Injury to the anterior cruciate ligament (ACL) is one of the most devastating and frequent injuries of the knee. Surgical reconstruction is the current standard of care for treatment of ACL injuries in active patients. The widespread adoption of ACL reconstruction over primary repair was based on early perception of the limited healing capacity of the ACL. Although the majority of ACL reconstruction surgeries successfully restore gross joint stability, post-traumatic osteoarthritis is commonplace following these injuries, even with ACL reconstruction. The development of new techniques to limit the long-term clinical sequelae associated with ACL reconstruction has been the main focus of research over the past decades. The improved knowledge of healing, along with recent advances in tissue engineering and regenerative medicine, has resulted in the discovery of novel biologically augmented ACL-repair techniques that have satisfactory outcomes in preclinical studies. This instructional review provides a summary of the latest advances made in ACL repair. Cite this article: Bone Joint Res 2014;3:20–31

Abstract. Aims. We studied the outcomes following arthroscopic primary repair of bucket handle meniscus tears to determine the incidence of re-tears and the functional outcomes of these patients. Methodology. Prospective cohort study. Over a 4-year period (2016 to 2020), 35 adult patients presented with a bucket handle tear of the meniscus. Arthroscopic meniscal repair was performed using either the all inside technique or a combination of all-inside and inside-out techniques. 15 patients also underwent simultaneous arthroscopic anterior cruciate ligament reconstruction. Functional knee scores were assessed using IKDC and Lysholm scores. Results. Mean patient age at surgery was 27 years (range, 17 to 53years). Medial meniscus was torn in 20 and lateral in 15 cases. Zone of tear was white on white in 19, red on white in 9 and red on red in 7 cases. Average delay from injury to surgery was 4 months. At a mean follow-up of 4.5 years, the meniscus repair failed in 3 patients (8.5 %). Outcome following re-tear was meniscus excision. Average IKDC scores in patients with intact repair were 74.04 against 56.67 in patients with a failed repair (p< 0.0001). Similarly, Lyshlom scores were 88.96 and 67.333, respectively (p<0.0001). Conclusion. The survivorship of primary repair of bucket handle meniscus tears in our series was 91.5% at medium term follow-up. Functional outcomes were significantly poor in patients with a failed repair compared to those with an intact repair

Aims

The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process.

Objectives. The lack of effective treatment for cartilage defects has prompted investigations using tissue engineering techniques for their regeneration and repair. The success of tissue-engineered repair of cartilage may depend on the rapid and efficient adhesion of transplanted cells to a scaffold. Our aim in this study was to repair full-thickness defects in articular cartilage in the weight-bearing area of a porcine model, and to investigate whether the CD44 monoclonal antibody biotin-avidin (CBA) binding technique could provide satisfactory tissue-engineered cartilage. Methods. Cartilage defects were created in the load-bearing region of the lateral femoral condyle of mini-type pigs. The defects were repaired with traditional tissue-engineered cartilage, tissue-engineered cartilage constructed with the biotin-avidin (BA) technique, tissue-engineered cartilage constructed with the CBA technique and with autologous cartilage. The biomechanical properties, Western blot assay, histological findings and immunohistochemical staining were explored. Results. The CBA group showed similar results to the autologous group in biomechanical properties, Moran’s criteria, histological tests and Wakitani histological scoring. Conclusions. These results suggest that tissue-engineered cartilage constructed using the CBA technique could be used effectively to repair cartilage defects in the weight-bearing area of joints. Cite this article: H. Lin, J. Zhou, L. Cao, H. R. Wang, J. Dong, Z. R. Chen. Tissue-engineered cartilage constructed by a biotin-conjugated anti-CD44 avidin binding technique for the repairing of cartilage defects in the weight-bearing area of knee joints in pigs. Bone Joint Res 2017;6:–295. DOI: 10.1302/2046-3758.65.BJR-2016-0277

We undertook 114 arthroscopic meniscal repairs in 111 patients and subsequently carried out second-look arthroscopy to confirm meniscal healing at a mean of 13 months after repair. Stable healing at the repaired site was seen in 90. Of these, however, 13 had another arthroscopy later for a further tear. The mean period between the repair and the observation of a repeat tear was 48 months. Of the 13 patients, 11 had returned to high activity levels (International Knee Documentation Committee level I or II) after the repair. An attempt should be made to preserve meniscal function by repairing tears, but even after arthroscopic confirmation of stable healing repaired menisci may tear again. The long-term rate of healing may not be as high as is currently reported. Second-look arthroscopy cannot predict late meniscal failure and may not be justified as a method of assessment for meniscal healing. Young patients engaged in arduous sporting activities should be reviewed regularly even after arthroscopic confirmation of healing

