This article proposes a "bedside-to-bench" approach as a model to improve clinical outcomes for patients through functional tissue engineering (TE). The link between the highest level of clinical research and evaluation criteria for musculoskeletal TE is in identifying clinically proven predictors that are amenable to functional TE. The TE solutions developed in the laboratory should then be tested in translational models to evaluate efficacy and safety prior to controlled clinical trials. The best available evidence for potentially decreasing the incidence of radiographically confirmed osteoarthritis after anterior cruciate ligament injury is preservation of meniscus function. Meniscus tears occur concurrently in approximately 50% of anterior cruciate ligament tears. TE could promote repair of torn meniscus and/or replacement of meniscus loss because meniscus tear is a proven predictor of clinically relevant outcomes (such as osteoarthritis) in patients and is amenable to a potential TE solution.

The development of premature osteoarthritis after anterior cruciate ligament (ACL) reconstruction is a significant cause of morbidity in young, active individuals. Meniscal injuries are frequently noted at the time of reconstruction, and the critical role of an intact meniscus in the prevention of osteoarthritis has been well documented. The purpose of this review is to evaluate the effects of meniscal status at ACL reconstruction on the subsequent development of osteoarthritis. A systematic review of the literature identified 11 studies with > or = 2 years of follow-up that compared patients' radiographic outcomes based on meniscus status at the time of ACL reconstruction. Patients undergoing partial meniscectomy at the time of ACL reconstruction were significantly more likely to develop radiographic evidence of osteoarthritis than those with normal menisci. Meniscal repair resulted in inconsistent findings. Virtually all patients who underwent complete meniscectomy at the time of ACL reconstruction had radiographic evidence of osteoarthritis at follow-up.

We performed a systematic review of the current literature to determine the efficacy and duration of intra-articular corticosteroid injection in reducing pain caused by knee osteoarthritis and to determine whether the type of corticosteroid used affected these results. Following an electronic search of multiple databases and a review of reference lists from various articles, we found six trials in five papers that compared corticosteroid versus placebo and four papers that compared different corticosteroids. Results of corticosteroid compared with placebo showed both a statistically and clinically significant reduction in pain at 1 week, with an average difference between groups of 22%. Two of four trials showed triamcinolone to be more effective in pain reduction than other corticosteroids. We concluded that intra-articular corticosteroids reduce knee pain for at least 1 week and that intra-articular corticosteroid injection is a short-term treatment of a chronic problem.

BACKGROUND: Anterior cruciate ligament reconstruction can be performed with use of either autograft or allograft tissue. It is currently unclear if the outcomes of these two methods differ significantly. This systematic review and meta-analysis investigated whether the short-term clinical outcomes of anterior cruciate reconstruction with allograft were significantly different from those with autograft. METHODS: A computerized search of the electronic databases MEDLINE and EMBASE was conducted. Only therapeutic studies with a prospective or retrospective comparative design were considered for inclusion in the present investigation. Two reviewers independently assessed the methodological quality and extracted relevant data from each included study. If a study failed the qualitative assessment and statistical tests of homogeneity, it was excluded from the meta-analysis. Furthermore, a study was withdrawn from the meta-analysis of a particular outcome if that outcome was not studied or was not reported adequately. A Mantel-Haenszel analysis utilizing a random-effects model allowed for pooling of results according to graft source while accounting for the number of subjects in individual studies. RESULTS: Nine studies were determined to be appropriate for the systematic review. Eight studies compared bone-patellar tendon-bone grafts, and one study compared quadruple-stranded hamstring grafts. Five studies were prospective comparative studies, and four were retrospective comparative studies. One study, which investigated allografts that underwent a unique sterilization process, demonstrated an allograft failure rate of 45%(thirty-eight of eighty-five). That study failed the qualitative assessment and statistical tests of homogeneity and consequently was excluded from the meta-analysis. When the outcomes from the remaining studies were pooled according to graft source, the meta-analyses of the Lysholm score, instrumented laxity measurements, and the clinical failure rate estimated mean differences and odds ratios that were not significant. These findings were robust during the sensitivity analysis, which varied the included studies or variables on the basis of graft type, instrumented laxity cut-off value, secondary sterilization technique, duration of follow-up, mean patient age, and study methodology. CONCLUSIONS: In general, the short-term clinical outcomes of anterior cruciate reconstruction with allograft were not significantly different from those with autograft. However, it is important to note that none of these nonrandomized studies stratified outcomes according to age or utilized multivariable modeling to mathematically control for age (or any other possible confounder, such as activity level, that is not equally distributed in the two treatment groups). Understanding these limitations of the best available evidence, the surgeon may incorporate the results of the present systematic review into the informed-consent and shared-decision-making process in order to individualize optimum patient care.

