BACKGROUND:Fresh osteochondral allograft (FOCA) transplantation is an increasingly used technique for treating symptomatic cartilage defects in young and active patients. However, insufficient osseous integration of the graft remains a primary cause of failure. Bone marrow aspirate concentrate (BMAC), rich in mesenchymal stem cells, may enhance graft integration. PURPOSE:To determine whether the use of autologous BMAC in FOCA transplantation of the knee improves osseous integration on computed tomography (CT) during the first postoperative year and yields superior clinical outcomes compared to non-BMAC-treated grafts at 2-year follow-up. STUDY DESIGN:Randomized clinical trial; Level of evidence, 1. METHODS:We conducted a single-center, prospective, randomized controlled trial in 36 patients undergoing FOCA transplantation. Patients who met the inclusion criteria were randomly assigned to either a BMAC group or non-BMAC group. CT was performed at 3, 6, and 12 months, and imaging findings were evaluated using the semiquantitative assessment CT osteochondral allograft (ACTOCA) scoring system. Clinical outcomes (International Knee Documentation Committee, Kujala, Western Ontario Meniscal Evaluation Tool, and Tegner scores) were assessed preoperatively and at 6, 12, and 24 months. RESULTS:Osseous integration at the host-graft junction on CT was superior in the BMAC group at 3 months postoperatively compared with the non-BMAC group (P < .05), with no differences between groups at 6 or 12 months. Regarding graft signal density relative to host bone, differences were observed between groups at 3 and 12 months, with better 3-month graft signaling in the BMAC group and better 12-month graft signaling in the non-BMAC group. No differences were observed at 6 months. Also, no differences were observed between groups in patient-reported outcome scores. CONCLUSION:BMAC augmentation in FOCA transplantation of the knee demonstrated improved early osseous integration at the host-graft junction at 3 months postoperatively, as assessed on CT using the ACTOCA scoring system, with no differences observed at 6 or 12 months. Regarding graft signal density relative to host bone, significant differences were observed at 3 and 12 months, with better 3-month graft signaling in the BMAC group and better 12-month graft signaling in the non-BMAC group. No differences were observed between groups in patient-reported outcome scores. REGISTRATION:NCT04236492 (ClinicalTrials.gov).

Distal femoral osteotomy (DFO) is commonly used to correct excessive valgus knee deformities. Valgus malalignment places increased loads on the lateral tibiofemoral joint, accelerating lateral compartment degeneration. This article explores the benefits of DFO in correcting valgus deformities and addresses concomitant procedures for managing lateral compartment pathology, offering practical guidance for surgeons to optimize outcomes and restore knee function.

ABSTRACT Purpose The aim of this study was to determine the influence of preoperative psychological factors on clinical outcomes of fresh osteochondral allograft (FOCA) transplantation of the knee. The hypothesis was that patients with preoperative pathological scores on psychological factors would show worsen functional outcomes after FOCA transplantation of the knee. Methods A prospective data collection study was performed from patients undergoing FOCA transplantation for osteochondral lesions of the knee. All patients were followed up for 30 months. Psychological factors of anxiety, depression, kinesiophobia and catastrophizing were assessed by means of self‐administered Hospital Anxiety and Depression Subscale (HADS), Tampa Scale for Kinesiophobia (TSK) and Pain Catastrophizing Scale (PCS) questionnaires one week prior to surgery. Clinical outcomes were evaluated preoperatively and at 3, 6, 9, 12, 15 and 30 months postoperatively using the Kujala score, the Western Ontario Meniscal Evaluation Tool (WOMET) score, the International Knee Documentation Committee (IKDC) score and the Tegner Activity Scale. Participants were classified as pathological or non‐pathological scores for each psychological parameter in accordance with the cut‐off point proposed by the authors of each questionnaire. The interaction between clinical outcome's evolution and pathological scores was analysed using two‐way ANOVA tests with Greenhouse–Geisser correction to avoid non‐sphericity errors. Results Forty‐one cases were included (mean age 37.1 years old, 41% female). In the postoperative clinical outcome's evolution, no differences were observed between preoperative pathological and non‐pathological scores (p > 0.05) regarding anxiety, depression, kinesiophobia and catastrophizing factors. Conclusions No significant differences were observed in the evolution of postoperative clinical outcomes between patients with pathological and non‐pathological psychological scores. Level of Evidence Level III, case series.

