Publications by authors named "Betina B Hinckel"

24 Publications

  • Page 1 of 1

Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic.

J Am Acad Orthop Surg Glob Res Rev 2020 10 1;4(10):e20.00083. Epub 2020 Oct 1.

From the Oakland University, Rochester (Dr. Hinckel, and Dr. Cavinatto); Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak (Dr. Hinckel, Dr. Cavinatto), MI; the University of Missouri-School of Medicine, Columbia, MO (Mr. Baumann); the Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, BR (Dr. Ejnisman); the Shoulder and Elbow Surgery, Beaumont Orthopaedic Associates, Beaumont Health (Dr. Martusiewicz); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Tanaka); the Department of Orthopedic Surgery, TRIA Orthopedic Center, University of Minnesota, Gillette Children's Specialty Healthcare, MN (Dr. Tompkins); the Department of Orthopedic Surgery, Stanford University, CA (Dr. Sherman); the Rush University Medical Center, Chicago, IL (Dr. Chahla); the Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, Aurora, CO (Dr. Frank); the Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Yamamoto); CEGH-CEL, Instituto de Biociências, Universidade de São Paulo (Dr. Yamamoto); DASA Laboratories, Sao Paulo, Brazil (Dr. Yamamoto); the Michigan Orthopedic Surgeons, Fellowship Director William Beaumont Sports Medicine Fellowship, Assistant Professor Oakland University William Beaumont School of Medicine, MI (Dr. Bicos); the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN (Dr. Arendt); the Southern California Permanente Medical Group and Torrey Pines Orthopaedic Medical Group, San Diego, CA (Dr. Fithian); and the Knee Preservation, Cartilage Regeneration and OrthoBiologics, Department of Orthopedic Surgery, Indiana University School of Medicine, OrthoIndy and OrthoIndy Hospital, Greenwood and Indianapolis, IN (Dr. Farr).

Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537824PMC
October 2020

Conversion rates and timing to total knee arthroplasty following anterior cruciate ligament reconstruction: a US population-based study.

Eur J Orthop Surg Traumatol 2021 Apr 23. Epub 2021 Apr 23.

Family Center for Sports Medicine at Keck Medicine of USA, USC Epstein, Los Angeles, CA, USA.

Purpose: To define the rate of subsequent TKA following ACLR in a large US cohort and to identify factors that influence the risk of later undergoing TKA after ACLR.

Methods: The California's Office of Statewide Health Planning and Development (OSHPD) database was queried from 2000 to 2014 to identify patients who underwent primary ACLR (ACL group). An age-and gender-matched cohort that underwent appendectomy was selected as the control group. The cumulative incidence of TKA was calculated and ten-year survival was investigated using Kaplan-Meier analysis with failure defined as conversion to arthroplasty. Univariate and multivariate analyses were performed to explore the risk factors for conversion to TKA following ACLR.

Results: A total of 100,580 ACLR patients (mean age 34.48 years, 66.1%male) were matched to 100,545 patients from the general population. The ACL cohort had 1374 knee arthroplasty events; conversion rate was 0.71% at 2-year follow-up, 2.04% at 5-year follow-up, and 4.86% at 10-year follow-up. This conversion rate was higher than that of the control group at all time points, with an odds ratio of 3.44 (p<0.001) at 10-year follow-up. Decreasing survivorship following ACLR was observed with increasing age, female gender, and worker's compensation insurance, while increased survivorship was found in patients of Hispanic and Asian Pacific Islander racial heritage and those who underwent concomitant meniscal repair.

Conclusions: In this US statewide study, the rate of TKA after ACLR is higher than reported elsewhere, with significantly increased odds when compared to a control group. Age, gender, concomitant knee procedures and other socioeconomic factors influence the rate of conversion to TKA following ACLR.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00590-021-02966-6DOI Listing
April 2021

and Effects of Light Therapy on Cartilage Regeneration for Knee Osteoarthritis: A Systematic Review.

Cartilage 2021 Apr 15:19476035211007902. Epub 2021 Apr 15.

Center for Micro-ElectroMechanical Systems (CMEMS-UMINHO), University of Minho, Guimarães, Portugal.

Objective: To analyze the effects of light therapy (LT) on cartilage repair for knee osteoarthritis (OA) treatment.

Design: The PubMed, Embase, Scopus, and Web of Science databases were searched up to August 31, 2020 to identify and studies that analyzed the effects of LT on knee cartilage for OA treatment. The study and sample characteristics, LT intervention parameters and posttreatment outcomes were analyzed. Risk of bias was assessed using the Risk of Bias Assessment for Non-randomized Studies (RoBANS) tool.

Results: Three and 30 studies were included. Most studies were judged as high risk of performance and detection bias. Biochemical outcomes were analyzed for both i and studies, and histological and behavioral outcomes were analyzed for studies. LT reduced extracellular matrix (ECM) degradation, inflammation, and OA progression, promoting ECM synthesis. LT improved pain-like behavior in animal models, having no apparent effect on gait performance. There were conflicting findings of some of the biochemical, histological, and behavioral outcomes.

Conclusion: The included studies presented different strategies and LT parameters. LT resulted in positive effects on cartilage repair and may be an adequate therapy for OA treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/19476035211007902DOI Listing
April 2021

Algorithm for Treatment of Focal Cartilage Defects of the Knee: Classic and New Procedures.