We describe 119 meniscal allograft transplantations performed concurrently with articular cartilage repair in 115 patients with severe articular cartilage damage. In all, 53 (46.1%) of the patients were over the age of 50 at the time of surgery. The mean follow-up was for 5.8 years (2 months to 12.3 years), with 25 procedures (20.1%) failing at a mean of 4.6 years (2 months to 10.4 years). Of these, 18 progressed to knee replacement at a mean of 5.1 years (1.3 to 10.4). The Kaplan-Meier estimated mean survival time for the whole series was 9.9 years (. sd. 0.4). Cox’s proportional hazards model was used to assess the effect of covariates on survival, with age at the time of surgery (p = 0.026) and number of previous operations (p = 0.006) found to be significant. The survival of the transplant was not affected by gender, the severity of cartilage damage, axial alignment, the degree of narrowing of the joint space or medial versus lateral allograft transplantation. Patients experienced significant improvements at all periods of follow-up in subjective outcome measures of pain, activity and function (all p-values < 0.05), with the exception of the seven-year Tegner index score (p = 0.076)

The tensile strength of the medial patellofemoral ligament (MPFL), and of surgical procedures which reconstitute it, are unknown. Ten fresh cadaver knees were prepared by isolating the patella, leaving only the MPFL as its attachment to the medial femoral condyle. The MPFL was either repaired by using a Kessler suture or reconstructed using either bone anchors or one of two tendon grafting techniques. The tensile strength and the displacement to peak force of the MPFL were then measured using an Instron materials-testing machine. The MPFL was found to have a mean tensile strength of 208 N (SD 90) at 26 mm (SD 7) of displacement. The strengths of the other techniques were: sutures alone, 37 N (SD 27); bone anchors plus sutures, 142 N (SD 39); blind-tunnel tendon graft, 126 N (SD 21); and through-tunnel tendon graft, 195 N (SD 66). The last was not significantly weaker than the MPFL itself

The management of traumatic dislocation of the knee in 40 patients (41 knees) with a mean age of 26.3 years is described. They were treated by primary repair and reconstruction with autologous grafting of the anterior (ACL) and posterior cruciate ligaments (PCL) and repair injuries to the collateral ligament and soft-tissue. The ACL and PCL were reconstructed using the patellar tendon and the gracilis and semitendinosus tendons, respectively. Early mobilisation using a continuous-passive-movement machine and active exercises was started on the second day after operation. At a mean follow-up of 39 months no patient reported ‘giving way’ and all except one had good range of movement. Of the 41 knees, 21 were rated as excellent, 15 good, four fair and one poor. Early reconstruction of the cruciate ligaments and primary repair of the collateral ligaments followed by an aggressive rehabilitation programme are recommended for these young, active patients

Aims. Adenosine, lidocaine, and Mg. 2+. (ALM) therapy exerts differential immuno-inflammatory responses in males and females early after anterior cruciate ligament (ACL) reconstruction (ACLR). Our aim was to investigate sex-specific effects of ALM therapy on joint tissue repair and recovery 28 days after surgery. Methods. Male (n = 21) and female (n = 21) adult Sprague-Dawley rats were randomly divided into ALM or Saline control treatment groups. Three days after ACL rupture, animals underwent ACLR. An ALM or saline intravenous infusion was commenced prior to skin incision, and continued for one hour. An intra-articular bolus of ALM or saline was also administered prior to skin closure. Animals were monitored to 28 days, and joint function, pain, inflammatory markers, histopathology, and tissue repair markers were assessed. Results. Despite comparable knee function, ALM-treated males had reduced systemic inflammation, synovial fluid angiogenic and pro-inflammatory mediators, synovitis, and fat pad fibrotic changes, compared to controls. Within the ACL graft, ALM-treated males had increased expression of tissue repair markers, decreased inflammation, increased collagen organization, and improved graft-bone healing. In contrast to males, females had no evidence of persistent systemic inflammation. Compared to controls, ALM-treated females had improved knee extension, gait biomechanics, and elevated synovial macrophage inflammatory protein-1 alpha (MIP-1α). Within the ACL graft, ALM-treated females had decreased inflammation, increased collagen organization, and improved graft-bone healing. In articular cartilage of ALM-treated animals, matrix metalloproteinase (MMP)-13 expression was blunted in males, while in females repair markers were increased. Conclusion. At 28 days, ALM therapy reduces inflammation, augments tissue repair patterns, and improves joint function in a sex-specific manner. The study supports transition to human safety trials. Cite this article: Bone Joint Res 2024;13(6):279–293

