that do not require surgical treatment. When the dislocation causes a fracture of the olecranon, the radial head, and/or the coronoid, this can justify surgical treatment to provide stability and allow for early rehabilitation in an attempt to avoid either the stiffness or the instability. The most frequent patterns of complex dislocation needing surgical treatment are transolecranon fracture-dislocations and elbow dislocations associated with fracture of the coronoid and/or the radial head. When both coronoid and radial head fractures are present, this pattern of injury is known as “elbow terrible triad” due to the bad outcomes associated with treatment. Surgical treatment can include open reduction and internal fixation of the fractures, exploration, and repair of the medial collateral ligament and/or the lateral ulnar collateral ligament. Dynamic external fixation is another useful option when the elbow remains unstable even after surgical treatment, allowing an early mobilization while maintaining a concentric and stable reduction. Its use needs a strict technique to avoid possible complications such as radial nerve palsy. In summary, ensuring a stable elbow that allows an early active range of motion is the critical point to improve elbow function after a complex elbow dislocation.(undefined)info:eu-repo/semantics/publishedVersio

Biomaterials for Tendon Regeneration

Tendon is a highly complex tissue that exhibits high mechanical strength, flexibility, and extensibility to perform movement and physical exercise. However, it is exposed at a high-risk of injury, namely, at the tendon–bone interface (TBi). The tendon natural healing process occurs by reactive scar formation, giving origin to a tissue that does not have the same characteristics of native tendon. As a consequence the healing response is suboptimal causing scar tissue formation, which implies inferior mechanical properties. Tissue engineering using biomaterials trying to regenerate tendon tissue and improve clinical outcomes when treating tendon pathology is the focus of intense investigation worldwide. The authors review tendon structure and healing process and summarize the current knowledge about biomaterials for tendon regeneration.(undefined)info:eu-repo/semantics/publishedVersio

Reverse shoulder arthroplasty for irreparable massive rotator cuff tears: a systematic review with meta-analysis and meta-regression

Background: Massive rotator cuff tears (MRCTs) are very large tears that are often associated with an uncertain prognosis. Indeed, some MRCTs even without osteoarthritis are considered irreparable, and nonanatomic solutions are needed to improve the patient's symptoms. Reverse shoulder arthroplasty (RSA) is an option that can provide a more predictable pain relief and recovery of function. Nonetheless, outcomes after RSA for irreparable MRCTs have not been well defined. The aim of this study was to quantitatively aggregate the findings associated with the use of RSA in this subset of patients and analyze the effect on patient functional status and pain. Methods: A comprehensive search was performed until October 2015 using MEDLINE, Scopus, Cochrane Database of Systematic Reviews, and Central Register of Controlled Trials databases. Studies that assessed the outcomes of RSA in patients with irreparable MRCT without osteoarthritis (with at least 2 years of follow-up) were included. If the results of MRCT without osteoarthritis were not possible to subgroup, the study was excluded. Methodologic quality was assessed using the Coleman Methodology Score. Results: Included were 6 studies (266 shoulders) with a follow-up ranging from 24 to 61.4 months. The mean Coleman Methodology Score was 58.2 +/- 11.8 points. There was an overall improvement from preoperative to postoperative assessments of the clinical score (Cohen d = 1.35, P < .001), forward flexion (d = 0.50, P = .009), external rotation (d = 0.40, P < .001), function (d = 1.04, P < .001), and pain (d = -0.89, P < .001). Conclusion: Patients with irreparable MRCT without presence of osteoarthritis have a high likelihood of achieving a painless shoulder and functional improvements after RSA. Level of evidence: Level IV; Meta-AnalysisThis study received support from the Portuguese Foundation for Science and Technology: IF Development Grant to Antonio J. Salgado (IF/00111/2013) and a predoctoral scholarship to Pedro Moreira (PDE/BDE/113601/2015) from the PhD-iHES program. This work has been funded by Fonds Europeen de Developpement Economique et Regional (FEDER) funds, through the Competitiveness Factors Operational Programme (COMPETE), and by National funds, through the Foundation for Science and Technology (FCT), under the scope of the project POCI-01-0145-FEDER-007038.Portuguese Foundation for Science and Technology: IF Development Grant to António J. Salgado (IF/00111/2013) and a predoctoral scholarship to Pedro Moreira (PDE/BDE/113601/2015) from the PhD-iHES program. This work has been funded by Fonds Européen de Développement Économique et Régional (FEDER) funds, through the Competitiveness Factors Operational Programme (COMPETE), and by National funds, through the Foundation for Science and Technology (FCT), under the scope of the project POCI-01-0145-FEDER-007038info:eu-repo/semantics/publishedVersio

