Purpose
Bone marrow concentrate (BMC) and platelet-rich plasma (PRP) are used extensively in regenerative medicine. The aim of this study was to determine differences in the cellular composition and ...cytokine concentrations of BMC and PRP and to compare two commercial BMC systems in the same patient cohort.
Methods
Patients (29) undergoing orthopaedic surgery were enrolled. Bone marrow aspirate (BMA) was processed to generate BMC from two commercial systems (BMC-A and BMC-B). Blood was obtained to make PRP utilizing the same system as BMC-A. Bone marrow-derived samples were cultured to measure colony-forming units, and flow cytometry was performed to assess mesenchymal stem cell (MSC) markers. Cellular concentrations were assessed for all samples. Catabolic cytokines and growth factors important for cartilage repair were measured using multiplex ELISA.
Results
Colony-forming units were increased in both BMCs compared to BMA (
p
< 0.0001). Surface markers were consistent with MSCs. Platelet counts were not significantly different between BMC-A and PRP, but there were differences in leucocyte concentrations. TGF-β1 and PDGF were not different between BMC-A and PRP. IL-1ra concentrations were greater (
p
= 0.0018) in BMC-A samples (13,432 pg/mL) than in PRP (588 pg/mL). The IL-1ra/IL-1β ratio in all BMC samples was above the value reported to inhibit IL-1β.
Conclusions
The bioactive factors examined in this study have differing clinical effects on musculoskeletal tissue. Differences in the cellular and cytokine composition between PRP and BMC and between BMC systems should be taken into consideration by the clinician when choosing a biologic for therapeutic application.
Level of evidence
Clinical, Level II.
Purpose This study compares retrospective functional and magnetic resonance imaging (MRI) outcomes after arthroscopic bone marrow stimulation (BMS) with and without concentrated bone marrow aspirate ...(cBMA) as a biological adjunct to the surgical treatment of osteochondral lesions (OCLs) of the talus. Methods Twenty-two patients who underwent arthroscopic BMS with cBMA (cBMA/BMS group) for an osteochondral lesion (OCL) of the talus and 12 patients who underwent arthroscopic BMS (BMS alone) for an OCL of the talus were retrospectively reviewed. The Foot and Ankle Outcome Score (FAOS) pain subscale and Short Form 12 general health questionnaire physical component summary score (SF-12 PCS) provided patient-reported outcome scores pre- and postoperatively. MRI scans were assessed postoperatively using the magnetic resonance observation of cartilage repair tissue (MOCART) score. All patients had postoperative MRI performed at the 2-year postoperative visit, and quantitative T2 mapping relaxation time values were assessed in a subset of the cBMA/BMS group. Results The mean FAOS and SF-12 PCS scores improved significantly pre- to post-operatively ( P < .01) at a mean follow-up of 48.3 months (range, 34 to 82 months) for the cBMA/BMS group and 77.3 months (range, 46 to 100 months) for the BMS-alone group. The MOCART score in the cBMA/BMS group was significantly higher than that in the BMS-alone group ( P = .023). Superficial and deep T2 relaxation values in cBMA/BMS patients were higher in repair tissue compared with measurements in adjacent native articular cartilage ( P = .030 and P < .001, respectively). Conclusions BMS is an effective treatment strategy for treatment of OCLs of the talus and results in good medium-term functional outcomes. Arthroscopic BMS with cBMA also results in similar functional outcomes and improved border repair tissue integration, with less evidence of fissuring and fibrillation on MRI. Level of Evidence Level III, retrospective comparative study.