Cartilage 2021 Mar 20:1947603521993219. Epub 2021 Mar 20.

Hospital for Special Surgery, New York, NY, USA.

Objective: To create a treatment algorithm for focal grade 3 or 4 cartilage defects of the knee using both classic and novel cartilage restoration techniques.

Design: A comprehensive review of the literature was performed highlighting classic as well as novel cartilage restoration techniques supported by clinical and/or basic science research and currently being employed by orthopedic surgeons.

Results: There is a high level of evidence to support the treatment of small to medium size lesions (<2-4 cm) without subchondral bone involvement with traditional techniques such as marrow stimulation, osteochondral autograft transplant (OAT), or osteochondral allograft transplant (OCA). Newer techniques such as autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate implantation have also been shown to be effective in select studies. If subchondral bone loss is present OAT or OCA should be performed. For large lesions (>4 cm), OCA or matrix autologous chondrocyte implantation (MACI) may be performed. OCA is preferred over MACI in the setting of subchondral bone involvement while cell-based modalities such as MACI or particulated juvenile allograft cartilage are preferred in the patellofemoral joint.

Conclusions: Numerous techniques exist for the orthopedic surgeon treating focal cartilage defects of the knee. Treatment strategies should be based on lesion size, lesion location, subchondral bone involvement, and the level of evidence supporting each technique in the literature.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1947603521993219DOI Listing
March 2021

Acute Patellofemoral Dislocation: Controversial Decision-Making.

Curr Rev Musculoskelet Med 2021 Feb 1;14(1):82-87. Epub 2021 Feb 1.

Department of Orthopaedic Surgery, Stanford University, Palo Alto, CA, USA.

Purpose Of Review: The topic of acute patella dislocations is controversial. Discussions revolve around which individuals need early surgery, identification of risk factors, and rehabilitation protocol. The purpose of this review is to discuss the current recommendations for non-operative and/or operative management of first-time dislocators.

Recent Findings: Recent studies have made it clear that not all patellar dislocations are the same, not all patients do well with conservative treatment, and risk stratification can identify individuals at high risk of recurrence who would benefit from early surgical intervention. Risk factors that have been identified include younger age, skeletally immature, contralateral instability, trochlear dysplasia, patella alta, increased tibial tubercle-trochlear groove distance, and increased patella tilt. The PAPI (Pediatric and Adolescent Patellar Instability) RCT study and JUPITER (Justifying Patellar Instability Treatment by Early Results) prospective cohort study have been carefully developed, are under way, and will provide further guidance. In summary, the management of acute patellar dislocations is evolving. Surgery for patients with osteochondral loose bodies should include fixation as well as soft tissue stabilization. The standard of care for patients with an acute patellar dislocation without osteochondral loose bodies or fracture is non-operative treatment. However, imaging for all first-time dislocators is indicated to stratify risks and determine risk profile. If an individual is at high risk, soft tissue stabilization may be considered. Still, most patients will be treated non-operatively.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12178-020-09687-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930146PMC
February 2021

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

Orthop J Sports Med 2020 Mar 26;8(3):2325967120907343. Epub 2020 Mar 26.

Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967120907343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7099674PMC
March 2020

Patellofemoral Cartilage Restoration: A Systematic Review and Meta-analysis of Clinical Outcomes.

Am J Sports Med 2020 06 3;48(7):1756-1772. Epub 2020 Jan 3.

Division of Sports, Department of Orthopedic Surgery, School of Medicine, Stanford University, Palo Alto, California, USA.

Background: Many surgical options for treating patellofemoral (PF) cartilage lesions are available but with limited evidence comparing their results.

Purpose: To determine and compare outcomes of PF cartilage restoration techniques.

Study Design: Systematic review and meta-analysis.

Methods: PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were followed by utilizing the PubMed, EMBASE, and Cochrane Library databases. Inclusion criteria were clinical studies in the English language, patient-reported outcomes after PF cartilage restoration surgery, and >12 months' follow-up. Quality assessment was performed with the Coleman Methodology Score. Techniques were grouped as osteochondral allograft transplantation (OCA), osteochondral autograft transfer (OAT), chondrocyte cell-based therapy, bone marrow-based therapy, and scaffolds.

Results: A total of 59 articles were included. The mean Coleman Methodology Score was 71.8. There were 1937 lesions (1077 patellar, 390 trochlear, and 172 bipolar; 298 unspecified). The frequency of the procedures was as follows, in descending order: chondrocyte cell-based therapy (65.7%), bone marrow-based therapy (17.2%), OAT (8%), OCA (6.6%), and scaffolds (2.2%). When compared with the overall pooled lesion size (3.9 cm; 95% CI, 3.5-4.3 cm), scaffold (2.2 cm; 95% CI, 1.8-2.5 cm) and OAT (1.5 cm; 95% CI, 1.1-1.9 cm) lesions were smaller ( < .001), while chondrocyte cell-based therapy lesions were larger (4.7 cm; 95% CI, 4.1-5.3 cm; = .039). Overall, the instability pool was 11.9%, and the anatomic risk factors pool was 32.1%. Statistically significant improvement was observed on at least 1 patient-reported outcome in chondrocyte cell-based therapy (83%), OAT (78%), OCA (71%), bone marrow-based therapy (64%), and scaffolds (50%). There were no significant differences between any group and the overall pooled change in International Knee Documentation Committee score (30.2; 95% CI, 27.4-32.9) and Lysholm score (25.2; 95% CI, 16.9-33.5). There were no significant differences between any group and the overall pooled rate in minor complication rate (7.6%; 95% CI, 4.7%-11.9%) and major complication rate (8.3%; 95% CI, 5.7%-12.0%); however, OCA had a significantly greater failure rate (22.7%; 95% CI, 14.6%-33.4%) as compared with the overall rate (6.8%; 95% CI, 4.7%-9.5%).