New tools for diagnosis, assessment of surgical outcome and follow-up

Objective evaluation of antero-posterior and rotatory laxity of the knee is a critical issue in anterior cruciate ligament (ACL) research. Th is is essential to allow surgeons to rigorously evaluate the outcome of the diff erent available techniques. Furthermore it will make it possible to carry out advance predictions of which patients can benefi t from a particular approach, i.e. partial reconstructions, single- or double-bundle techniques. Th e ideal method should be able to assess anatomic and functional features of the ACL-defi cient knee, besides being accurate, reproducible and cost-eff ective. Th is is an overview of the most recent achievements and the scientifi c-technical considerations in this particular area of research. Th is chapter presents the advantages and limitations of robotic systems and manual instrumented devices compared to manual tests that are commonly used in the clinical setting. It also highlights the Porto-knee testing device as a new tool to assess laxity in ACL-defi cient knee during magnetic resonance imaging. Insights of intraoperative navigation-assisted tools are also considered

Mesenchymal stem cell secretome improves tendon cell viability in vitro and tendon-bone healing in vivo when a tissue engineering strategy is used in a rat model of chronic massive rotator cuff tear

BACKGROUND: Massive rotator cuff tears (MRCTs) represent a major clinical concern, especially when degeneration and chronicity are involved, which highly compromise healing capacity. PURPOSE: To study the effect of the secretome of mesenchymal stem cells (MSCs) on tendon cells (TCs) followed by the combination of these activated TCs with an electrospun keratin-based scaffold to develop a tissue engineering strategy to improve tendon-bone interface (TBi) healing in a chronic MRCT rat model. STUDY DESIGN: Controlled laboratory study. METHODS: Human TCs (hTCs) cultured with the human MSCs (hMSCs) secretome (as conditioned media [CM]) were combined with keratin electrospun scaffolds and further implanted in a chronic MRCT rat model. Wistar-Han rats (N = 15) were randomly assigned to 1 of 3 groups: untreated lesion (MRCT group, n = 5), lesion treated with a scaffold only (scaffold-only group, n = 5), and lesion treated with a scaffold seeded with hTCs preconditioned with hMSCs-CM (STC_hMSC_CM group, n = 5). After sacrifice, 16 weeks after surgery, the rotator cuff TBi was harvested for histological analysis and biomechanical testing. RESULTS: The hMSCs secretome increased hTCs viability and density in vitro. In vivo, a significant improvement of the tendon maturing score was observed in the STC_hMSC_CM group (mean ± standard error of the mean, 15.6 ± 1.08) compared with the MRCT group (11.0 ± 1.38; P < .05). Biomechanical tests revealed a significant increase in the total elongation to rupture (STC_hMSC_CM, 11.99 ± 3.30 mm; scaffold-only, 9.89 ± 3.47 mm; MRCT, 5.86 ± 3.16 mm; P < .05) as well as a lower stiffness (STC_hMSC_CM, 6.25 ± 1.74 N/mm; scaffold-only, 6.72 ± 1.28 N/mm; MRCT, 11.54 ± 2.99 N/mm; P < .01). CONCLUSION: The results demonstrated that hMSCs-CM increased hTCs viability and density in vitro. Clear benefits also were observed when these primed cells were integrated into a tissue engineering strategy with an electrospun keratin scaffold, as evidenced by improved histological and biomechanical properties for the STC_hMSC_CM group compared with the MRCT group. CLINICAL RELEVANCE: This work supports further investigation into the use of MSC secretome for priming TCs toward a more differentiated phenotype, and it promotes the tissue engineering strategy as a promising modality to help improve treatment outcomes for chronic MRCTs.info:eu-repo/semantics/publishedVersio