Purpose To examine the level of evidence and methodologic quality of studies reporting surgical treatments for osteochondral lesions of the ankle. Methods A search was performed using the ...PubMed/Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases for all studies in which the primary objective was to report the outcome after surgical treatment of osteochondral lesions of the ankle. Studies reporting outcomes of microfracture, bone marrow stimulation, autologous osteochondral transplantation, osteochondral allograft transplantation, and autologous chondrocyte implantation were the focus of this analysis because they are most commonly reported in the literature. Two independent investigators scored each study from 0 to 100 based on 10 criteria from the modified Coleman Methodology Score (CMS) and assigned a level of evidence using the criteria established by the Journal of Bone and Joint Surgery . Data were collected on the study type, year of publication, number of surgical procedures, mean follow-up, preoperative and postoperative American Orthopaedic Foot & Ankle Society score, measures used to assess outcome, geography, institution type, and conflict of interest. Results Eighty-three studies reporting the results of 2,382 patients who underwent 2,425 surgical procedures for osteochondral lesions of the ankle met the inclusion criteria. Ninety percent of studies were of Level IV evidence. The mean CMS for all scored studies was 53.6 of 100, and 5 areas were identified as methodologically weak: study size, type of study, description of postoperative rehabilitation, procedure for assessing outcome, and description of the selection process. There was no significant difference between the CMS and the type of surgical technique ( P = .1411). A statistically significant patient-weighted correlation was found between the CMS and the level of evidence ( r = −0.28, P = .0072). There was no statistically significant patient-weighted correlation found between the CMS and the institution type ( r = 0.05, P = .6480) or financial conflict of interest ( r = −0.16, P = .1256). Conclusions Most studies assessing the clinical outcomes of cartilage repair of the ankle are of a low level of evidence and of poor methodologic quality. Level of Evidence Level IV, systematic review of Level I through IV studies.
Purpose To determine if functional outcomes and magnetic resonance imaging (MRI) outcomes were significantly different between patients receiving primary autologous osteochondral transplantation ...(AOT) and patients receiving secondary AOT surgery after failed microfracture. Methods A group of 76 patients enrolled into the Foot and Ankle Service between 2006 and 2012 was retrospectively analyzed. Patient-reported outcomes were evaluated in 76 patients using the Foot and Ankle Outcome Score (FAOS). Superficial and deep tissues at the repaired defect site, as well as the adjacent normal cartilage, were analyzed using quantitative T2 mapping MRI. Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) allowed for morphological evaluation of the repair tissue. The mean clinical follow-up time was 51 ± 23 months (range, 12 to 97 months), and the mean MRI follow-up time was 26 months (range, 24 to 36 months). Results Twenty-two patients received primary AOT and 54 received secondary AOT after failed microfracture. Patient characteristics between groups were similar with regard to age, gender, lesion size, and follow-up time. The mean postoperative FAOS was 10 points higher in the primary AOT group (83.2 ± 17.0) compared with the secondary AOT group (72.4 ± 19.4) ( P = .01). Regression analysis showed that secondary AOT patients preoperative to postoperative change in FAOS was 9 points lower than in primary AOT patients after adjustment for age, preoperative FAOS, and lesion size ( P = .045). The mean MOCART score, superficial T2 and deep T2 values, and the difference between normal and repair cartilage T2 values were not significantly different between groups. Lesion size was negatively correlated with MOCART scores (ρ = −0.2, P = .04), but positively correlated with difference in T2 values between repair and adjacent normal cartilage in the superficial layer (ρ = 0.3, P = .045). Conclusions Primary AOT shows better functional outcomes compared with secondary AOT after failed microfracture in patients with similar characteristics and lesion size. No significant differences in T2 mapping relaxation times and MOCART scores were identified. Level of Evidence Level III, case control study.
Computer assisted surgical (CAS) navigation and robotic-assisted total hip arthroplasty (THA) have the potential to improve the reproducibility of accurate component positioning and facilitate ...complex cases, including revision and preoperative deformity. Numerous studies, including multiple comparing technology with conventional THA control groups, suggest that CAS navigation may improve component accuracy in cases of deformity such as hip dysplasia and significant leg length discrepancy. Revision THA data is also encouraging but limited. The functional benefits compared to conventional techniques remain unclear. The evidence for robot-assisted THA in complex cases is more limited but also demonstrates utility. For complex cases, studies comparing results with conventional THA are not yet available. The limitations of these systems, including cost, operative time, learning curves, and possible complications, require further study. The available data for CAS navigation and robotic-assisted THA indicates that they may play a role in complex deformity and revision cases. Further high-quality randomized studies should be undertaken.
Abstract Talar osteochondral lesions (OCL) frequently occur following injury. Surgical interventions such as femoral condyle allogeneic or autogenic osteochondral transplant (AOT) are often used to ...treat large talar OCL. Although AOT aims to achieve OCL repair by replacing damaged cartilage with mechanically matched cartilage, the spatially inhomogeneous material behavior of the talar dome and femoral donor sites have not been evaluated or compared. The objective of this study was to characterize the depth-dependent shear properties and friction behavior of human talar and donor-site femoral cartilage. To achieve this objective, depth-dependent shear modulus, depth-dependent energy dissipation and coefficient of friction were measured on osteochondral cores from the femur and talus. Differences between anatomical regions were pronounced near the articular surface, where the femur was softer, dissipated more energy and had a lower coefficient of friction than the talus. Conversely, shear modulus near the osteochondral interface was nearly indistinguishable between anatomical regions. Differences in energy dissipation, shear moduli and friction coefficients have implications for graft survival and host cartilage wear. When the biomechanical variation is combined with known biological variation, these data suggest the use of caution in transplanting cartilage from the femur to the talus. Where alternatives exist in the form of talar allograft, donor-recipient mechanical mismatch can be greatly reduced.
Young players experience pressure to focus on ice hockey at the exclusion of other sports in order to improve chances of success. Early specialization in other sports has been associated with ...increased injury without the benefit of improved success. The objective of the current study was to investigate whether earlier specialization results in increased injury without higher rates of career success. This study also aimed to compare rates of injury in athletes at various levels of competition.
An original survey was issued to men's ice hockey players at the junior
A, collegiate, and professional levels. The survey consisted of 34 questions on various demographic, specialization, and injury variables. All participants were >18 years of age.
The survey was completed by 101 athletes. The mean age at specialization was 13 (±4) overall and 14 (±3), 13 (±4), and 11(±4) for professional, collegiate, and junior players, respectively. There was no difference in age at specialization between each group and professional players did not specialize earlier than the remainder of the cohort as a whole (p > 0.05). There was no significant correlation between age at specialization and total injuries (p > 0.05). There was no difference in concussions causing missed play time between groups (p > 0.05) but professional players had more overall concussions and underwent more surgeries due to hockey-related injuries (p = 0.01).
Specializing exclusively in ice hockey earlier in life was not associated with playing professionally. Both collegiate and professional players do not tend to specialize prior to age 12. Age at specialization was not associated with overall number of injuries. Professional players with longer careers appear to sustain more concussions and undergo more surgery.
The purpose of this study was to compare the outcomes of primary reverse total shoulder arthroplasty (rTSA) using glenoid bone grafting (BG rTSA) with primary rTSA using augmented glenoid baseplates ...(Aug rTSA) with a minimum 2-year follow-up.
A total of 520 primary rTSA patients treated with 8° posterior glenoid augments (n = 246), 10° superior glenoid augments (n = 97), or combined 10° superior/8° posterior glenoid augments (n = 177) were compared with 47 patients undergoing glenoid bone grafting for glenoid bone insufficiency. The mean follow-up was 37.0(±16) and 53.0(±27) months, respectively. Outcomes were analyzed preoperatively and at the latest follow-up using conventional statistics and stratification by minimum clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds where applicable. Radiographs were analyzed for baseplate failure, and the incidences of postoperative complications and revisions were recorded.
The glenoid Aug rTSA cohort had greater improvements in patient-reported outcome measures (PROMs) and range of motion when compared with the BG rTSA group at a minimum of 2-year follow-up, including Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles score, Shoulder Pain and Disability Index score, shoulder function, Shoulder Arthroplasty Smart score, abduction, and external rotation (P < .05). Patient satisfaction was higher in the Aug rTSA group compared with the BG rTSA group (P = .006). The utilization of an augmented glenoid component instead of glenoid bone grafting resulted in approximately 50% less total intraoperative time (P < .001), nearly 33% less intraoperative blood loss volume (P < .001), approximately 3-fold less scapular notching (P < .01), and approximately 8-fold less adverse events requiring revision (P < .01) when compared with the BG rTSA cohort. Aside from SCB for abduction, the Aug rTSA cohort achieved higher rates of exceeding MCID and SCB for every PROM compared with BG rTSA. More specifically, 77.6% and 70.2% of the Aug rTSA achieved SCB for American Shoulder and Elbow Surgeons and Shoulder Pain and Disability Index vs. 55% and 48.6% in the BG rTSA, respectively (P = .003 and P = .013).
The present midterm clinical and radiographic study demonstrates that the utilization of an augmented baseplate for insufficient glenoid bone stock is superior as judged by multiple PROMs and range of motion metrics when compared with bone graft augmentation at minimum 2-year follow-up. In addition, when analyzed according to MCID and SCB thresholds, the use of augmented baseplates outperforms the use of glenoid bone grafting. Complication and revision rates also favor the use of augmented glenoid baseplates over glenoid bone grafting. Long-term clinical and radiographic follow-up is necessary to confirm that these promising midterm results are durable.
Osteochondral lesions (OCL) of the knee are a common pathology that can be challenging to address. Due to the innate characteristics of articular cartilage, OCLs generally do not heal in adults and ...often progress to involve the subchondral bone, ultimately resulting in the development of osteoarthritis. The goal of articular cartilage repair is to provide a long-lasting repair that replicates the biological and mechanical properties of articular cartilage, but there is no widely adopted technique that results in true pre-injury state hyaline cartilage. Current treatment modalities have seen reasonable clinical success, but significant limitations remain. Microfracture provides short-term benefit with a fibrocartilage-based repair. While osteochondral autograft or allograft and autologous chondrocyte implantation can be effective, each have their strengths and shortcomings. Emerging concepts in cartilage repair, including scaffold engineering and one stage cell-based options, are continually advancing. These have the benefits of reduced surgical morbidity and potentially improved integration with surrounding articular cartilage but have not yet reached widespread clinical application. Tissue engineering strategies and gene therapy have the potential to advance the field, however, they remain in the early stages. The current article reviews the structure and physiology of articular cartilage, the strengths and limitations of present treatment modalities, and the newer ongoing innovations that may change the way we approach osteochondral lesions and osteoarthritis.
Purpose To evaluate morphological alterations, microarchitectural disturbances, and the extent of bone marrow access to the subchondral bone marrow compartment using micro–computed tomography ...analysis in different bone marrow stimulation (BMS) techniques. Methods Nine zones in a 3 × 3 grid pattern were assigned to 5 cadaveric talar dome articular surfaces. A 1.00-mm microfracture awl (s.MFX), a 2.00-mm standard microfracture awl (l.MFX), or a 1.25-mm Kirschner wire (K-wire) drill hole was used to penetrate the subchondral bone in each grid zone. Subchondral bone holes and adjacent tissue areas were assessed by micro–computed tomography to analyze adjacent bone area destruction and communicating channels to the bone marrow. Grades 1 to 3 were assigned, where 1 = minimal compression/sclerosis; 2 = moderate compression/sclerosis; 3 = severe compression/sclerosis. Bone volume/total tissue volume, bone surface area/bone volume, trabecular thickness, and trabecular number were calculated in the region of interest. Results Visual assessment revealed that the s.MFX had significantly more grade 1 holes ( P < .001) and that the l.MFX had significantly more poor/grade 3 holes ( P = .002). Bone marrow channel assessment showed a statistically significant increase in the number of channels in the s.MFX when compared with both K-wire and l.MFX holes ( P < .001). Bone volume fraction for the s.MFX was significantly less than that of the l.MFX ( P = .029). Conclusions BMS techniques using instruments with larger diameters resulted in increased trabecular compaction and sclerosis in areas adjacent to the defect. K-wire and l.MFX techniques resulted in less open communicating bone marrow channels, denoting a reduction in bone marrow access. The results of this study indicate that BMS using larger diameter devices results in greater microarchitecture disturbances. Clinical Relevance The current study suggests that the choice of a BMS technique should be carefully considered as the results indicate that smaller diameter hole sizes may diminish the amount of microarchitectural disturbances in the subchondral bone.