This study aimed to determine the incidence of meniscal tears and describe the tear morphology and selected treatment in patients undergoing anterior cruciate ligament (ACL) reconstruction. We also will discuss the potential market for future tissue engineering aimed at preserving meniscal function. A multicenter cohort of 1014 patients undergoing ACL reconstruction between January 2002 and December 2003 was evaluated. Data on patient demographics, presence of a meniscus tear at time of ACL reconstruction, tear morphology, and meniscal treatment were collected prospectively. Meniscal tears were categorized into 3 potential tissue engineering treatment strategies: all-biologic repair, advanced repair, and scaffold replacement. Of the knees, 36% had medial meniscal tears and 44% had lateral meniscal tears. Longitudinal tears were the most common tear morphology. The most frequent treatment method was partial meniscectomy. Thirty percent of medial meniscal tears and 10% of lateral meniscal tears are eligible for all-biologic repair; 35% of medial meniscal tears and 35% of lateral meniscal tears are eligible for an advanced repair technique; and 35% of medial meniscal tears and 55% of lateral meniscal tears are eligible for scaffold replacement. Although meniscal preservation is generally accepted in the treatment of meniscal tears, most tears in this cohort were not repairable, despite contemporary methods. The results of this cohort will hopefully stimulate and focus future research and development of new tissue engineering strategies for meniscus repair.

Background Meniscal repair is performed in an attempt to prevent posttraumatic arthritis resulting from meniscal dysfunction after meniscal tears. The socioeconomic implications of premature arthritis are significant in the young patient population. Investigations and techniques focusing on meniscus preservation and healing are now at the forefront of orthopaedic sports medicine. Hypothesis Concomitant meniscal repair with anterior cruciate ligament reconstruction is a durable and successful procedure at 2-year follow-up. Study Design Case series; Level of evidence, 4. Methods All unilateral primary anterior cruciate ligament reconstructions entered in 2002 in a cohort who had meniscal repair at the time of anterior cruciate ligament reconstruction were evaluated. Validated patient-oriented outcome instruments were completed preoperatively and then again at the 2-year postoperative time point. Reoperation after the index procedure was also documented and confirmed by operative reports. Results A total of 437 unilateral primary anterior cruciate ligament reconstructions were performed with 82 concomitant meniscal repairs (54 medial, 28 lateral) in 80 patients during the study period. Patient follow-up was obtained on 94%(77 of 82) of the meniscal repairs, allowing confirmation of meniscal repair success (defined as no repeat arthroscopic procedure) or failure. The overall success rate for meniscal repairs was 96%(74 of 77 patients) at 2-year follow-up. Conclusion Meniscal repair is a successful procedure in conjunction with anterior cruciate ligament reconstruction. When confronted with a "repairable" meniscal tear at the time of anterior cruciate ligament reconstruction, orthopaedic surgeons can expect an estimated >90% clinical success rate at 2-year follow-up using a variety of methods as shown in our study.

BACKGROUND: The outcome of anterior cruciate ligament (ACL) reconstruction is variable, and many patients have increased joint laxity postoperatively. HYPOTHESIS: Placement of a collagen-platelet composite (CPC) around the graft at the time of ACL reconstruction decreases postoperative knee laxity and improves the structural properties of the graft compared with standard ACL reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: Thirteen immature pigs underwent unilateral ACL reconstruction with a bone-patellar tendon-bone allograft. In 6 pigs, a standard allograft was used to reconstruct the ACL. In 7 pigs, a CPC was placed around the allograft. After 15 weeks of healing, the animals were euthanized, and the anterior-posterior (AP) knee laxity and structural properties of the graft were measured. Qualitative histology of the grafts was also performed. RESULTS: The AP laxity values of the reconstructed knees, normalized to the contralateral control, were significantly reduced by 28% and 57% at 60 degrees and 90 degrees of knee flexion, respectively, with the addition of CPC (P <.001). Significant improvements in the graft structural properties were also found; the normalized yield (P =.044) and maximum failure loads (P =.025) of the CPC group were 60% higher than the standard ACL-reconstructed group. Although cellular and vessel infiltration were observed in the grafts of both groups, regions of necrosis were present only in the standard ACL-reconstructed group. CONCLUSION: These data demonstrate that the application of CPC at the time of ACL reconstruction improves the structural properties of the graft and reduces early AP knee laxity in the porcine model after 15 weeks of healing. CLINICAL RELEVANCE: Application of a CPC to an ACL graft at the time of surgery decreased knee laxity and increased the structural properties of the graft after 15 weeks of healing.

