Osteochondritis dissecans of the knee is being seen with increased frequency in pediatric and young adult athletes and is thought to be, in part, owing to earlier and increasingly competitive sports participation. Despite much speculation, the cause of both juvenile and adult osteochondritis dissecans remains unclear. Early recognition is essential. Whereas adult osteochondritis dissecans lesions have a greater propensity to instability, juvenile osteochondritis dissecans lesions are typically stable, and those with an intact articular surface have a potential to heal with nonoperative treatment through cessation of repetitive impact loading. The value of adjunctive immobilization, protected weightbearing, and unloader bracing has not been established. Skeletally immature patients with stable lesions that have not healed with nonoperative treatment should have consideration given to arthroscopic drilling to promote healing before the lesion progresses and requires more involved treatment with a less optimistic prognosis. Magnetic resonance imaging may allow early prediction of lesion healing potential. The majority of adult osteochondritis dissecans cases as well as those skeletally immature patients with unstable lesions and secondary loose bodies require fixation and possible bone grafting. Many unstable lesions will heal after stabilization, but long-term prognosis is not clear. Chronic loose fragments can be difficult to fix and have poor healing potential. Results of excision of large lesions from weightbearing zones are poor. Chondral resurfacing techniques have limited long-term data for cases of osteochondritis dissecans in skeletally immature patients.

Management of Osteochondritis Dissecans of the Knee: Current Concepts Review

Platelet Rich Plasma (PRP), a blood-derived product rich in growth factors, is a promising treatment for cartilage defects but there is still a lack of clinical evidence. The aim of this study is to show, through a randomized double blind prospective trial, the efficacy of this procedure, by comparing PRP to Hyaluronic Acid (HA) injections for the treatment of knee chondropathy or osteoarthritis (OA). 109 patients (55 treated with HA and 54 with PRP) were treated and evaluated at 12 months of follow-up. The patients were enrolled according to the following inclusion criteria: age> 18 years, history of chronic (at least 4 months) pain or swelling of the knee and imaging findings of degenerative changes of the joint (Kellgren-Lawrence Score up to 3). A cycle of 3 weekly injections was administered blindly. All patients were prospectively evaluated before and at 2, 6, and 12 months after the treatment by: IKDC, EQ-VAS, TEGNER, and KOOS scores. Range of motion and knee circumference changes were measured over time. Adverse events and patient satisfaction were also recorded. Only minor adverse events were detected in some patients, such as mild pain and effusion after the injections, in particular in the PRP group, where a significantly higher post-injective pain reaction was observed (p=0.039). At the follow-up evaluations, both groups presented a clinical improvement but the comparison between the two groups showed a not statistically significant difference in all scores evaluated. A trend favorable for the PRP group was only found in patients with low grade articular degeneration (Kellgren-Lawrence score up to 2). Results suggest that PRP injections offer a significant clinical improvement up to one year of follow-up. However, conversely to what was shown by the current literature, for middle-aged patients with moderate signs of OA, PRP results were not better than those obtained with HA injections, and thus it should not be considered as first line treatment. More promising results are shown for its use in low grade degeneration, but they still have to be confirmed.

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Platelet-rich plasma vs hyaluronic acid to treat knee degenerative pathology: study design and preliminary results of a randomized controlled trial

Purpose The purposes of this systematic review were (1) to determine whether there is a minimum hamstring autograft size for anterior cruciate ligament (ACL) reconstruction that significantly decreases the risk of failure and (2) to evaluate the methods to accurately and reliably predict the size of hamstring grafts. Methods We performed a systematic review of Level III and IV studies using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies assessing failure of quadrupled-strand autograft hamstring ACL reconstruction as a function of graft diameter with at least 1 year of follow-up and those that assessed the use of imaging or anthropometric patient-specific factors to predict hamstring autograft size were included. Results We identified 4 clinical studies that directly compared graft size and failure rate. These correlated with a 6.8 times greater relative risk of failure if the graft diameter was equal to or less than 8 mm ( P  = .008). All 9 anthropometric-based prediction studies were able to significantly correlate at least 1 parameter with intraoperative graft size. Height was the most common correlation, with r  = 0.45 ( P r  = 0.66 ( P Conclusions On the basis of the available evidence, ACL reconstruction with a quadrupled-strand hamstring autograft with a diameter equal to or larger than 8 mm decreases failure rates. In addition, grafts larger than 8 mm decrease failure rates in patients aged younger than 20 years, a group identified to be at increased risk of failure. Both patient height and magnetic resonance imaging–derived cross-sectional area of the hamstring tendons can be used preoperatively to reliably predict the hamstring autograft diameter. Level of Evidence Level IV, systematic review of Level III and IV studies.

