Background: There is currently no optimal method for cartilage restoration in large, full-thickness cartilage defects in older patients. Purpose: To determine whether implantation of a composite of allogeneic umbilical cord blood–derived mesenchymal stem cells and 4% hyaluronate (UCB-MSC-HA) will result in reliable cartilage restoration in patients with large, full-thickness cartilage defects and whether any clinical improvements can be maintained up to 5 years postoperatively. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A randomized controlled phase 3 clinical trial was conducted for 48 weeks, and the participants then underwent extended 5-year observational follow-up. Enrolled were patients with large, full-thickness cartilage defects (International Cartilage Repair Society [ICRS] grade 4) in a single compartment of the knee joint, as confirmed by arthroscopy. The defect was treated either with UCB-MSC-HA implantation through mini-arthrotomy or with microfracture. The primary outcome was proportion of participants who improved by ≥1 grade on the ICRS Macroscopic Cartilage Repair Assessment (blinded evaluation) at 48-week arthroscopy. Secondary outcomes included histologic assessment; changes in pain visual analog scale (VAS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and International Knee Documentation Committee (IKDC) score from baseline; and adverse events. Results: Among 114 randomized participants (mean age, 55.9 years; 67% female; body mass index, 26.2 kg/m2), 89 completed the phase 3 clinical trial and 73 were enrolled in the 5-year follow-up study. The mean defect size was 4.9 cm2 in the UCB-MSC-HA group and 4.0 cm2 in the microfracture group ( P = .051). At 48 weeks, improvement by ≥1 ICRS grade was seen in 97.7% of the UCB-MSC-HA group versus 71.7% of the microfracture group ( P = .001); the overall histologic assessment score was also superior in the UCB-MSC-HA group ( P = .036). Improvement in VAS pain, WOMAC, and IKDC scores were not significantly different between the groups at 48 weeks, however the clinical results were significantly better in the UCB-MSC-HA group at 3- to 5-year follow-up ( P < .05). There were no differences between the groups in adverse events. Conclusion: In older patients with symptomatic, large, full-thickness cartilage defects with or without osteoarthritis, UCB-MSC-HA implantation resulted in improved cartilage grade at second-look arthroscopy and provided more improvement in pain and function up to 5 years compared with microfracture. Registration: NCT01041001, NCT01626677 (ClinicalTrials.gov identifier).

PurposeThe purpose of this study was to report the results of anatomic single bundle anterior cruciate ligament (ACL) reconstruction by the two anteromedial portal method.Materials and MethodsWe evaluated the clinical results in 33 patients with ACL rupture who were treated by anatomic ACL reconstruction using the two anteromedial portal technique. The control group included 33 patients with ACL rupture who were treated with the conventional transtibial non-anatomic method. We performed an objective instability test, both preoperatively and at the final follow-up. We also compared the clinical results of both groups using International Knee Documentation Committee and Lysholm scores as a subjective test.ResultsAt the final follow up, the study showed that in the control group, the Lachman test was negative in 27 cases (81.8%), the pivot shift test was negative in 26 cases (78.8%), and the average anterior translocation was 3.1 mm on a KT-2000 arthrometer. In the group of patients who underwent anatomic reconstruction by the two anteromedial portal method, the Lachman test was negative in 28 cases (84.8%), the pivot shift test was negative in 30 cases (90.9%), and the average anterior translocation was 2.8 mm on the KT-2000 arthrometer. Results in the pivot shift showed statistically significant improvement compared to the control group.ConclusionsAnatomic ACL reconstruction by two anteromedial portals is an effective surgical technique that restores the rotational stability with excellent clinical results.

clinicaltrials.gov NCT02072070 and CRiS: KCT0001112.