Meniscus tears in athletes display a variety of clinical presentations. Three different case scenarios are presented along with diagnoses and treatment options, and the best available evidence, at present, is reviewed.

BACKGROUND: Osteochondritis dissecans (OCD) can progress to loose body formation, resulting in a grade IV defect. The decision to fix versus excise the loose body is controversial. Published operative fixation outcomes are small case series with short follow-up. HYPOTHESIS: Operative fixation (ORIF) of the loose body into the grade IV defect will heal and approximate "normal" knee function at long-term follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twelve patients were identified who underwent ORIF of a knee OCD loose body into the grade IV osteochondral defects ranging in size from 2.0 to 8.0 cm(2)(mean, 3.5 cm(2)). After 12 weeks, hardware was removed, and healing was assessed. Long-term outcomes were assessed with a Knee injury and Osteoarthritis Outcome Score (KOOS) and a Marx activity score. RESULTS: Arthroscopy for screw removal revealed stable healing in 92%(11 of 12) of patients. No patients required subsequent surgery for a loose body. At an average of 9.2 years' follow-up (range, 3.8-15.8 years), 83%(10 of 12) of patients completed the KOOS. The KOOS subscale scores for pain (mean, 87.8; range, 67-100), other symptoms (mean, 81.8; range, 61-96), function in activities of daily living (mean, 93.1; range, 72-100), and sports and recreation function (mean, 74.0; range, 40-100) were not significantly lower than those of published age-matched controls. However the KOOS subscale score for knee-related quality of life (mean, 61.9; range, 31-88) was significantly lower (P =.003). CONCLUSION: Operative fixation of grade IV OCD loose bodies results in stable fixation. At an average 9 years after surgery, patients did not have symptoms of osteoarthritis pain and had normal function in activities of daily life. However, patients reported significantly lower knee-related quality of life. Operative fixation of OCD loose bodies is a better alternative to lesion excision.

The purpose of this retrospective study was to compare early lower limb dysaesthesia after anterior cruciate ligament (ACL) reconstructions. The procedures were performed with ST and GR tendons using vertical or oblique harvest site incisions. In the year 2006 52 patients were treated due to total ACL rupture. In 35 we performed vertical harvest site incision and in 17 oblique incision were performed. Average follow-up was 1 month. At this time patients were asked to draw any dysaesthesia area on a knee diagram, if present. In the vertical harvest site incision 31 patients had dysaesthesia about the knee, and the average dysaesthesia area was 46.8 cm2. In the oblique harvest site incision 15 patients had dysaesthesia about the knee and the average dysaesthesia area was 44.3 cm2. The dysaesthesia areas were mostly of ellipse-like shape. There was no signigicant difference between two groups.

AIM: The aim of this study was to examine radiological and functional outcome measurements after anterior cruciate ligament (ACL) reconstruction with a bone-tendon-bone (BTB) graft. Investigations included assessment of bony integration conditions regarding the use of bioabsorbable cross pins or a lateral screw for femoral graft fixation. A description of radiological parameters in contrast with IKDC findings is also given. METHOD: After ACL injuries, 45 patients underwent an ACL repair. For tibial tunnel placement the tibial guide was used in full knee extension. A size-specific femoral aimer was placed by using the transtibial technique in the "over the top" position and the tunnel was reamed with the acorn reamer to 30 mm depth. In 15 patients the BTB graft was fixed with a titanium blunt nose screw from the lateral aspect. The cross-pin technique with bioabsorbable RIGIDFIX implants was used in 30 patients. All patients underwent a follow-up study 36 month postoperatively. Geometric tests of digitised X-rays were performed. For clinical and functional outcome studies of ACL repairs the IKDC score is widely accepted. The score was modified into numeric parameters for 15 selected groups of the IKDC score. All 15 categories were rated from 1 to 4 points (Category A = 4, B = 3, C = 2, D = 1). Clinical and radiological results were statistically analysed. RESULTS: According to the literature, tunnel placement tibial was physiological in 91 % and femoral in 93 % of the cases. The femoral tunnel was completely invisible in all patients. No necrosis or pathological findings in former pin holes were seen. In 24 patients the medial compartment space was smaller, but less than 50 % compared to intraoperative X-rays. Even if the mean of tibial tunnel widening was 2.65 mm it was statistically not connected to the results of the IKDC score or X-ray findings of the femoral tunnel. Results in the IKDC groups and categories were seen to be in accord with overall very good and good outcomes. The modified IKDC score showed a mean of 55 points with a range from 46 as lowest (1 patient) and 60 in 4 patients (9 %) as highest numeric score. CONCLUSION: Lateral femoral fixation with screws or bioabsorbable cross-pins shows a biological bony incorporation of a BTB graft. Tibial tunnel widening was seen but without any functional effects. Overall radiological and functional outcomes based on the IKDC score demonstrate results in favour of ACL reconstruction with BTB grafts. Due to the narrowing of the medial compartment space, more radiological outcome studies with a special emphasis on degenerative aspects have to be done.

AIM: Most surgeons favour a one-stage procedure for ACL revision surgery. Tunnel widening, limited range of motion or existent hardware can make a two-stage procedure necessary. Studies evaluating the results between both procedures are still lacking. Thus, we performed a prospective preliminary study comparing early results after one- and two-stage procedures for ACL revision reconstruction. METHOD: Between 1/2005 and 1/2006 21 patients were operated on for ACL revision. The follow-up period of the 4 women and 16 men was 12 months. One patient was excluded due to a juvenile osteoporosis. Median age was 34 years. All patients had a subjective instability, including 11 patients (55 %) with a traumatic rerupture. The indication for a two-stage procedure depended on tunnel widening under consideration of tunnel placement, disturbing existing hardware and extension deficits. Eleven patients received a one-stage procedure while 9 patients were operated in a two-stage process. Seven received autogenous bone grafting. RESULTS: The preoperative tunnel diameter was for one-stage revisions (OS) femoral 7.9 +/- 1.8 mm and tibial 8.8 +/- 2.2 mm. For the two-stage (TS) procedure mean femoral tunnel was preoperativly 10.1 +/- 1.4 mm and tibial 12.1 +/- 1.4 mm. Femoral tunnel placement after revision (OS/TS) yielded a mean angle in anteroposterior view of 28.7 degrees /26.9 degrees and in the sagittal view most tunnels were placed in the dorsal quadrant. Tibial placement was in the sagittal view at 46.1 %/46.9 % in the anteroposterior direction and for mediolateral direction in the a. p. view at 44.2 %/44.5 %. Results for Lysholm score were 85.7/83.9 and for IKDC 73.6/76.4. The anterior tibial translation compared to the healthy side was 1.5 mm/1.8 mm. In one leg jumping patients obtained a distance of 83 %/86 % of the healthy side and stated their pain on a VAS to be as low as 1.9/1.4 points. Both groups had similar ranges of motion as well. CONCLUSION: The success of ACL revision surgery crucially depends on preoperative planning and analysis. No functional or radiological differences could be observed between one- and two-stage procedures. Although the one-stage procedure might be favourable because of faster convalescence and shorter work incapacity, it should not be enforced at the price of an insufficient ACL.

AIM: The results of 16 patients in growth age (mean age at surgery 13.7 years) with an ACL rupture that was treated with an ACL reconstruction using an periost-patella tendon-periost graft were reviewed. RESULTS: The follow-up was done 12 months postoperatively. All patients were satisfied with the result of the surgery. No leg length differences or abnormalities of the axis were found. 14 patients had already regained their original sports level. In the Tegner score, an average level of 8 was reached and a mean of 97 points in the Lysholm score. In the IKDC score we found a level of A (normal) 9 times and of B (nearly normal) 7 times. CONCLUSION: These follow-up examinations show that the treatment of an ACL rupture in growth age with a periost-patella tendon-periost graft leads to good results. It is a good alternative to the other methods (e.g., semitendinosus). Today, it can be regarded as a standard that an ACL rupture with open growth plates should be treated operatively.

OBJECTIVE: To study the clinical effect of anterior cruciate ligament (ACL) reconstruction with different grafts under arthroscope. METHODS: A retrospective analysis was done on 68 cases of ACL injury. ACL reconstruction with bone-patellar tendon-bone autograft and interface screw fixation were performed in 26 cases (group A) and quadruple semitendinosus tendon autograft and endobutton plate fixationin in 38 cases (group B). ACL reconstruction with bone-patellar tendon-bone allograft cryopreserved and interface screw fixation were performed in 4 cases (group C). There were 16 males and 10 females with an average age of 26.4 years (16-45 years) in group A, 24 males and 14 females with an average age of 24.6 years (13-48 years) in group B, and 3 males and 1 female (55-65 years) in group C. The left knee involved in 14 cases, 27 cases and 3 cases, and the right knee involved in 12 cases, 11 cases and 1 case in groups A, B and C, respectively. The disease courses were 1 week to 15 months (group A), 1 week to 16 months (group B) and 2 weeks to 28 months (group C). The intermediate myodynamic recovery, IKDC score and Lysholm score were compared among 3 groups. RESULTS: All patients were followed 12-36 months (17.5 months in group A, 18.5 months in group B and 16.5 months in group C). No intra-articular infection, phlebothrombosis of leg, vascular injury and nerve injury occurred. Lysholm scores was increased from preoperative 65.3+/-4.8 to postoperative 95.1+/-4.3 in group A, from 68.4+/-5.6 to 93.0+/-5.9 in group B and from 60.3+/-6.7 to 92.2+/-4.3 (excellent in 3 cases and good in 1 case) in group C; the excellent and good rates were 88.5%(excellent in 18 cases, good in 5 cases and fair in 3 cases) in group A, 86.8%(excellent in 28 cases, good in 5 cases and fair in 5 cases) in group B, IKDC scores were 93.7+/-3.8 (group A), 95.7+/-4.7 (group B) and 94.8+/-3.6 (group C); the knee joint functions were normal in 19 cases (73.1%), in 30 cases (78.9%) and in 3 cases, were fair in 5 cases (19.2%), in 5 cases (13.2%) and in 1 cases in groups A, B and C respectively. CONCLUSION: The transplantation of bone-patellar tendon-bone autograft , quadruple semitendinosus tendon autograft and bone-patellar tendon-bone allograft all can reconstruct and strengthen the stability of knee joint. Bone-patellar tendon-bone allograft is better selection for the ACL injury in elder and quadruple semitendinosus tendon autograft is suitable to adolescent patients with disrupted ACL.

BACKGROUND: Low postoperative pain level, decreased length of hospital stay and accelerated rehabilitation are the major benefits of unicondylar knee arthroplasty. Especially in comparably young, not yet retired and still active patients with an isolated medial gonarthrosis, these prostheses offer many advantages. However, one important requirement to be treated with such implants is a well functioning stability system of the muscles and ligaments. Thus in patients with degenerated or destroyed anterior cruciate ligaments it is contraindicated to use this method. In order to still take advantage of this therapy for treatment of isolated arthrosis, reestablishment of the proprioceptive structures through simultaneous or staged ACL reconstruction is mandatory. PATIENTS AND METHODS: Pursuing this goal we performed unicondylar knee arthroplasty with simultaneous ACL reconstruction on eligible patients. Between 2003 and 2006 we treated 32 knees with this combined surgery and followed them for a mean of 31 months (range: 10-38). RESULTS: The mean Knee Society Score significantly improved from 83.2 (44-103) to 167.6 (145-177) at a mean follow-up of 31 months (10-38). CONCLUSIONS: Preliminary results of this short-term follow-up are promising. Especially the predominant number of patients who were able to return to work soon after rehabilitation and the significantly improved score postoperatively reflect the benefits of this prosthesis system in select patients. However, long-term follow-up and larger case numbers are necessary to confirm these encouraging results in the future.