Conclusion: PF cartilage restoration leads to improved clinical outcomes, with low rates of minor and major complications. There was no difference among techniques; however, failures were higher with OCA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0363546519886853DOI Listing
June 2020

Cartilage Restoration of Patellofemoral Lesions: A Systematic Review.

Cartilage 2019 Dec 17:1947603519893076. Epub 2019 Dec 17.

Clínica do Dragão, Espregueira-Mendes Sports Centre - FIFA Medical Centre of Excellence, Porto, Portugal.

Purpose: This study aimed to systematically analyze the postoperative clinical, functional, and imaging outcomes, complications, reoperations, and failures following patellofemoral cartilage restoration surgery.

Methods: This review was conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed, EMBASE, and Cochrane Library databases were searched up to August 31, 2018, to identify clinical studies that assessed surgical outcomes of patellofemoral cartilage restoration surgery. The Methodological Index for Non-Randomized Studies (MINORS) was used to assess study quality.

Results: Forty-two studies were included comprising 1,311 knees (mean age of 33.7 years and 56% males) and 1,309 patellofemoral defects (891 patella, 254 trochlear, 95 bipolar, and 69 multiple defects, including the patella or trochlea) at a mean follow-up of 59.2 months. Restoration techniques included autologous chondrocyte implantation (56%), particulated juvenile allograft cartilage (12%), autologous matrix-induced chondrogenesis (9%), osteochondral autologous transplantation (9%), and osteochondral allograft transplantation (7%). Significant improvement in at least one score was present in almost all studies and these surpassed the minimal clinically important difference threshold. There was a weighted 19%, 35%, and 6% rate of reported complications, reoperations, and failures, respectively. Concomitant patellofemoral surgery (51% of patients) mostly did not lead to statistically different postoperative outcomes.

Conclusion: Numerous patellofemoral restoration techniques result in significant functional improvement with a low rate of failure. No definitive conclusions could be made to determine the best surgical technique since comparative studies on this topic are rare, and treatment choice should be made according to specific patient and defect characteristics.

Level Of Evidence: Level IV, systematic review of level II to IV studies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1947603519893076DOI Listing
December 2019

When to Add Lateral Soft Tissue Balancing?

Sports Med Arthrosc Rev 2019 Dec;27(4):e25-e31

Brigham and Woman's Hospital, Harvard Medical School, Boston, MA.

Lateral patellofemoral (PF) soft tissue abnormalities range from excessive lateral PF tightness (lateral patellar compression syndrome, lateral patellar instability and arthritis), to excessive laxity (iatrogenic lateral PF soft tissue insufficiency postlateral release). The lateral soft tissue complex is composed of the iliotibial band extension to the patella, the vastus lateralis tendon, the lateral PF ligament, lateral patellotibial ligament, and lateral patellomeniscal ligament, with intimate connections between those structures. To identify lateral retinaculum tightness or insufficiency the most important tests are the patellar glide test and patellar tilt test. Imaging aids in that evaluation relying mostly on the patella position assessed by radiographs, computed tomography, and magnetic resonance imaging with referencing to the posterior femoral condyles. Lateral retinaculum lengthening (preferred) or release may be added when there is excessive lateral retinaculum tightness. A lengthening may be performed using a minimally invasive approach without compromising the lateral patella restraint. Lateral retinaculum repair or reconstruction is indicated when there is lateral retinaculum insufficiency. Lateral retinaculum surgery to balance the medial/lateral soft tissue restraints, improves patellar positioning and clinical results.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JSA.0000000000000268DOI Listing
December 2019

Concepts of the Distal Medial Patellar Restraints: Medial Patellotibial Ligament and Medial Patellomeniscal Ligament.

Sports Med Arthrosc Rev 2019 Dec;27(4):143-149

Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN.

The important medial patellar ligamentous restraints to lateral dislocation are the proximal group (the medial quadriceps tendon femoral ligament and the medial patellofemoral ligament) and the distal group [medial patellotibial ligament (MPTL) and medial patellomeniscal ligament (MPML)]. The MPTL patellar insertion is at inferomedial border of patella and tibial insertion is in the anteromedial tibia. The MPML originates in the inferomedial patella, right proximal to the MPTL, inserting in the medial meniscus. On the basis of anatomy and biomechanical studies, the MPTL and MPML are more important in 2 moments during knee range of motion: terminal extension, when it directly counteracts quadriceps contraction. In a systematic review on MPTL reconstructions 19 articles were included detailing the clinical outcomes of 403 knees. All were case series. Overall, good and excellent outcomes were achieved in >75% of cohorts in most studies and redislocations were <10%, with or without the association of the medial patellofemoral ligament. The MPTL is a relevant additional tool to proximal restraint reconstruction in select patient profiles; however, more definitive clinical studies are necessary to better define surgical indications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JSA.0000000000000269DOI Listing
December 2019

Anatomic Risk Factors for Focal Cartilage Lesions in the Patella and Trochlea: A Case-Control Study.