IntroductionNumerous techniques have been introduced for the treatment of acute acromioclavicular (AC) joint dislocation. We aim to report the midterm results of coracoclavicular (CC) stabilization with double augmentation for the acute AC joint dislocation.Case descriptionForty-three patients who underwent surgery for acute AC joint dislocation were followed up for an average of 59.6 months (range 40–97). The study composed of two treatment groups: group S, with 25 patients, in whom two suture anchors were used; and group B, with 18 patients, in whom a suture anchor and a double flip-button device were used, however the techniques in both groups are based on the same principle which is double augmentation. Postoperative evaluations were made retrospectively, clinically, and radiographically.Discussion and EvaluationAt the last follow-up, the mean Constant score was 91.2 (range 74–100) and the UCLA scale was 31.4 (range 24–35). The overall ratio of the CC distance in the injured shoulder to that in the uninjured shoulder, expressed as a percentage, significantly decreased, to 93.4 ± 22.7 %, immediate postoperatively, and significantly increased, to 113.8 ± 23.4 %, at the final follow-up. Complete reduction of the AC joint was achieved in 34 patients (79.1 %), and 8 patients (18.6 %) exhibited a slight loss of reduction, although their functional outcomes were good.ConclusionsThe results of this study provide evidence that double augmentation is effective in the treatment of acute AC dislocation.Level of evidenceTherapeutic study, case series, Level IV.

Background: The best strategy for implant selection in midshaft clavicular fractures (MCF) remains controversial. The present study aims to determine the optimal strategy for implant selection by comparing plate and Titanium Elastic Nail (TEN) with respect to outcomes and related complications and analyze the results based on fracture patterns. Methods: A total of 97 patients with MCF who underwent plate (48 patients) or TEN (49 patients) fixation were retrospectively reviewed. Both groups were divided into three subgroups by fracture type using the AO Foundation/Orthopaedic Trauma Association classification: simple fracture (type A), wedge fracture (type B), and multi-fragmentary fracture (type C). The observed outcome measures were bone union rate, related complications, functional scores, and patient satisfaction score. These outcomes were analyzed based on the fracture classification. Results: Both groups demonstrated excellent union rates (p = 0.495) and similar functional scores (p > 0.05). Visual analog scale (VAS) for satisfaction was better in TEN than plate fixation (p < 0.001). In type A and B subgroups, there were no significant difference in functional scores between plate and TEN fixation (p > 0.05). In type C subgroup, however, both VAS for pain and DASH score in TEN fixation were significantly worse than in plate fixation at 2 and 6 weeks postoperatively (p < 0.05). The incidences of clavicle shortening and skin irritation are higher especially in type C subgroup of TEN fixation (p < 0.05). Conclusion: Patient satisfaction of TEN fixation was higher than that of plate fixation, but TEN fixation had a higher incidence of early postoperative pain and migration in type C fractures. Therefore, type A and B fractures can successfully be treated with plate or TEN fixation, but type C fractures should be treated with plate fixation.

Level II, therapeutic study.

Hansenula anomala (H. anomaly) is part of the normal flora in the alimentary tract and throat. It has been reported to be an organism causing opportunistic infections in immunocompromised patients. However, cases of fungal arthritis caused by H. anomala are rare. We encountered a case of H. anomala arthritis in a 70-year-old man who was treated with an empirical antibiotic treatment and surgery under the impression of septic arthritis. However, the patient did not improve after antibiotic therapy and surgery. Consequently, knee joint aspiration was performed again, which identified fungal arthritis caused by H. anomala. It was treated successfully with amphotericin B and fluconazole. When treating arthritis patients with diabetes, it is important to consider the possibility of septic arthritis by H. anomala and provide the appropriate treatment.

Background and Objectives: Intraarticular injection of tranexamic acid (IA-TXA) plus drain-clamping is a preferred method of reducing bleeding after total knee arthroplasty (TKA). However, no consensus has been reached regarding the timing of the clamping. The purpose of this study was to determine the optimum duration of drain-clamping after TKA with IA-TXA. Materials and Methods: We retrospectively reviewed 151 patients that underwent unilateral TKA with IA-TXA plus drain-clamping for 30 min, 2 h, or 3 h. The total drained volume was reviewed as the primary outcome, and hematocrit (Hct) reductions, estimated blood loss (EBL), transfusion rates, and wound complications were reviewed as secondary outcomes. Results: The mean total drained volume, Hct reduction, and EBL were significantly less in the 3 h group than in the 30 min group. Between the 2 h and 3 h groups, there was no statistical difference in the mean total drained volume, Hct reduction, or EBL. The proportion of patients who drained lesser than 300 mL was high in the 3 h group. No significant intergroup difference was observed for transfusion volume, transfusion rate, and wound related complications. Conclusions: In comparison of the IA-TXA plus drain-clamping after TKA, there was no difference in EBL between the 2 h group and the 3 h group, but the amount of drainage volume was small in the 3 h group.