Recent advances in orthopedic biomaterials and implant technologies have expanded the treatment landscape for knee cartilage defects and early osteoarthritis. This chapter provides a comprehensive overview of several next-generation devices currently undergoing US Food and Drug Administration trials, expected to reshape clinical and surgical practice over the next 5 to 10 years. Highlighted innovations in the world of cartilage include the Hyalex Knee Cartilage System, which mimics native cartilage biomechanics; the BioPoly partial resurfacing knee implant, with demonstrated long-term success in European trials; and the Engineered Biomimetic Osteochondral Construct (EB-OC), a tissue-engineered graft designed to regenerate both cartilage and bone. Other promising options include the Ormi Implant, using Galene biomaterial, the minimally invasive ZKR LIFT System for patellofemoral degeneration, and Medipost's CARTISTEM, an off-the-shelf mesenchymal stem cell therapy already approved in Korea and now undergoing US trials. Each implant targets specific patient populations and offers alternatives to traditional surgical treatment options such as microfracture, osteotomy, or joint replacement. Collectively, these trials signal a shift toward personalized, biologically inspired innovations that may improve long-term joint preservation, function, and quality of life. This article aims to summarize device designs, clinical trial protocols, and early outcomes where available, thus equipping providers with insight into the future of cartilage restoration therapies. Oper Tech Sports Med 34:151243 (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
Cartilage lesions are relatively common with an incidence of around 60% at the time of arthroscopy, of which 5% to 10% are grade IV lesions in patients under 40 years of age. Treatment options for these lesions range from nonoperative treatments, including activity modification, bracing, and various injections, to operative treatments, including chondroplasty or more advanced cartilage restoration techniques, such as osteochondral autograft, osteochondral allograft, and autologous chondrocyte implantation (ACI). ACI has been available as a treatment option for 3 decades, and the third-generation ACI is currently used in the United States, which is defined as matrix-induced ACI (MACI). With this treatment, the patient articular cartilage is harvested during a first-stage arthroscopy and then transplanted back to the patient's knee during second-stage surgery with a graft that consists of a manufactured collagen membrane with chondrocytes attached to the scaffold. Randomized trials have shown that MACI is superior to microfracture at short- and midterm follow-up. More recently, arthroscopic MACI has become available to reduce the morbidity of the second-stage procedure. The technique is straightforward, and arthroscopy-dedicated equipment is helpful in performing the procedure. Previous first- and second-generation studies have shown that arthroscopic treatment leads to easier recovery and superior patient-reported outcomes at 1-year follow-up, with similar outcomes at 5-year follow-up. Initial series of arthroscopic third-generation MACI have been shown to lead to excellent outcomes and similarly superior short-term outcomes with fewer complications, but larger comparative studies are warranted. Oper Tech Sports Med 34:151239 (c) 2026 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
There are limited treatment options available for patients with mild to moderate medial knee osteoarthritis (OA) who are not yet candidates for or wish to avoid arthroplasty. The MISHA (medial implantable shock absorber) device addresses the gap in treatment options for this patient population who have failed non-operative treatment or have symptomatic medial OA despite prior surgical treatment and are not arthroplasty candidates. The MISHA procedure can be considered as a bridge treatment to allow restoration of mobility and activity while simultaneously delaying arthroplasty. Patients with medial compartment Kellgren-Lawrence grade 1-3 OA with relatively well persevered lateral and patellofemoral compartments who have load related medial knee symptoms, are active, and are motivated to avoid arthroplasty may be good candidates for this procedure. The MISHA device itself is comprised of a shock absorber which is affixed with locking screws through bases at the medial distal femur and proximal tibia. It is placed in an anisometric position by a simple intra-operative guide system and works by dissipating the pathologic joint loading during weight bearing. Importantly, in distinction to valgus producing osteotomy, the MISHA device offloads the medial compartment without shifting any load to the lateral compartment. Two and five-year results from a prospective trial comparing the MISHA procedure to high tibial osteotomy (HTO) have demonstrated a quicker recovery, better pain and function scores, as well as 99% two-year and 90% five-year survival free from conversion to arthroplasty(1,12). Thus, the MISHA device provides a durable treatment option for medial OA which restores function and mobility and delays arthroplasty.
Focal articular cartilage lesions of the knee present a significant clinical challenge, particularly in middle-aged patients who fall between the optimal candidacy of cartilage preservation and knee arthroplasty. Recent advancements in focal metallic resurfacing offer a promising joint-preserving alternative for this population. These implants are designed to treat well-defined, full-thickness chondral defects while maintaining native joint anatomy and delaying more invasive procedures. Careful patient selection, including lesion size, cartilage status, and mechanical alignment, is critical to success. Clinical studies have shown encouraging short- to mid-term outcomes, especially when comparing defect progression and revision rates to biologic treatment options. Despite mixed patient-reported outcomes and durability in certain implants, newer systems incorporating patient-specific designs and advanced materials may offer improved fixation and reduced opposing cartilage stress. A panel consensus supports their use in selected patients, though long-term data and high-level evidence remain limited. As technologies evolve, focal metallic resurfacing may increasingly serve as a viable intermediate option in knee preservation strategies, providing meaningful symptom relief and function restoration in appropriately selected patients.
Muscle injuries in athletes are common and account for a substantial amount of time lost from sport, making it crucial that muscle healing is optimized after injury. Historical methods of treating muscle injuries included the PRICE (protection, rest, ice, compression, and elevation) method, oral medications including non-steroidal anti-inflammatories (NSAIDs), and progressive rehabilitation which have limited evidence and may not be optimal for recovery after injury. In recent years, there has been a push to elucidate other modalities and interventions that may aid in the muscle healing process and reduce athletes missed time from sport. The goal of this review is to highlight techniques that can maximize muscle healing in athletes. Specifically, the review focuses on imaging techniques that may aid in tracking muscle recovery including ultrasound and elastography, as well as novel rehabilitation approaches and newer modalities such as extracorporeal shockwave therapy, photobiomodulation, and orthobiologic injections. Additionally, this review also analyzes the role of nutrition and sleep in muscle healing after injury.
Gluteal tendinopathy and greater trochanteric pain syndrome (GTPS) often present a challenge to manage given its prevalence, chronic nature, and lack of consistent treatments. Historically considered an inflammatory condition, treatments initially focused on anti-inflammatory medication and physical therapy. More recently, degenerative gluteal tendinopathy has been indicated as the driving force behind GTPS, and biologic treatments have been considered and rigorously studied. Mixed results were found for the efficacy of biologic treatments in multiple randomized controlled trials and case series. Studies included are quite heterogeneous, limiting the ability to complete and draw conclusions from large-scale meta-analyses. Platelet-rich plasma (PRP) appears to have moderate efficacy in the treatment of gluteal tendinopathy, especially in longer-term follow up with a relatively benign risk profile. Bone marrow aspirate concentrate (BMAC) has not been shown to have efficacy in randomized trials for gluteal tendinopathy, however in other tendinopathy models, its positive results warrant further study in this population.
Muscle injuries are a leading cause of time loss and reinjury in athletes, particularly in field and running-based sports. While traditional management emphasizes rest and progressive rehabilitation, increasing interest has focused on orthobiologic therapies that may modulate the muscle healing environment. Platelet-rich plasma (PRP) has been widely studied due to the central role of platelets in inflammation and tissue repair and has demonstrated benefit in other musculoskeletal conditions such as osteoarthritis and various tendinopathies. However, basic science data increasingly suggest that unmodified PRP promotes muscle cell proliferation, profibrotic signaling, and scar formation rather than organized myocyte differentiation and regeneration. Consistent with these mechanistic concerns, clinical trials evaluating PRP for acute muscle injury have produced mixed and largely inconsistent results. Platelet-poor plasma (PPP), which preserves key growth factors while reducing platelet concentration, has emerged as a potential alternative. Preclinical studies suggest that PPP supports myocyte differentiation and more physiologic muscle regeneration and healing as opposed to fibrosis and scarring seen with PRP. Although clinical evidence for PPP remains limited, early cohort studies and comparative data demonstrate promising improvements in return-to-play timelines, recovery, and post-procedural tolerance. This review synthesizes the basic science and clinical evidence comparing PRP and PPP for muscle injury and highlights directions for future investigation.
Partial thickness rotator cuff tears (PTRCTs) are a common degenerative shoulder pathology that often results in pain, functional weakness, and eventual progressive glenohumeral joint degeneration.1, 2 The optimal management approach and the decision to progress to surgical intervention remains nuanced and patient-specific. Orthobiologics are autologous cell and non-cell based therapies that are derived from tissues of the body including blood, bone marrow, and adipose tissue that are utilized with the intention of promoting healing of injured muscles, tendons, ligaments or bones. In recent years, there has been great interest into the possibility of using these injections as an efficacious alternative or adjunct to surgery. However, the evidence supporting orthobiologic clinical efficacy in PTRCTs remains inconclusive in part due to a lack of standardized dosing and heterogenous formulations. This review summarizes the currently available literature regarding the efficacy of platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), stromal vascular fraction (SVF) and microfragmented fat (MFAT) in the management of PTRCTs and highlights practical considerations for clinical use.