Am J Sports Med 2019 08 9;47(10):2444-2453. Epub 2019 Jul 9.

Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.

Background: Focal cartilage lesions in the patellofemoral (PF) joint are common. Several studies correlated PF risk factors with PF instability, anterior knee pain, and PF arthritis; however, there is a lack of evidence correlating those factors to PF focal cartilage lesions.

Purpose: To evaluate the influence of the anatomic PF risk factors in patients with isolated focal PF cartilage lesions.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: Patients with isolated PF focal cartilage lesions were included in the cartilage lesion group, and patients with other pathologies and normal PF cartilage were included in the control group. Multiple PF risk factors were accessed on magnetic resonance imaging scans: patellar morphology (patellar width, patellar thickness, and patellar angle), trochlear morphology (trochlear sulcus angle, lateral condyle index, and trochlear sulcus depth), patellar height (Insall-Salvati ratio and Caton-Deschamps index), axial patellar positioning (patellar tilt, angle of Fulkerson), and quadriceps vector (tibial tuberosity-trochlear groove distance).

Results: A total of 135 patients were included in the cartilage lesion group and 100 in the control group. As compared with the control group, the cartilage lesion group had a higher sulcus angle ( = .0007), lower trochlear sulcus depth ( < .0001), lower angle of Fulkerson ( < .0001), lower patellar width ( = .0003), and higher Insall-Salvati ratio ( < .0001). From the patients in the cartilage lesion group, 36% had trochlear dysplasia; 27.6%, patella alta; and 24.7%, abnormal patellar tilt. These parameters were more frequent in the cartilage lesion group ( < .0001). Trochlear lesions were more frequent in men, presented at an older age, and had fewer associated anatomic risk factors. Patellar lesions, conversely, were more frequent in women, presented at younger age, and were more closely associated with anatomic risk factors.

Conclusion: PF anatomic abnormalities are significantly more common in patients with full-thickness PF cartilage lesions. Trochlear dysplasia, patella alta, and excessive lateral patellar tilt are the most common correlated factors, especially in patellar lesions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0363546519859320DOI Listing
August 2019

A new device for patellofemoral instrumented stress-testing provides good reliability and validity.

Knee Surg Sports Traumatol Arthrosc 2020 Feb 28;28(2):389-397. Epub 2019 Jun 28.

Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, USA.

Purpose: To evaluate the reliability of an instrumented patellofemoral (PF) stress-testing-the Porto Patellofemoral Testing Device (PPTD)-and validate the instrumented assessment method comparing to manual physical examination.

Methods: Eight asymptomatic volunteers underwent bilateral PF-instrumented examination with the PPTD and magnetic resonance imaging (MRI) to assess intra-rater reliability of the instrumented assessment methodology. Six patients with unilateral PF instability underwent physical examination and PPTD concomitantly with MRI. Manual examination was performed by two blinded surgeons and compared with PPTD test. Ligament stiffness was calculated and compared between injured and non-injured lower limbs.

Results: PPTD showed a pre-determined and reproducible stress-force application with excellent intra-rater agreement (intra-class correlation coefficient 0.83-0.98). The manual exam was imprecise with variable examiner-dependent stress-force application. The PPTD resulted in greater lateral patellar translation (converted in quadrants) than manual exam for patients that have reached maximum translation force. Measurement of patellar position and displacement using PPTD was more accurate and precise than the visual estimation of translated quadrants by manual exam. Ligament stiffness curves showed no relevant changes in patellar displacement after 62 N.

Conclusion: The PPTD instrumented stress-testing is a valid device to quantify PF position and displacement with high intra-rater reliability, showing more accuracy, more precision and less variability than physical examination. This device provides an accurate and objective measure to quantify the patellar movement which can augment the physical examination procedures and assist clinicians in the management of decision-making and in the assessment of post-treatment outcomes of PF pathological conditions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00167-019-05601-4DOI Listing
February 2020

Accurate Reporting of Concomitant Procedures Is Highly Variable in Studies Investigating Knee Cartilage Restoration.

Cartilage 2019 Apr 11:1947603519841673. Epub 2019 Apr 11.

1 Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA.

Objective: Successful clinical outcomes following cartilage restoration procedures are highly dependent on addressing concomitant pathology. The purpose of this study was to document methods for evaluating concomitant procedures of the knee when performed with articular cartilage restoration techniques, and to review their reported findings in high-impact clinical orthopedic studies. We hypothesized that there are substantial inconsistencies in reporting clinical outcomes associated with concomitant procedures relative to outcomes related to isolated cartilage repair.

Design: A total of 133 clinical studies on articular cartilage repair of the knee were identified from 6 high-impact orthopedic journals between 2011 and 2017. Studies were included if they were primary research articles reporting clinical outcomes data following surgical treatment of articular cartilage lesions with a minimum sample size of 5 patients. Studies were excluded if they were review articles, meta-analyses, and articles reporting only nonclinical outcomes (e.g., imaging, histology). A full-text review was then used to evaluate details regarding study methodology and reporting on the following variables: primary cartilage repair procedure, and the utilization of concomitant procedures to address additional patient comorbidities, including malalignment, meniscus pathology, and ligamentous instability. Each study was additionally reviewed to document variation in clinical outcomes reporting in patients that had these comorbidities addressed at the time of surgery.