Abstract. INTRODUCTION. To preserve knee function and reduce degenerative, meniscal tears should be repaired where possible. Meniscal wrapping with collagen matrices has shown promising clinical outcome (AAOS meniscal algorithm), however there is limited basic science to support this. AIM. to model the contact pressures on the human tibial plateau beneath a (1) a repaired radial meniscal tear and (2) a wrapped and repaired radial meniscal tear. METHODOLOGY. Complete anterolateral radial tears were formed across 4 lateral human menisci, before repairing with ‘rip-stop’ H sutures using 2mm Arthrex Meniscal Suture tape. This was then repeated with the addition of a ChondroGide collagen matrix wrapping. From this experimental setup a finite element (FE) analysis model was construted. FE models of the two techniques (i) suture alone and (ii) suture and collagen-matrix wrap, were then modelled; bone was linear elastic, articular cartilage was a hyperelastic Yeoh model, and a linear elastic and transversely isotropic material model for the meniscus. The contact areas of the articulating surfaces, meniscus kinematics, and stress distribution around the repair were compared between the two systems. RESULTS. Meniscal suture-tape repair had higher local stresses and strains (σ_max=51 MPa ε_max=25%) around the repair compared to with Collagen wrapping (σ_max=36.6MPa ε_max=15%). Radial displacement and pressure on the meniscal contact surfaces were higher in the suture only repair. CONCLUSION. Collagen-matrix wrapping strengthens the repair, reducing local peak stresses and strains around the suture-tape. This could reduce the chance of suture-tape pull-out and subsequent repair failure

Aims. The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods. A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results. Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion. The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed. Cite this article: Bone Joint J 2023;105-B(12):1259–1264

Abstract. Introduction. Augmentation of meniscus repairs with fibrin clot may enhance the healing capacity. Pulling the clot into the tear with a suture ensures that it stays in position. This paper aims to assess the outcome of this technique. Methods. 52 patients over 4 years undergoing suture repair of a meniscus tear with blood clot augmentation were collected from a prospective database. Follow up included outcome scores and a questionnaire. Failure was defined as pain or further surgery secondary to meniscal pathology. Results. There were 32 males and 20 females, mean age of 35 (14–70). The medial meniscus was repaired in 32 knees and the lateral in 20. Complete radial tears were the most common type. Only 2% of tears were in the red-red zone. Follow-up ranged from 12 months to 7 years. Only 1 patient is known to have come to subsequent arthroscopy. Lysholm scores improved from 53.97 (SD 18.14) to 92.08 (SD 8.97), Oxford Knee Scores from 29.84 (SD 9.65) to 45.79 (SD 2.66), KOOS pain scores from 61.49 (SD 22.76) to 93.54 (SD 8.06) and Tegner scores from 4.56 (SD 3.35) to 6.05 (SD 2.41). Conclusions. Pulling a fibrin blood clot into a meniscus tear with a suture ensures that the clot remains in place while the meniscus is repaired. Patients have shown excellent outcomes with 98% survivorship at 45 months. This is a reliable technique for augmenting meniscus repairs especially for tears which otherwise may not have been repaired

Abstract. Introduction. The popularity of all-inside meniscal repair devices has led to a shift away from inside-out meniscus repair without comparative studies to support the change. The aim of this study was to compare the failure rate and time to failure of all-inside and inside-out meniscus repair performed in elite athletes. Methodology. A retrospective review was performed of all elite athletes who underwent meniscal repair, with a minimum of two-year follow-up between 2013 and 2019. Repairs were classified as all-inside or inside-out according to the repair technique. Failure was defined as undergoing a subsequent surgery to address a persistent meniscal tear. Results. 192 (135 lateral and 57 medial) meniscal repairs in elite athletes were included and 41 (21%) failed. Medial meniscus tears repaired with the all-inside technique failed at a significantly higher rate (58%) than medial meniscus tears repaired with the inside-out (23%) or lateral meniscus tears repaired with the all-inside (12%) or inside-out (14%) technique (p<.001). At 1 year following repair, 8% of lateral meniscus repairs had failed regardless of technique. Medial meniscus repairs failed at an approximate rate of 15% for inside-out technique and 42% for all-inside technique. By 2 years, approximately 54% of all-inside medial meniscus repairs had failed and by 5 years over 60% of repairs had failed. Conclusion. All-inside medial meniscal repair led to a higher rate of failure compared to inside-out medial or lateral meniscus repair in elite athletes. Medial meniscus repairs failed at a high rate than lateral meniscal repairs