Osteochondral injuries of the knee can be a frequent source of debilitating pain and dysfunction. Significant chondral (>1.5-2 cm2) lesions of the femoral condyles can be especially difficult to manage with nonsurgical measures. Fresh osteochondral allograft (OCA) transplantation has been shown to be a reliable surgical procedure to manage a wide array of high-grade focal chondral lesions, with or without subchondral bone involvement. OCA transplantation affords the transfer of a size-matched allograft of mature hyaline cartilage with its associated subchondral bony scaffold. Indications include primary or secondary management of large, high-grade chondral or osteochondral defects secondary to trauma, developmental malformation, osteonecrosis, or other focal degenerative disease. Contraindications include end-stage osteoarthritis, uncorrected malalignment, ligament or meniscus deficiency, and inflammatory joint disease. Improvements in surgical technique, allograft storage, and tissue availability have created more reproducible clinical results and increased chondrocyte viability. Long-term (>10 year) graft survival rates have been shown to be between 70% and 91%, and the procedure has been shown to be cost-effective based on cost per quality-adjusted life year. Finally, OCA transplantation has been shown to provide excellent return to play rate for athletes with medium-to-large cartilage lesions. OCA transplantation is therefore an important option in the treatment algorithm of articular cartilage injuries.

Optimal graft fixation in anterior cruciate ligament reconstruction is critical. Several direct and indirect methods of graft fixation exist, each with advantages and disadvantages. This Technical Note describes a tibial hybrid anterior cruciate ligament graft fixation technique combining direct and indirect fixation methods, including autologous bone augmentation of the drill tunnel using cancellous bone fragments.

Purpose: To report the clinical outcomes, radiologic evolution, and survivorship of a series of patients affected by the postmeniscectomy syndrome and treated with a polyurethane scaffold at a minimum 10-year follow-up. In addition, the radiologic evolution of these patients was also assessed. Methods: All the patients operated on with a polyurethane meniscal scaffold implantation to treat postmeniscectomy syndrome from 2008 to 2011 were prospectively followed. Clinical evaluations and radiologic studies were assessed at the preoperative period, at 5-year follow-up, and at minimum 10-year follow-up. Clinical outcomes were based on patient-reported outcomes (e.g., the Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee, Lysholm, and Tegner). Radiographical evaluation of the joint-space narrowing was done in the Rosenberg view. Failure was defined as patients who required surgery to remove the scaffold or those patients who needed surgery for a total or partial knee replacement. Results: Twenty-one of 27 patients, with a mean age of 56 +/- 9.8 years, were available for the final follow-up. The mean follow-up was 11.8 (range, 10-12.7) years. Six patients were lost to follow-up. All functional scores showed a significant improvement (P < .001) at the 5- and 10-year follow-up. The exception was the Tegner score, which remained stable. The joint-space width was maintained from the preoperative period (1.9 +/- 1.2 mm) up to the 5-year follow-up (1.3 +/- 1.5 mm, P = .3) and decreased by the last evaluation (0.6 +/- 1.2 mm, P = .001) at the last follow-up. Two (9.5%) of 21 patients were converted to a total knee replacement during the study period. None of the other patients needed revision surgery during the study period. Conclusions: The polyurethane meniscal scaffold provides significant and stable pain relief over time and improved functional outcomes at a minimum of 10 years after surgery. However, degenerative changes progressed in the treated compartment, with a joint-space narrowing over the 10-year period. Level of evidence: Level IV, retrospective case series.