Results: All studies reported on the type of primary cartilage repair procedure, with autologous chondrocyte implantation (ACI) noted in 43% of studies, microfracture (MF) reported in 16.5%, osteochondral allograft (OCA) in 15%, and osteochondral autograft transplant (OAT) in 8.2%. Regarding concomitant pathology, anterior cruciate ligament (ACL) reconstruction (24.8%) and meniscus repair (23.3%) were the most commonly addressed patient comorbidities. A total of 56 studies (42.1%) excluded patients with malalignment, meniscus injury, and ligamentous instability. For studies that addressed concomitant pathology, 72.7% reported clinical outcomes separately from the cohort treated with only cartilage repair. A total of 16.5% of studies neither excluded nor addressed concomitant pathologies. There was a significant amount of variation in the patient reported outcome scores used among the studies, with the majority of studies reporting International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcomes Score (KOOS) in 47.2% and 43.6% of articles, respectively.

Conclusions: In this study on knee cartilage restoration, recognition and management of concomitant pathology is inadequately reported in approximately 28% of studies. Only 30% of articles reported adequate treatment of concomitant ailments while scoring their outcomes using one of a potential 18 different scoring systems. These findings highlight the need for more standardized methods to be applied in future research with regard to inclusion, exclusion, and scoring concomitant pathologies with regard to treatment of cartilage defects in the knee.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1947603519841673DOI Listing
April 2019

The Role of Bone Marrow Aspirate Concentrate for the Treatment of Focal Chondral Lesions of the Knee: A Systematic Review and Critical Analysis of Animal and Clinical Studies.

Arthroscopy 2019 06 11;35(6):1860-1877. Epub 2019 Mar 11.

Jefferson 3B Orthopaedics, Philadelphia, Pennsylvania, U.S.A.

Purpose: To summarize currently available data regarding the use of bone marrow aspirate concentrate (BMAC) for the treatment of focal chondral lesions of the knee in experimental animal models and human clinical studies.

Methods: A systematic review searching for the terms "(bone marrow)" AND "(aspirate OR concentrate)" AND "(cartilage OR chondral OR osteochondral)" was performed in the databases PubMed, Cochrane Central Register of Controlled Trials, and Google Scholar regarding the use of BMAC for the treatment of focal chondral lesions of the knee. The inclusion criteria were animal and clinical studies published in English that used autologous BMAC to treat focal chondral defects of the knee. We excluded studies that evaluated nonconcentrated preparations of bone marrow aspirate or preparations that were culture expanded.

Results: A total of 23 studies were included: 10 studies performed in animal models and 13 human clinical studies. Animal studies showed inconsistent outcomes regarding the efficacy of BMAC for the treatment of chondral or osteochondral lesions, assessed by gross morphology, second-look arthroscopy, magnetic resonance imaging, histology, immunohistochemistry, mechanical testing, and micro-tomography. Chondral defect filling was achieved with fibrocartilage or "hyaline-like" cartilage. Cells present in BMAC did not meet the criteria to be characterized as mesenchymal stem cells according to the International Society for Cell Therapy because freshly isolated cells failed to show tri-lineage differentiation. Overall, all clinical studies, independent of the study group or level of evidence, reported improved clinical outcomes and higher macroscopic, magnetic resonance imaging, and histology scores. Comparative trials favored BMAC over microfracture and reported equivalent outcomes between BMAC and matrix-induced autologous chondrocyte implantation. However, clinical studies were scant and showed low scientific rigor, poor methodologic quality, and low levels of evidence on average.

Conclusions: Although clinical success in short-term and midterm applications has been suggested for the application of BMAC for the restoration of cartilage defects in lesions of the knee, current study designs are generally of low scientific rigor. In addition, clinical applications of this technology in animal model investigations have shown inconsistent outcomes. Thus, clinicians should apply this technology cautiously.

Level Of Evidence: Level IV, systematic review of Level II, III, and IV evidence studies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arthro.2018.11.073DOI Listing
June 2019

Articular Cartilage Lesion Characteristic Reporting Is Highly Variable in Clinical Outcomes Studies of the Knee.

Cartilage 2019 07 6;10(3):299-304. Epub 2018 Feb 6.

3 Department of Orthopedic Surgery, University of Missouri Health, Columbia, MO, USA.

Objective: The purpose of this study was to investigate the degree of standardized evaluation and reporting of cartilage lesion characteristics in high-impact clinical studies for symptomatic lesions of the knee. We hypothesized that there are significant inconsistencies in reporting these metrics across orthopedic literature.

Design: A total of 113 clinical studies on articular cartilage restoration of the knee were identified from 6 high-impact orthopedic journals between 2011 and 2016. Full-text review was used to evaluate sources for details on study methodology and reporting on the following variables: primary procedure, location, size, grade, and morphology of cartilage lesions.

Results: All studies reported on the type of primary cartilage procedure and precise lesion location(s). Approximately 99.1% reported lesion morphology (chondral, osteochondral, mixed). For lesion size, 32.7% of articles did not report how size was measured and 11.5% did not report units. The lesion sizing method was variable, as 27.4% used preoperative magnetic resonance imaging to measure/report lesion size, 31.0% used arthroscopy, and 8.8% used both. The majority of studies (83.2%) used area to report size, and 5.3% used diameter. Formal grading was not reported in 17.7% of studies. Only 54.8% of studies reported depth when sizing osteochondral defects.