Aims. Implantation of ultra-purified alginate (UPAL) gel is safe and effective in animal osteochondral defect models. This study aimed to examine the applicability of UPAL gel implantation to acellular therapy in humans with cartilage injury. Methods. A total of 12 patients (12 knees) with symptomatic, post-traumatic, full-thickness cartilage lesions (1.0 to 4.0 cm. 2. ) were included in this study. UPAL gel was implanted into chondral defects after performing bone marrow stimulation technique, and assessed for up to three years postoperatively. The primary outcomes were the feasibility and safety of the procedure. The secondary outcomes were self-assessed clinical scores, arthroscopic scores, tissue biopsies, and MRI-based estimations. Results. No obvious adverse events related to UPAL gel implantation were observed. Self-assessed clinical scores, including pain, symptoms, activities of daily living, sports activity, and quality of life, were improved significantly at three years after surgery. Defect filling was confirmed using second-look arthroscopy at 72 weeks. Significantly improved MRI scores were observed from 12 to 144 weeks postoperatively. Histological examination of biopsy specimens obtained at 72 weeks after implantation revealed an extracellular matrix rich in glycosaminoglycan and type II collagen in the reparative tissue. Histological assessment yielded a mean overall International Cartilage Regeneration & Joint Preservation Society II score of 69.1 points (SD 10.4; 50 to 80). Conclusion. This study provides evidence supporting the safety of acellular UPAL gel implantation in facilitating cartilage repair. Despite being a single-arm study, it demonstrated the efficacy of UPAL gel implantation, suggesting it is an easy-to-use, one-step method of cartilage tissue repair circumventing the need to harvest donor cells. Cite this article: Bone Joint J 2023;105-B(8):880–887

Abstract. Introduction. Traumatic knee dislocations are devastating injuries and there is no single best accepted treatment. This study looked at functional outcome of a single surgeon case series of patients who underwent surgical management of their knee dislocation. Methods. Eighty-seven patients with knee dislocation were treated at a major trauma centre. Acute surgical repair and reconstruction with fracture fixation within 4 weeks was preferred unless the patient was too unstable (Injury severity score>16). The collaterals were repaired and augmented using a variety of autografts, allografts or synthetic grafts. PCL was primarily braced and reconstructed subsequently, if required. Outcome was collected prospectively using IKDC score, KOOS and Tegner score. Results. The mean age of the patients was 33.6yrs (SD 11.9), 66 males and 21 females. According to Schenck classification, 26 were KD-I (30%), 6 KD-II (7%), 13 were KD-III (15%), 7 were KD-IV (8%) and 35 were KD-V (40%). 7 patients had CPN injury (8%), 3 had vascular injury (3.4%), 2 had combined CPN and vascular injury (2.3%). Acute surgical treatment was done in 62 patients while 10 had staged reconstruction. 22 patients had delayed reconstruction. The mean follow-up period was 5.8 years (1- 12 yrs), mean IKDC score was 57.6 (SD 23.6). The mean Tegner activity scale postoperatively was 4.5(SD 2) and the mean KOOS score was 74.9 (SD 19.6). Conclusion. A large proportion of cases were KD-V but still had a good outcome with surgical management. Current classification systems do not cover all dislocation patterns and a modification is proposed

Abstract. Introduction. Knee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons. Methods. At a single institution, ten junior doctors (FY1 to CT2), were recruited as a part of a five, two-hour session, training programme utilising the Simbionix® ARTHRO Mentor knee arthroscopy simulator, supplemented alongside educational guidance with a consultant orthopaedic knee surgeon. All students had minimal to no levels of prior arthroscopic experience. Exercises completed included maintaining steadiness, image centering and orientation, probe triangulation, arthroscopic knee examination, removal of loose bodies, and meniscectomy. Pre and post-experience questionnaires and quantitative repeat analysis on simulation exercises were undertaken to identify levels of improvement. Results. Comparing pre and post-experience questionnaires significant improvements in levels of confidence were noted in the following domains: naming arthroscopic instruments, port positioning and insertion, recognising normal anatomy arthroscopically, holding and using arthroscopic instruments and assisting in a live theatre setting (p<0.05). Significant improvements were noted in time taken to complete, distance covered in metres and roughness of instruments used on the simulated exercises on repeat performance (p<0.05). Conclusion. With only five sessions under senior guidance, using a simulator such as the ARTHRO Mentor, significant improvements in both levels of confidence and skill can be developed even among individuals with no prior experience