To carry out an in vivo kinematic analysis of isolated modified Lemaire lateral extra-articular tenodesis (LET) to explore its ability to modify the stability of anterior cruciate ligament (ACL) deficient knees. The secondary aim was to look at the clinical outcomes of the isolated LET to analyze whether biomechanical changes have an influence on clinical improvement or not. A total of 52 patients who underwent an isolated modified Lemaire LET were prospectively studied. Twenty-two were over 55-year-old patients with ACL rupture and subjective instability (group 1). They were followed up for 2 years postoperatively. Thirty were patients underwent a two-stage ACL revision (group 2). They were followed up for 4 months postoperatively (up to the second stage of the ACL revision). Preoperative, intraoperative, and postoperative kinematic analyses were carried out using the KiRA accelerometer and KT1000 arthrometer to look for residual anterolateral rotational instability and residual anteroposterior instability. Functional outcomes were measured with the single-leg vertical jump test (SLVJT) and the single-leg hop test (SLHT). Clinical outcomes were evaluated using the IKDC 2000, Lysholm, and Tegner scores. A significant reduction of both rotational and anteroposterior instability was detected. It was present both with the patient under anesthesia (p < 0.001 and p = 0.007 respectively) as well as with the patient awake (p = 0.008 and p = 0.018 respectively). Postoperative analysis of knee laxity did not show any significant variation from the first to the last follow-up. Both the SLVJT and SLHT improved significantly at the last follow-up (p < 0.001 and p = 0.011 respectively). The mean values of both the IKDC and Lysholm and Tegner scores showed an improvement (p = 0.008; p = 0.012; p < 0.001). The modified Lemaire LET improves the kinematics of ACL-deficient knees. The improvement in the kinematics leads to an improvement in subjective stability as well as in the function of the knee and in the clinical outcomes. At the 2-year follow-up, these improvements were maintained in a cohort of patients over 55 years. Following our findings, to reduce knee instability, an isolated LET in ACL-deficient knees may be used when ACL reconstruction in patients over 55 years is not indicated. Level IV

To determine the correlation between the assessment computed tomography osteochondral allograft (ACTOCA) scoring system and clinical outcomes scores. The hypothesis was that the ACTOCA score would show sufficient correlation to support its use in clinical practice. We prospectively collected data from all consecutive patients who underwent cartilage restitution with fresh osteochondral allograft (FOCA) transplantation for osteochondral lesions of the knee and had a minimum follow-up of two years. CT scans were performed at three, six and 24 months post-operatively. A musculoskeletal radiologist blinded to the patients’ medical history evaluated the scans using the ACTOCA scoring system. Clinical outcomes collected preoperatively and at three, six and 24 months postoperatively were evaluated using the International Knee Documentation Committee (IKDC), Kujala, the Western Ontario Meniscal Evaluation Tool (WOMET), and the Tegner Activity Scale. The mean total ACTOCA score showed a statistically significant correlation with the clinical outcome. The correlation was optimal at 24 months. We found a high negative correlation with the IKDC, Kujala and Tegner (− 0.737; − 0.757, and − 0.781 respectively), and a moderate negative correlation with WOMET (− 0.566) (p < 0.001). IKDC, Kujala, WOMET, and Tegner scores showed a significant continuous improvement in all scores (p < 0.001). The mean total ACTOCA score showed a linear correlation with clinical results in IKDC, Kujala, WOMET, and Tegner scores, being the highest at 24 months post-surgery. This finding supports the use of ACTOCA to standardize CT scan reports following fresh osteochondral allograft transplantation in the knee.

Osteochondritis dissecans (OCD) is a pathologic condition, most commonly affecting the knee joint in ado-lescents and young adults, although pathology can also be found at the elbow and ankle. Lesions to the medial femoral condyle are classically associated with varus alignment, while lesions to the lateral femoral condyle are seen in patients with valgus malalignment. Common risk factors for failed fixation of OCD lesions include unstable lesions to the lateral femoral condyle, screw breakage, older age, and closed physes. The purpose of this technical note is to describe the preoperative planning and step-by-step surgical approach for treatment of failed fixation of an OCD lesion of the posterior aspect of the lateral femoral condyle in young, active patients using an osteochondral allograft, a lateral opening wedge distal femoral osteotomy to correct malalignment, and a tibial tubercle osteotomy to facilitate access to the lesion.

The preservation conditions of fresh osteochondral allografts for clinical applications are critical due their objective: to transplant mature hyaline cartilage containing viable chondrocytes, maintaining their metabolic activity and also preserving the structural and functional characteristics of the extracellular matrix. The aim of the present study was to compare fluorescence confocal microscopy and flow cytometry techniques to evaluate the viability of the chondrocytes present in the osteochondral tissue, in order to determine their effectiveness and thus ensure reproducibility and robustness of the analysis. To this end, osteochondral allografts from human cadaveric donors were preserved at 4 °C for 3 weeks in a preservation medium supplemented with antibiotic and antifungal agents. Cell viability of chondrocytes was determined by monitoring the cartilage for 3 weeks of preservation by confocal fluorescence microscopy and flow cytometry, obtaining cell viabilities of 83.7 ± 2.6% and 55.8 ± 7.8% for week three, respectively. The confocal fluorescence microscopy approach is more advantageous and accurate, as it correlates better with actual cell viability values for monitoring osteochondral graft preservation, detecting only the cells that died a natural death associated with the preservation method.

Patellar tendon injuries are a group of different injuries involving the lower part of the extensor mechanism. Two types of patellar tendon injuries are the most common. On one hand, acute injuries can lead to a tendon tear at different locations of the tendon. In general, these injuries have good overall outcomes. On the other hand, patellar tendinopathy refers to an alteration of the patellar tendon architecture caused by chronic malfunctioning or overload. With several different modalities to treat these injuries, they represent a growing challenge for the treating doctor or physiotherapist.

This chapter describes in detail the indications, surgical planning, and step-by-step procedure for combined anterior cruciate ligament (ACL) reconstruction and open wedge high tibial osteotomy (HTO).

Background: There is a lack of information regarding the ability of imaging studies to predict clinical outcomes after fresh osteochondral allograft (FOCA) transplantation of the knee. Purpose: To determine the value of computed tomography (CT) scans to predict the clinical outcome of FOCA transplantation using the assessment computed tomography osteochondral allograft (ACTOCA) score. Study Design: Cohort study; Level of evidence, 3. Methods: We prospectively collected data from all consecutive patients who underwent FOCA transplantation for osteochondral knee lesions at one institution between August 2017 and August 2019. All patients were followed up for a minimum of 2 years. CT scans performed 6 months after surgery were evaluated by a musculoskeletal radiologist using the ACTOCA scoring system. The radiologist was blinded to the patient’s medical history. Clinical outcomes were assessed preoperatively and at 12 and 30 months postoperatively using the International Knee Documentation Committee (IKDC) score, the Kujala score, the Tegner activity scale, and the Western Ontario Meniscal Evaluation Tool (WOMET) score. Results: A total of 38 cases were included. The ACTOCA score at 6 months after surgery showed a statistically significant correlation with clinical results at 12 and 30 months. The correlation was better at 30 months, showing a high negative correlation with the IKDC score (−0.663) and a moderate negative correlation with the Kujala, WOMET, and Tegner scores (−0.593; −0.547, and −0.593, respectively) ( P < .001). Conclusion: A statistically significant correlation between the mean ACTOCA score on CT scans at 6 months and the clinical results measured by the IKDC, Kujala, WOMET, and Tegner scores at 30 months confirmed the predictive value of the ACTOCA score for use in clinical practice.

Lower-extremity misalignment hastens the development of chondral and osteochondral knee lesions. In active young patients with bipolar osteochondral lesions, the bipolar fresh osteochondral allograft procedure is a useful salvage treatment option. Although the surgical technique is technically demanding and high reoperation and failure rates are expected, patients with surviving allografts show a significant clinical improvement. Careful patient selection is key to delivering desired results. In this review, we present and discuss recent surgical techniques and developments in bipolar fresh osteochondral allograft procedures. (C) 2022 Elsevier Inc. All rights reserved.

AIM OF THE STUDY:To describe a new semiquantitative computed tomography (CT) scoring system for multi-feature analysis of cartilage defect repair by osteochondral allografts for the knee and to assess its intra-observer and inter-observer variability.METHOD:A semiquantitative assessment CT osteochondral allograft (ACTOCA) scoring system was designed based on fresh osteochondral allograft transplantations for the knee. The system includes five CT features: density relative to host bone, integration at the host-graft junction, surface percentage with a discernible cleft at the host-graft junction, cystic changes, and intra-articular fragments. Inter-observer variability was calculated by three observers blinded to the patient's medical history and treatment. Intra-observer variability was also determined.RESULTS:Inter-observer agreement was moderate to substantial for all CT score components and intra-observer agreement was moderate to almost perfect for all CT score components (κ > 0.5, p < 0.05).CONCLUSION:The ACTOCA score is a reliable tool to evaluate integration of osteochondral allograft transplantations. It provides an accurate evaluation of bone changes and may help to standardize CT scan reports following osteochondral allograft transplantation for the knee.