Conclusions: Recent literature on cartilage restoration provides adequate information on surgical technique, lesion location, and morphology. However, there is wide variation and incomplete reporting on lesion size, depth, and grading. Future clinical studies should include these important data in a consistent manner to facilitate comparison among surgical techniques.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1947603518756464DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585291PMC
July 2019

Reconstruction of the medial patellotibial ligament results in favorable clinical outcomes: a systematic review.

Knee Surg Sports Traumatol Arthrosc 2018 Oct 17;26(10):2920-2933. Epub 2018 Jan 17.

Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA.

Purpose: The medial patellotibial ligament (MPTL), the medial patellofemoral ligament (MPFL), and the medial patellomeniscal ligament (MPML) support the stability of the patellofemoral joint. The purpose of this systematic review was to report the surgical techniques and clinical outcomes of the repair or reconstruction of the MPTL in isolation or concomitant with the MPFL and/or other procedures.

Methods: A systematic review of the literature was conducted. Inclusion criteria were articles in the English language that reported clinical outcomes of the reconstruction of the MPTL in isolation or in combination with the MPFL and/or other procedures. Included articles were then cross-referenced to find additional journal articles not found in the initial search. The methodological quality of the articles was determined using the Coleman Methodology Score.

Results: Nineteen articles were included detailing the clinical outcomes of 403 knees. The surgical procedures described included hamstrings tenodesis with or without other major procedures, medial transfer of the medial patellar tendon with or without other major procedures and the reconstruction of the MPTL in association with the MPFL. Overall, good and excellent outcomes were achieved in > 75% of cohorts in most studies and redislocations were < 10%, with or without the association of the MPFL. An exception was one study that reported a high failure rate of 82%. Results were consistent across different techniques. The median CMS for the articles was 66 out of 100 (range 30-85).

Conclusion: Across different techniques, the outcomes are good with low rates of recurrence, with one article reporting a high rate of recurrence. Quality of the articles is variable, from low to high. Randomized control trials are needed for a better understanding of the indications, surgical techniques, and clinical outcomes. This systematic review suggests that the reconstruction of the MPTL leads to favorable clinical outcomes and supports the role of the procedure as a valid surgical patellar stabilization procedure.

Level Of Evidence: IV: systematic review of level I-IV studies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00167-018-4833-6DOI Listing
October 2018

Comparison of Lateral Retinaculum Release and Lengthening in the Treatment of Patellofemoral Disorders.

Am J Orthop (Belle Mead NJ) 2017 Sep/Oct;46(5):224-228

Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY.

For lateral retinaculum (LR) tightness, release or lengthening is the indicated surgical correction. LR release (LRR) or lengthening (LRL) may be a primary treatment for painful lateral compression syndrome or as an adjunct treatment in the setting of patellofemoral instability. Although it is challenging, assessment of the soft-tissue balance between the medial restraint (the medial patellofemoral ligament) and the lateral restraint (the lateral retinaculum) is fundamental to a good outcome. LRR and LRL are effective in the treatment of patellofemoral disorders in which lateral tightness is part of the pathology. Understanding the indications for treatment is essential. Although both procedures have standard postoperative complications, LRL as an alternative to LRR maintains lateral soft-tissue integrity and avoids iatrogenic medial patellar laxity, which is a serious complication with LRR. For these reasons, we recommend using LRL to address LR tightness in patellofemoral disorders.
View Article and Find Full Text PDF

Download full-text PDF

Source
June 2018

Cartilage Restoration in the Patellofemoral Joint.

Am J Orthop (Belle Mead NJ) 2017 Sep/Oct;46(5):217-222

OrthoIndy Hospital, Greenwood, IN.

Although patellofemoral (PF) chondral lesions are common, the presence of a cartilage lesion does not implicate a chondral lesion as the sole source of pain. As attributing PF pain to a chondral lesion is "diagnosis by exclusion," thorough assessment of all potential structural and nonstructural sources of pain is the key to proper management. Commonly, multiple factors contribute to a patient's symptoms. Each comorbidity must be identified and addressed, and the cartilage lesion treatment determined. Comprehensive preoperative assessment is essential and should include a thorough "core-to-floor" physical examination. Treatment of symptomatic chondral lesions in the PF joint requires specific technical and postoperative management, which differs significantly from management involving the tibiofemoral joint. Attending to all these details makes the outcomes of PF cartilage treatment reproducible. These outcomes may rival those of chondral repair in the tibiofemoral joint.
View Article and Find Full Text PDF

Download full-text PDF

Source
June 2018

Patellofemoral Cartilage Restoration: Indications, Techniques, and Outcomes of Autologous Chondrocytes Implantation, Matrix-Induced Chondrocyte Implantation, and Particulated Juvenile Allograft Cartilage.

J Knee Surg 2018 Mar 16;31(3):212-226. Epub 2017 Oct 16.

Cartilage Repair Center, Brigham and Women's Hospital, Boston, Massachusetts.

Focal chondral defects are common in the patellofemoral (PF) joint and can significantly impair the quality of life. The autologous chondrocytes implantation (ACI) technique has evolved over the past 20 years: the first-generation technique involves the use of a periosteal patch, the second-generation technique (collagen-cover) uses a type I/III collagen membrane, and the newest third-generation technique seeds and cultivates the collagen membrane with chondrocytes prior to implantation and is referred to as matrix-induced autologous chondrocyte implantation. Particulated juvenile allograft cartilage (PJAC) (DeNovo NT) is minced cartilage allograft from juvenile donors. A thorough physical exam is important, especially for issues affecting the PF joint, to isolate the location and source of pain, and to identify associated pathologies. Imaging studies allow further characterization of the lesions and identification of associated pathologies and alignment. Conservative management should be exhausted before proceeding with surgical treatment. Steps of surgical treatment are diagnostic arthroscopy and biopsy, chondrocytes culture and chondrocyte implantation for the three generations of ACI, and diagnostic arthroscopy and implantation for PJAC. The techniques and their outcomes will be discussed in this article.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0037-1607294DOI Listing
March 2018

Medial Patellofemoral Ligament, Medial Patellotibial Ligament, and Medial Patellomeniscal Ligament: Anatomic, Histologic, Radiographic, and Biomechanical Study.

Arthroscopy 2017 Oct 26;33(10):1862-1873. Epub 2017 Jun 26.

Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of Sao Paulo, Sao Paulo, Brazil.

Purpose: To describe the anatomy (quantitative macroscopic and histologic), radiographic parameters of the insertions, and biomechanical characteristics of the medial ligamentous restrictors of the patella (medial patellofemoral ligament [MPFL], medial patellotibial ligament [MPTL], and medial patellomeniscal ligament [MPML]) in cadaveric knees. Because the MPTL and the MPML are not as well known as the MPFL, they were the focus of this study.

Methods: MPFLs, MPTLs, and MPMLs from 9 knees were dissected. Histologic evaluations were conducted. Length, width, and insertion relations with anatomic references were determined. Metallic spheres were introduced into the insertion points of each ligament, and anteroposterior and lateral radiographs were taken. The distances of the insertions from the baselines were measured on radiographs. Tensile tests of the ligaments were performed.

Results: All the samples showed dense connective tissue characteristic of ligaments. The MPTL was inserted into the proximal tibia (13.7 mm distal to the joint line) and in the distal end of the patella (3.6 mm proximal to the distal border). The MPTL had a length of 36.4 mm and a width of 7.1 mm. The MPML was inserted into the medial meniscus and distally in the patella (5.7 mm proximal to the distal border). Per radiography, on the anteroposterior view, the tibial insertion of the MPTL was 9.4 mm distal to the joint line and in line with the medial border of the medial spine. On the lateral view, the patellar insertions of the MPTL and MPML were 4.8 and 6.6 mm proximal to its distal border, respectively. The MPTL was stiffer than the MPFL (17.0 N/mm vs 8.0 N/mm, P = .024) and showed less deformation in the maximum tensile strength (8.6 mm vs 19.3 mm, P = .005).

Conclusions: The MPTL inserts into the proximal tibia and into the distal pole of the patella. The MPML inserts into the medial meniscus and into the distal pole of the patella. They present with identifiable anatomic and radiographic parameters. Grafts commonly used for ligament reconstructions should be adequate for reconstruction of the MPTL.

Clinical Relevance: The study contributes to the anatomic, radiographic, and biomechanical knowledge of the MPTL to improve the outcomes of its reconstruction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arthro.2017.04.020DOI Listing
October 2017

Autologous Chondrocytes and Next-Generation Matrix-Based Autologous Chondrocyte Implantation.

Clin Sports Med 2017 Jul;36(3):525-548

Cartilage Repair Center, Brigham and Women's Hospital, Chestnut Hill, MA, USA. Electronic address:

Focal chondral defects of the knee are common and can significantly impair quality of life. The autologous chondrocyte implantation technique has evolved over the past 20 years; the newest third-generation technique is matrix-induced autologous chondrocyte implantation. Physical examination is important to characterize location and source of pain and identify associated injuries. Imaging studies allow characterization of the lesions, identification of associated lesions, and alignment. Conservative measures should be exhausted before proceeding with surgical treatment. Steps of surgical treatment are diagnostic arthroscopy and biopsy, chondrocyte culture, and chondrocyte implantation. The techniques and their outcomes are discussed in this article.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.csm.2017.02.008DOI Listing
July 2017

The Effect of Mechanical Varus on Anterior Cruciate Ligament and Lateral Collateral Ligament Stress: Finite Element Analyses.

Orthopedics 2016 Jul 27;39(4):e729-36. Epub 2016 Apr 27.

The current study analyzed changes in anterior cruciate ligament (ACL) and lateral collateral ligament stress as a result of mechanical varus. In an exploratory pilot study, progressive mechanical varus was introduced to a male finite element model of the lower limb at different knee flexion angles. Nine situations were analyzed (combinations of 0°, 30°, and 60° knee flexion and 0°, 5°, and 10° varus). The ACL stress was measured via changes in section force, von Mises stress, and fiber stress. Lateral collateral ligament stress was measured via changes in section force. For all 3 measures of the ACL, maximum stress values were found in extension, stress decreased with flexion, and the effect of varus introduction was most significant at 30° flexion. With 60° flexion, varus introduction produced a decrease in section force and von Mises stress and a small increase in fiber stress. In all situations and stress measures except fiber stress at 60° flexion, stress was concentrated at the posterolateral bundle. For the lateral collateral ligament, the introduction of 5° and 10° varus caused an increase in section force at all degrees of flexion. Stress in the ligament decreased with flexion. Mechanical varus of less than 10° was responsible for increased ACL stress, particularly at 0° and 30° knee flexion, and for increased lateral collateral ligament stress at all degrees of flexion. Stress was mostly concentrated on the posterolateral bundle of the ACL. [Orthopedics. 2016; 39(4):e729-e736.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3928/01477447-20160421-02DOI Listing
July 2016

Why are bone and soft tissue measurements of the TT-TG distance on MRI different in patients with patellar instability?