Abstract. Background. Fracture dislocation of the knee involves disruption of knee ligaments with associated tibial plateau fracture. If these injuries are not evaluated swiftly, can result in a limb-threatening injury. The aim of this study is to look at the clinical outcomes of a single surgeon case series at a major trauma centre. Methods. Prospectively collected data was analysed for a 5-year period. Primary outcome measures used were International Knee Documented Committee (IKDC) score and Knee Injury & Osteoarthritis Outcome Score (KOOS). The secondary outcome measures include Tegner activity scale, knee range of movements and complications. Results. 32 patients were presented with the mean age was 34 years (range 17–74). 14% of patients sustained vascular injury and 19% had common peroneal nerve injury. Priority was given for early total repair/reconstruction with fracture fixation within three weeks where feasible (90% of patients), and if not, a staged approach was adopted. The mean IKDC score was 67 (35–100) & KOOS was 74 (40–100). The mean preoperative Tegner Activity Scale was 6.5 whereas post-operative Tegner Activity Scale was 3.6 The mean flexion achieved postoperative was 115 (90–130). The two common patterns of injuries seen were Anterio-medial rim fractures (52%) with avulsion injuries of posterio-lateral corner structures and posteriomedial plateau fractures with ACL avulsion injuries. The first pattern was commonly associated with vascular and common peroneal nerve injury (90% of patients). Conclusion. To our knowledge, this is the first kind of study to report some fracture patterns that can be associated with particular ligamentous injuries

Abstract. Methodology. Prospective single-surgeon case-series evaluating patients undergoing surgery by this technique. 76 cases (mean age of 33.2 years) who had primary ACL reconstruction with BTB or quadriceps tendon with bone block, were divided into 2 matched groups (age, sex and type of graft) of 38 each based on the method of femoral fixation used (interference screw or adjustable cortical suspension). Patients were followed up clinically and using PROMS from NLR with EQ-5D, KOOS, IKDC and Tegner scores. Complications and return to theatre were noted. Paired two-tailed student t-tests and Chi-square tests were employed for statistical analysis. Results. At a mean follow-up of 82 months, peri-operative mean EQ-5D VAS, EQ-5D Index, KOOS, IKDC and Tegner activity scores showed significant improvement (p<0.05), but no significant difference between the two groups (p>0.05). Mean graft length and diameter was 77mm and 9.3 respectively. Mean interval from injury to surgery was 10.5 months. 18(23.7%) patients had associated meniscal tear with 73.3 % undergoing repair. 10 cases (13.2 %) returned to theatre including, MUA for arthrofibrosis (n=2) and intra-substance graft failure (n=2). 3 cases had to be converted to interference screw fixation due to the tightrope cutting through from the femoral bone block as a result of a technical pitfall. Conclusion. Primary ACL reconstruction using adjustable cortical suspension on femoral side for BTB or quadriceps bone-block tendon graft is a safe technique with added advantages of 360 degree bone ingrowth and no screw in the femoral tunnel

Abstract. Introduction. Derby technique for posterolateral corner (PLC) reconstruction uses a doubled gracilis autograft to reconstruct the popliteo-fibular ligament (PFL) and a split biceps tendon transfer to reconstruct the lateral collateral ligament (LCL). We report midterm outcomes of a case series who underwent PLC reconstruction. Methodology. A retrospective review of 27 patients who underwent PLC reconstruction from 2012 until 2018 was performed (6 females, 21 males, median age 26). Median time interval from injury to primary procedure was 10 months. Outcomes were recorded as per clinical assessment and outcome scores. Results. All patients had no varus laxity in full knee extension. Similarly, at 30° of knee flexion, 25 patients (92.5%) had no varus laxity and 2 patients (7.5%) had grade 1 laxity. No patients demonstrated abnormal external rotation at final follow up. Outcome scores were obtained from 17 patients who underwent primary ligament reconstruction at a mean follow up of 72 months postoperatively. The mean Lysholm score was 94 +/-5.5 (72–100) and mean subjective IKDC score was 78/87 (89.6%) (51–87). 90% of our patients had gained normal or nearly normal IKDC scores on returning to routine activities of daily living and sports following surgery compared to their pre-injury status. Conclusion. Our technique enables an anatomical LCL & PFL reconstruction in isolation or in combination with ACL/PCL reconstruction or to augment an acute repair without contralateral graft harvest or allograft. The functional knee scores demonstrated in this cohort are comparable and in fact superior to previously published knee scores after PLC reconstruction

Aims

To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration.