BACKGROUND: "Why try to convert other collagen substitutes into ligament if the original can be preserved?" said Sherman1. Nowadays, reconstruction became the gold standard treatment for ACL injuries. Despite current treatment, secondary knee osteoarthritis has been described in more than 70% of the injured patients after 10 years follow up.2 Recent studies have reported that tears involving the proximal ACL have an intrinsic healing response. This response has been compared to the one observed in MCL injuries.3, 4 OBJECTIVE: The aim of this study is to initiate a scientific analysis of our experience in patients diagnosed with an acute, proximal ACL tear treated with a primary repair arthroscopic technique. We suggest the creation of a symposium that reconsiders the ACL repair as a tool for treatment, on a selected subset of patients. METHODS: We analyzed retrospectively the data of 12 consecutive patients diagnosed clinically and radiologically (MRI) with proximal ACL tears in our clinic. The inclusion criteria were: proximal ACL tear (type 1 tear in Sherman´s classification), good remaining ACL quality tissue and less than 3 months from injury. The mean age at time of surgery was 33 years (16 to 55). Patients included in this study are athletes either at an amateur or professional level. The technique consists of an anatomical reinsertion of native ACL by reinforcing the anteromedial and posterolateral bundles of the ACL with a series of high strength locking Bunnell-type sutures, moving up the ligament from distal to proximal with an arthroscopic suture passer. The normal ACL insertional footprint within the notch is then debrided to provide a bleeding surface for healing. Finally, the torn ligament is opposed to the native footprint using 1-2 absorbable anchors that recreate the anatomic bundle insertional sites of the native ACL. RESULTS: Associated injuries were found in 7 of the 12 patients, these included 4 knees with lateral and 1 with medial meniscal tear which were repaired in the same procedure. Also, one knee had a medial bucket handle tear, partial meniscectomy was performed, and one knee with a combined ACL/MCL injury in which the MCL was simultaneously repaired. In our ongoing series, were excluded patients that had sustained complex knee injuries with multi-ligament damage (except ACL/MCL injuries), those with ACL re-ruptures, and previous knee surgery with cartilage repair procedures. Validated functional outcomes scores were collected after a mean follow up of 20 months (14-26). For the IKDC subjective score 11 of 12 patients rated their knees as normal or nearly normal. Lachman and Pivot Shift was negative in all patients. Lysholm score postoperatively averaged 93.5 ± 7; preoperatively 48 ± 7. Tegner preinjury 7.5 ± 1.2 postinjury: 7 ± 1.4. The KT-1000 knee arthrometer, objectively measured < 3mm of anterior tibial motion relative to the femur in the injured knee compared to the non-injured knee at all levels of force, including manual max tests, in all patients included in the study. No comp...
Background: A relatively new technology for the treatment of high grade articular cartilage lesions is the implantation of particulated articular cartilage obtained from a juvenile allograft donor (PJAC).1-2 Previous studies have reported the ability of juvenile chondrocytes to migrate from cartilage explants after being secured in a cartilage defect.3 There is little in the literature to use as a reference with respect to the use of PJAC for high grade articular cartilage lesion of the lateral femoral condyle after a failure of treatment with a microfracture in the high level athlete. Objective: The aim of this report is to describe the technique of PJAC transplantation for the treatment of chondral lesions of the lateral femoral condyle and to report the short term outcomes in the high performance athlete. Methods: We present a case report of two patients who were treated in our clinic in December 2014. Case 1: 16 year old female Division 1 university soccer player, who one year prior to our index surgery underwent microfractures of a symptomatic lateral femoral condyle articular cartilage lesion without relief. Cae 2: 29 year old male professional tennis player (case 2) with a recurrent, symptomatic chondral defect on the lateral femoral condyle. The player had undergone multiple arthroscopic procedures on the same knee following an injury sustained while playing in the Australian Open, including a surgery 8 months prior to our index operation that had included lateral meniscal tear repair and microfractures. PJAC procedure consists of a minimal debridement and chondroplasty, performed arthroscopically. For these central lateral femoral condyle lesions, a mini-arthrotomy is created along the lateral parapatellar longitudinal axis over a length of about 3 cm. With the chondral defect localized and prepared, a thin fresh layer of fibrin glue is then applied. The PJAC graft is equally distributed in the defect with space in between the fragments so as not over-fill the defect. Then, a new fibrin glue layer is placed to cover the graft. The overall construct remains just below the level of the normal articular surface. The knee is cycled through the range of motion to ensure that the tissue construct is stable. We present images of the cartilage defect after debridement and the allograft implantation procedure. In addition we will submit an instructional video performed on a knee specimen. Results: Outcomes measured were: IKDC, Lysholm, and Tegner knee scores together with arc of motion of the joint. After 28 months follow up, patients had gained complete range of motion and significantly decreased pain. Improvement for each outcome measure used is reported. Conclusions: PJAC transplantation offers pain relief and improved short term outcomes in high level performance athletes. Both of our patients are back to practicing their sport with notable improvement in symptoms. No complications have been noted. Long-term data is not yet available. References: Am J Farr J, Tabet SK, Margerrison E, Cole BJ. Clinical, Radiographic, and Histological Outcomes After Cartilage Repair With Particulated Juvenile Articular Cartilage: A 2-Year Prospective Study. Sports Med. 2014 Jun;42(6):1417-25. Saltzman BM, Lin J, Lee S. Particulated Juvenile Articular Cartilage Allograft Transplantation for Osteochondral Talar Lesions. Cartilage. 2017 Jan;8(1):61-72. Arshi A, Wang D, Jones KJ. Combined Particulated Juvenile Cartilage Allograft Transplantation and Medial Patellofemoral Ligament Reconstruction for Symptomatic Chondral Defects in the Setting of Recurrent Patellar Instability. Arthrosc Tech. 2016 Oct 10;5(5)
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