Knee Surg Sports Traumatol Arthrosc 2017 Oct 31;25(10):3053-3060. Epub 2016 Mar 31.

Department of Orthopaedics and Traumatology, Institute of Orthopaedics and Traumatology, University of São Paulo, Ovídio Pires de Campos St, 333, 2nd Floor, Cerqueira César, São Paulo, SP, 5403-010, Brazil.

Purpose: To determine whether the tibial tuberosity-to-trochlear groove distance (TT-TG) and patellar tendon-to-trochlear groove distance (PT-TG) are equal, whether the bony and cartilaginous points coincide in the trochlea, and whether the insertion of the PT coincides with the most anterior point of the TT in patients with patellar instability.

Methods: Fifty-three MRI scans of patients with patellar instability were examined. TT-TG and PT-TG were measured by three examiners in 31 knees. Additionally, the bone-cartilage distance in the trochlea [trochlear cartilage to trochlear bone (TC-TB)] and the distance between the mid-point of the PT insertion and the most anterior point of the TT (PT-TT) were measured by one examiner. The intraclass correlation coefficient was used to evaluate the reliability of the measurements between the three examiners. The relationships between the measurements were determined, the means of the measurements were calculated, and the correlations between PT-TG and TT-TG, PT-TT, and TC-TB were assessed.

Results: The ICC was above 0.8. PT-TG was 3.7 mm greater than TT-TG. The TC and TB coincided in 73 % of cases, and the mean TC-TB was 0.3 mm. The PT was lateral to the TT in 94 % of the cases, and the mean PT-TT was 3.4 mm. The Pearson's correlation coefficients between PT-TG and TT-TG, PT-TT, and TC-TB were 0.946, 0.679, and 0.199, respectively.

Conclusion: TT-TG underestimated PT-TG, primarily due to the lateralization of the PT insertion relative to the most anterior point of the TT.

Clinical Relevance: our study shows that in patients with patellar instability, there are differences in the absolute values of TT-TG and PT-TG, as previously reported for patients without patellar instability. Hence, normal cut-off values based on case-control studies of TT-TG cannot be equivalently used when measuring PT-TG to indicate TT medialization in patients with patellar instability. It is also important to note that the clinical outcomes cannot be directly compared between patients evaluated using TT-TG versus PT-TG measurements.

Level Of Evidence: III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00167-016-4095-0DOI Listing
October 2017

Patellar Tendon-Trochlear Groove Angle Measurement: A New Method for Patellofemoral Rotational Analyses.

Orthop J Sports Med 2015 Sep 2;3(9):2325967115601031. Epub 2015 Sep 2.

Institute of Orthopedics and Traumatology of the Clinical Hospital, Medical School, University of São Paulo, São Paulo, Brazil.

Background: The tibial tubercle-trochlear groove (TT-TG) is used as the gold standard for patellofemoral malalignment.

Purpose: To assess 3 patellar tendon-trochlear groove (PT-TG) angle measurement techniques and the PT-TG distance measurement (tendinous cartilaginous TT-TG) as predictors of patellar instability.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: Three PT-TG angle measurements and the PT-TG distance were measured in 82 participants with patellar instability and 100 controls using magnetic resonance imaging (MRI). Measurement landmarks were the line tangent to the posterior femoral condyles, the deepest point of the trochlea, the transepicondylar line, and the patellar tendon center. All measurements were recorded once by 1 examiner, and the measurements were recorded twice by 2 examiners in a random group of 100 knees. Mean values and standard deviations (SDs) were obtained. Normality cutoff values were defined as 2 and 3 SDs above the mean in the control group. The sensitivity, specificity, and positive likelihood ratio (LR+) were calculated. Inter- and intrarater reliability were assessed based on the intraclass correlation coefficient (ICC).

Results: The measurements from the patellar instability and control groups, respectively, for angle 1 (16.4° and 8.4°), angle 2 (31° and 15.6°), angle 3 (30.8° and 15.7°), PT-TG distance (14.5 and 8.4 mm), and patellar tilt (21.1° and 7.5°) were significantly different (P < .05). The angle measurements showed greater sensitivity, specificity, and LR+ than the PT-TG distance. Inter- and intrarater ICC values were >0.95 for all measurements.

Conclusion: The PT-TG angle and the PT-TG distance are reliable and are different between the patellar instability and control groups. PT-TG angles are more closely associated with patellar instability than PT-TG distance.

Clinical Relevance: PT-TG angle measurements show high reliability and association with patellar instability and can aid in the assessment of extensor mechanism malalignment. A more sensitive and specific evaluation of extensor mechanism malalignment can improve patient care by preventing both redislocation and abnormal tracking of overlooked malalignment and complications of unnecessary tibial tuberosity medialization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967115601031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4622295PMC
September 2015