The management of posterolateral corner (PLC) injuries has significantly evolved over the past 2 decades. The purpose of this study was to determine the current worldview of key concepts on the diagnosis, treatment strategy, and rehabilitation for patients presenting with PLC injuries. A 12-question multiple-choice online survey was designed to address key questions in the diagnosis, treatment, and rehabilitation of PLC injuries. The survey was distributed to the most important international sports medicine societies worldwide. Clinical agreement was defined as > 80% of agreement in responses and general agreement was defined as > 60% of agreement in responses. 975 surgeons completed the survey with 49% from Europe, 21% from North America, 12% from Latin America, 12% from Asia, and smaller percentages from Africa and Oceania. Less than 14% of respondents manage more than ten PCL injuries yearly. Clinical agreement of > 80% was only evident in the use of MRI in the diagnosis of PLC injury. Responses for surgical treatment were split between isometric fibular-based reconstruction techniques and anatomically based fibular and tibial-based reconstructions. A general agreement of > 60% was present for the use of a post-operative brace in the early rehabilitation. In the global surgical community, there remains a significant variability in the diagnosis, treatment, and postoperative management of PLC injuries. The number of PLC injuries treated yearly by most surgeons remains low. As global clinical consensus for PLC remains elusive, societies will need to play an important role in the dissemination of evidence-based practices for PLC injuries. IV.

BACKGROUND:A biodegradable polyurethane scaffold was developed to treat patients with the challenging clinical condition of painful partial meniscal defects.HYPOTHESIS:The use of an acellular polyurethane scaffold in patients with symptomatic partial meniscal defects would result in both midterm pain relief and improved function.STUDY DESIGN:Case series; Level of evidence, 4.METHODS:A total of 155 patients with symptomatic partial meniscal defects (101 medial and 54 lateral) were implanted with a polyurethane scaffold in a prospective, single-arm, multicentric study with a minimum 5-year follow-up. Clinical outcomes were measured with the visual analog scale for pain, International Knee Documentation Committee subjective knee evaluation form, Lysholm knee scale, and Knee injury and Osteoarthritis Outcome Score at baseline and at 2- and 5-year follow-ups. Magnetic resonance imaging (MRI) was used to evaluate the knee joint, meniscal implant, and meniscal extrusion. Kaplan-Meier survival analysis was also performed. Removal of the scaffold, conversion to a meniscal transplant, and unicompartmental/total knee arthroplasty were used as endpoints.RESULTS:Eighteen patients were lost to follow-up (11.6%). The patients who were included in this study showed significant clinical improvement after surgery as indicated by the different outcome measures (P = .01). However, the clinical improvement tended to stabilize between 2 and 5 years of follow-up. MRI scans of the scaffolds in 56 patients showed a smaller-sized implant in the majority of the cases when compared with the native meniscus with an irregular surface at the 5-year follow-up. During the follow-up period, 87.6% of the implants survived in this study. At 5 years of follow-up, 87.9% of the medial scaffolds were still functioning versus 86.9% of the lateral scaffolds. In total, 23 treatments had failed: 10 removed scaffolds because of breakage, 7 conversions to meniscal allograft transplantation, 4 conversions to unicompartmental knee arthroplasty, and 2 conversions to total knee arthroplasty.CONCLUSION:The polyurethane meniscal implant was able to improve knee joint function and reduce pain in patients with segmental meniscal deficiency over 5 years after implantation. The MRI appearance of this scaffold was different from the original meniscal tissue at the midterm follow-up. The treatment survival rates of 87.9% of the medial scaffolds and 86.9% of the lateral scaffolds in the present study compared favorably with those published concerning meniscal allograft transplantation after total meniscectomy.

The primary objective was to compare the functional outcomes after an isolated MPFL reconstruction using either a quasi-anatomical technique (group A) or an anatomical MPFL reconstruction (group B). The secondary objectives were to compare the rates of redislocation, range-of-motion and subjective patellar instability (Smillie test). A multicenter longitudinal prospective comparative study was performed. Group A had 29 patients and 28 were included in Group B. Patients with trochlear dysplasia types C and D and patients who had undergone a trochleoplasty, a distal realignment or patella distalization concurrently with MPFL reconstruction were excluded. The main evaluation criterion was the Kujala functional score. The mean postoperative Kujala was 90.4 (89.4 in group A and 92.1 in group B). Upon comparing the mean difference between pre- and post-operative values, no differences were detected between the two groups (n.s). Isolated quasi-anatomical MPFL reconstruction using a gracilis tendon autograft for recurrent patellar dislocation provides outcomes as good as the isolated anatomical MPFL reconstruction in patients with no trochlear dysplasia up to those with trochlear dysplasia type A and B at the 2–5 years follow-up. Level IV.