Background. Full-thickness cartilage lesions of the patella represent a common source of pain and dysfunction. Previously reported surgical treatment options include marrow stimulation, cell-based treatments, and osteochondral transfer. Minced juvenile allograft cartilage is a novel treatment option that allows for a single stage approach for these lesions. Hypothesis. Particulated juvenile allograft cartilage (PJAC) for the treatment of chondral defects of the patella would offer acceptable lesion fill rates, mature over time, and not be associated with any negative biologic effects on the surrounding tissue. Methods. A retrospective chart review of prospectively collected data was conducted to identify consecutive patients who were treated with PJAC for a full thickness symptomatic cartilage lesion. Qualitative (fast spin echo) and quantitative (T2 mapping) magnetic resonance imaging (MRI) was undertaken at the 6-, 12-, and 24-month postoperative mark. Numerous patient, lesion, and graft specific factors were assessed against MRI scores and percent defect fill of the graft. Graft maturation over time was also assessed. Results. Forty-five patients total were included in the study. Average age at the time of surgery was 26.5 years (range 13-45 years), average lesion size was 208 mm 2 (range 4-500 mm 2 ), and average donor age was 49.5 months (range 3-120 months). Sixty percent of the patients were female, while 93% of all patients underwent a concomitant procedure at the time of the index operation. Six-month MRI findings revealed that no patient-, graft-, or donor-specific factors correlated with MR scores, and 82% of the knees demonstrated good to excellent fill. Twelve-month MRI findings revealed that T2 relaxation times of deep graft demonstrated negative correlation with patient age (P = 0.049) and donor age (P = 0.006), the integration zone showed a negative correlation with donor age (P = 0.026). In all, 85% of patients at 12 months displayed good to moderate fill of the graft. At 24 months, patient age demonstrated negative correlation with average T2 relaxation times of the deep and superficial graft (P = 0.005; P = 0.0029) and positive correlation with the superficial zone of the adjacent cartilage (P = 0.001). Donor age showed negative correlation with grayscale score (P = 0.004) and T2 relaxation times at deep integration zone (P = 0.018). T2 relaxation times of deep and superficial graft and integration zone improved over time (P < 0.001) and between each time point.Conclusions. Particulated juvenile allograft tissue appears to be an acceptable reconstructive option for full-thickness cartilage lesions of the patella, offering satisfactory tissue defect fill at 6, 12, and 24 months after surgery. Imaging of the repaired cartilage demonstrates progressive graft maturation over time.
Background: Medial patellofemoral ligament (MPFL) reconstruction is the treatment of choice for recurrent patellar instability in the skeletally immature patient. Avoiding the open physes during anatomic MPFL reconstruction is a challenge in this population. Purpose: To describe a novel method using magnetic resonance imaging (MRI) to determine the distance from the Schöttle point to the medial distal femoral physis among skeletally immature individuals with patellar instability. Study Design: Descriptive laboratory study. Methods: Preoperative MRI scans were analyzed from 34 patients with open distal femoral physes and lateral patellar instability. With the multiplanar reconstruction mode on a picture archiving and communication system (PACS), the location of the Schöttle point was determined according to previously reported distances from the posterior femoral cortical line and the posterior origin of the medial femoral condyle. This location was then extrapolated to the most medial sagittal slice on MRI showing the medial distal femoral physis. The distance was measured from this point to the most distal aspect of the physis. Results: The mean age of the study cohort was 13.6 years (range, 10.6-15.7 years); there were 13 males and 21 females. The mean distance from the medial distal femoral physis to the Schöttle point was 7.27 ± 1.78 mm. The Schöttle point was distal to the medial distal femoral physis in all cases. There was no significant correlation between age and mean distance in either the overall study population ( r = 0.046, P = .798) or when stratified by sex (females, P = .629; males, P = .089). The distance between the Schöttle point and the medial distal femoral physis was shorter for females than for males (6.51 vs 7.71 mm, P = .043). After adjustment for age, females on average were 1.31 mm closer to the Schöttle point than were males ( B = –1.31, P = .041). Conclusion: This technique can be used to determine the distance between the medial distal femoral physis and the Schöttle point. The Schöttle point was distal to the physis in all patients, and it was closer to the physis in skeletally immature females compared with age-matched males. Clinical Relevance: The long-term repercussions of improperly placed MPFL reconstruction include recurrent patellar instability, increased patellofemoral contact pressures and overtensioning of the ligament, and possibly patellofemoral arthritis. The current technique can be used preoperatively to determine the appropriate safe distance for drilling a socket distal to the physis.
Purpose: To report changes in outcomes for these 3 treatment options for meniscal root tears. Methods: We systematically searched databases including PubMed, SCOPUS, and ScienceDirect for relevant articles. Criteria from the National Heart, Lung, and Blood Institute was used for a quality assessment of the included studies. A meta-analysis was performed to analyze changes in outcomes for meniscal repair. Results: Nineteen studies, 12 level III and 7 level IV, were included in this systematic review, with a total of 1086 patients. Conversion to total knee arthroplasty (TKA) following partial meniscectomy ranged from 11% to 54%, 31% to 35% for nonoperative, conservative treatment, and 0% to 1% for meniscal repair. Studies comparing repair with either meniscectomy or conservative treatment found greater improvement and slower progression of KellgreneLawrence grade with meniscal repair. A meta-analysis of the studies included in the systematic review using forest plots showed repair to have the greatest mean difference for functional outcomes (International Knee Documentation Committee and Lysholm Activity Scale) and the lowest change in follow-up joint space. Conclusions: In patients who experience meniscal root tears, meniscal repair may provide the greatest improvement in function and lowest risk of conversion to TKA when compared with partial meniscectomy or conservative methods. Partial meniscectomy appears to provide no benefit over conservative treatment, placing patients at a high risk of requiring TKA in the near future. However, future high-quality studiesdboth comparative studies and randomized trialsdare needed to draw further conclusions and better impact treatment decision-making. Level of Evidence: Level IV, systematic review of level III and level IV evidence
Osteotomy of the tibial tubercle is a versatile procedure that can be utilized for several common pathologies about the patellofemoral joint. Most commonly, tuberosity transfer is employed for the treatment of patellar instability or symptomatic overload of the patella. The osteotomy can be combined with soft tissue realignment procedures or cartilage reconstructive techniques. A precise understanding of the surgical anatomy and the biomechanics of the patellofemoral articulation is essential for producing a successful outcome during surgery. Tailoring the direction of transfer to the pathoanatomy of each patient is critical for producing a durable and lasting result following a tibial tubercle osteotomy. When evaluating a patient for a possible transfer, a thorough history and physical evaluation must be undertaken, along with imaging to the patellofemoral joint. Several useful advanced imaging techniques can also be used to guide the surgeon toward the most appropriated osteotomy for the patient. The purpose of this article is to review the indications for performing a tibial tubercle osteotomy, and highlighting the various techniques for transfer.
Background: Understanding specific risk profiles for each patient and their propensity to experience clinically meaningful improvement after anterior cruciate ligament reconstruction (ACLR) is important for preoperative patient counseling and management of expectations. Purpose: To develop machine learning algorithms to predict achievement of the minimal clinically important difference (MCID) on the International Knee Documentation Committee (IKDC) score at a minimum 2-year follow-up after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: An ACLR registry of patients from 27 fellowship-trained sports medicine surgeons at a large academic institution was retrospectively analyzed. Thirty-six variables were tested for predictive value. The study population was randomly partitioned into training and independent testing sets using a 70:30 split. Six machine learning algorithms (stochastic gradient boosting, random forest, neural network, support vector machine, adaptive gradient boosting, and elastic-net penalized logistic regression [ENPLR]) were trained using 10-fold cross-validation 3 times and internally validated on the independent set of patients. Algorithm performance was assessed using discrimination, calibration, Brier score, and decision-curve analysis. Results: A total of 442 patients, of whom 39 (8.8%) did not achieve the MCID, were included. The 5 most predictive features of achieving the MCID were body mass index ≤27.4, grade 0 medial collateral ligament examination (compared with other grades), intratunnel femoral tunnel fixation (compared with suspensory), no history of previous contralateral knee surgery, and achieving full knee extension preoperatively. The ENPLR algorithm had the best relative performance (C-statistic, 0.82; calibration intercept, 0.10; calibration slope, 1.15; Brier score, 0.068), demonstrating excellent predictive ability in the study’s data set. Conclusion: Machine learning, specifically the ENPLR algorithm, demonstrated good performance for predicting a patient’s propensity to achieve the MCID for the IKDC score after ACLR based on preoperative and intraoperative factors. The femoral tunnel fixation method was the only significant intraoperative variable. Range of motion and medial collateral ligament integrity were found to be important physical examination parameters. Increased body mass index and prior contralateral surgery were also significantly predictive of outcome.
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