Subchondral insufficiency fracture of the knee (SIFK) is increasingly being identified as a cause of knee pain in older adults. These lesions were previously described as spontaneous osteonecrosis of the knee (SONK), but evidence has helped better elucidate the pathophysiology behind these lesions. Chronic overload and repeated microtrauma compromise the osteochondral unit. Due to repeated mechanical overload, SIFK develops from a repeated cycle of subsequent bone marrow edema and elevated intraosseous pressure, which in turn compromises neurovascular supply to the region. This contributes to pain and worsening insufficiency. SIFK primarily affects patients above the age of 50 and has a 2:1 predisposition for women. Primarily affecting the medial femoral condyle (MFC), it typically presents as sudden-onset, atraumatic knee pain that is exacerbated by weight-bearing activities and may persist at rest. Physical exam typically reveals effusion and joint line tenderness that localizes to the medial knee. Magnetic resonance imaging (MRI) is the most sensitive and frequently used imaging modality, for which multiple grading criteria exist. Criteria rely on MRI results, typically comparing lesions' appearance, size, location, and/or extent of bone marrow edema. Initial nonoperative treatment utilizes nonsteroidal anti-inflammatory drugs and temporary restriction of weight-bearing, which improves pain and function in some patients. However, some patient cohorts, after initial conservative management, have developed osteoarthritis and required subsequent total knee arthroplasty (TKA) without operative intervention, suggesting that larger lesion size and/or concomitant meniscal damage may compromise patient outcomes. Surgical treatment options include subchondroplasty, core decompression, IntraOsseous BioPlasty, and the KneeBar procedure. The latter involves incorporation of an OSSIOfiber biointegrative nail, which allows precise implant placement and preservation of local joint anatomy. Patients are typically allowed immediate weight-bearing and full range of motion, with no restrictions on activity during the early postoperative period. In some cases of SIFK, patients undergo TKA as definitive treatment. Patient cohorts have demonstrated excellent implant survival at 25 years postoperatively. These data emphasize the importance of individualized treatment for SIFK. Oper Tech Sports Med 34:151240 (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
The use of three-dimensional patient-specific instrumentation (3D PSI) for osteotomies about the knee involves the fabrication of custom intraoperative guides based on patient-specific 3D computed tomography anatomy and planning. The large majority of the literature base has been on 3D PSI for high tibial osteotomy. These systems demonstrate improved accuracy in cadaveric and clinical studies, resulting in a very small margin of error in all planes. When compared to conventional techniques, 3D PSI can also lead to a shorter learning curve as well as less operative time, reliance on fluoroscopy, and blood loss. For more experienced surgeons, these benefits may be less pronounced. Case series demonstrate safety, feasibility, and improvement in clinical outcomes after using 3D PSI. Only a few studies have published clinical outcomes against conventional techniques, and the data are more equivocal. Albeit promising, there are only a few studies evaluating 3D PSI for other procedures, including distal femoral osteotomy, tibial tubercle osteotomy, and slope correcting osteotomies. Future comparative studies are needed to evaluate the longterm clinical outcomes of 3D PSI osteotomies around the knee. (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
Cartilage defects are a common cause of pain, swelling, and functional limitation, especially in young, active individuals. When left untreated, these lesions frequently worsen and progress to osteoarthritis. Accurate diagnosis relies on a combination of patient history, physical exam, advanced imaging, and often, diagnostic arthroscopy. While some patients respond to conservative treatments, numerous surgical options exist for those who have failed these measures. Among these, osteochondral allograft transplantation has become a well-established approach for treating many of these lesions. This article reviews recent advances in osteochondral allograft transplantation, detailing the diagnosis, surgical indications, operative techniques, and clinical outcomes associated with their use in the treatment of cartilage defects. Oper Tech Sports Med 34:151238 (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
Rotator cuff tears are a highly prevalent cause of shoulder pain and dysfunction, with incidence increasing substantially with age. Despite advances in arthroscopic repair techniques and fixation constructs, structural failure remains common, particularly in chronic and larger tears, largely due to the limited ability to regenerate the native tendon-to-bone enthesis and the tendency for healing to occur through scar-mediated attachment. Both intrinsic factors (tendon degeneration, fatty infiltration, and dysregulated inflammation) and extrinsic factors (mechanical loading environment) contribute to impaired healing. Orthobiologic strategies have emerged as promising adjuncts to improve repair biology through modulation of inflammation, cellular signaling, and extracellular matrix remodeling. Blood-derived products, such as platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) may reduce retear rates and improve early pain and function, though results remain variable due to heterogeneity in preparation and delivery. Cell-based therapies including bone marrow aspirate concentrate (BMAC) and mesenchymal stromal cell (MSC) approaches offer immunomodulatory potential but remain limited by inconsistent clinical evidence. In addition, extracellular matrix scaffolds and biologic graft augmentation may provide both mechanical reinforcement and a favorable healing microenvironment, with dermal allografts demonstrating the most consistent support in high-risk repairs. While cost and variability in outcomes remain major limitations, orthobiologics represent a growing area of interest, and future work must focus on standardized protocols and improved patient selection to clarify their clinical value.
Meniscus allograft transplantation has become a reliable option to restore knee joint stability, biomechanics, and load transmission in patients with symptomatic meniscal deficiency after injury or failed meniscal repair. Ongoing improvements in surgical technique, fixation, and biologic augmentation continue to enhance success rates and overall outcomes. This chapter provides an overview of current indications, surgical techniques, rehabilitation protocols, clinical outcomes, and future directions for meniscus allograft transplantation. Oper Tech Sports Med 34:151241 (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
The treatment of knee malalignment has entered a renaissance period. Recent refinement in our understanding of the disease process continues to support early intervention strategies and corrective surgeries. MRI imaging provides the potential for the early detection of chondral damage and may enhance our ability to accurately indicate patients when they become clinically available. Available advanced imaging modalities including weightbearing CT, EOS (R), and hybrid 3-dimensional modeling are in the early phases of clinical implementation but are already revolutionizing presurgical planning. A deeper understanding of soft tissue balance is helping surgeons systematically reduce outliers in surgical correction. Utilizing these resources, surgeons are increasingly capable of addressing deformity in multiple planes while accounting for concomitant procedures. Even in salvage situations, new surgical options such as the implantable shock absorber are diversifying surgical treatment options for malalignment patients. In summary, innovation is driving rapid growth in the treatment of knee malalignment which may herald a new era in osteotomy. Oper Tech Sports Med 33:151206 (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
Sports medicine is an ever-evolving field of medicine that continues to adapt and improve to better care for the population of recreational, amateur, and professional athletes. In addition to improvements in surgical techniques, medical devices, and rehabilitation protocols, advancements in sports medicine imaging have allowed for more comprehensive, efficient, and detailed evaluation and management of injury pathologies. This review describes the emerging imaging modalities and complementary interpretive techniques in sports medicine that offer immense potential in diagnosis of injuries in the shoulder, knee, and ankle. These modalities include 3-dimensional magnetic resonance imaging (3D-MRI), quantitative MRI, ultrasound elastography, weight-bearing computed tomography (WBCT), dualenergy computed tomography (DECT), and artificial intelligence guided imaging analysis. The innovations discussed in this article have collectively enabled improved evaluation of osseous morphology and joint instability, earlier detection of cartilage and ligamentous injury, and enhanced assessment of tissue healing and rehabilitation. This review examines how modern imaging modalities have shifted to become dynamic and personalized diagnostic tools to better optimize injury management, intervention, and rehabilitation of pathologies in the shoulder, knee, and ankle. Oper Tech Sports Med 33:151213 (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
Biomaterials play a central role in modern sports medicine by enabling effective repair, reconstruction, and regeneration of musculoskeletal tissues exposed to high mechanical demands. Over the past century, the field has evolved from simple autograft and allograft tissue transfers to advanced synthetic polymers, bioactive scaffolds, growth-factor-rich biologics, and hybrid constructs that integrate mechanical support with biologic healing potential. This chapter reviews the fundamental material-science principles relevant to sports medicine-including biomechanics, biocompatibility, and degradation kinetics- before outlining a variety of biomaterials currently in use. Applications across ligament and tendon reconstruction, cartilage restoration, meniscal repair, and soft-tissue fixation are described with attention to current indications, limitations, and outcomes data. By linking bioengineering fundamentals with clinical practice, this chapter provides an overview of how biomaterials are shaping contemporary sports medicine and driving the next generation of soft-tissue repair technologies. Oper Tech Sports Med 33:151212 Published by Elsevier Inc.