Hamstring Autograft Size Can Be Predicted and Is a Potential Risk Factor for Anterior Cruciate Ligament Reconstruction Failure

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Evidence Bulletin: Decision aids for people facing health treatment or screening decisions

Background:Osteoarthritis (OA) is a common disease that will affect almost half the population at some point in their lives through pain and decreased functional capacity. New nonoperative options are being proposed to treat earlier stages of joint degeneration to provide symptomatic relief and delay surgical intervention.Purpose:To evaluate the benefit provided by platelet-rich plasma (PRP) injections to treat knee joint degeneration in comparison with hyaluronic acid (HA), the most common injective treatment currently adopted for this condition.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:A total of 443 patients were screened, and 192 of them were enrolled in the study according to the following inclusion criteria: (1) unilateral symptomatic knee with history of chronic pain (at least 4 months) or swelling and (2) imaging findings of degenerative changes (Kellgren-Lawrence score of 0-3 at radiographs or MRI evidence of degenerative chondropathy). Patients underwent 3 weekly int...

Platelet-Rich Plasma Intra-articular Knee Injections Show No Superiority Versus Viscosupplementation: A Randomized Controlled Trial

Purpose The aim of the study was to evaluate the clinical outcome of a collagen meniscus graft implanted in an injured medial meniscus after a minimum of 10 years' follow-up. Methods Twenty-five patients underwent arthroscopic implantation of the collagen meniscus device. They had either persistent compartmental joint line pain due to a previous medial meniscus resection (5 cases) or a large irreparable meniscus tear at arthroscopy (20 cases). Implant failure was defined as infection due to the implant or mechanical failure of the device. Twenty-two patients returned for clinical, functional, and radiographic evaluation. Magnetic resonance imaging was also performed and was analyzed with the criteria of Genovese et al. (where type 3 indicates normal and type 1 indicates completely abnormal). All the aforementioned evaluations were carried out at a minimum of 10 years (range, 10.1 to 12.5 years) after the procedure. Results The mean Lysholm score improved from 59.9 preoperatively to 89.6 at 1 year ( P P P > .05). The mean pain score on a visual analog scale improved by 3.5 points at final follow-up. Patient satisfaction with the procedure was 3.4 of 4 points. Radiographic evaluation showed either minimal or no narrowing of the joint line. Magnetic resonance imaging showed type 2 in 64% of cases and type 3 in 21%. All cases showed less volume than expected (size type 2 in 89%). The failure rate in the patient population was 8% (2 of 25). There were no complications related to the device. Conclusions Although there were several different types of patients and acute and chronic tears were treated in a limited number of patients, meniscal substitution with the collagen meniscal implant provides significant pain relief and functional improvement after a minimum of 10 years' follow-up. The implant generally diminished in size, but the procedure proved to be safe and had a low rate of implant failure on a long-term basis. No development or progression of degenerative knee joint disease was observed in most cases. Level of Evidence Level IV, therapeutic case series.

Outcome After Partial Medial Meniscus Substitution With the Collagen Meniscal Implant at a Minimum of 10 Years' Follow-up

Background:Most of the published series of transplanted menisci have consistently shown some degree of allograft extrusion. The speculation is that this meniscal extrusion may be caused by the soft tissue technique used to fix the allograft.Hypothesis:The percentage of extruded meniscal graft would be higher if the allograft were only fixed with sutures rather than with associated bony fixation.Study Design:Cohort study; Level of evidence, 2.Methods:We performed a prospective series of 88 meniscal allograft transplantations. Thirty-three of the grafts were fixed with the suture-only technique (group A). The remaining 55 cases were performed with the bone plug method (group B). All patients were studied with magnetic resonance imaging (MRI) at a minimum 3 years’ follow-up to determine the degree of meniscal extrusion. The time between surgery and MRI evaluation was 40 months (range, 36-48 months) in both groups. Meniscal extrusion was measured on coronal MRI. The percentage of the meniscal body width that ...

Suture-Only Fixation Technique Leads to a Higher Degree of Extrusion Than Bony Fixation in Meniscal Allograft Transplantation

Young patients with early osteoarthritis (OA) represent a challenging population due to a combination of high functional demands and limited treatment options. Conservative measures such as injection and physical therapy can provide short-term pain relief but are only palliative in nature. Joint replacement, a successful procedure in the older population, is controversial in younger patients, who are less satisfied and experience higher failure rates. Therefore, while traditionally not indicated for the treatment of OA, cartilage repair has become a focus of increased interest due to its potential to provide pain relief and alter the progression of degenerative disease, with the hope of delaying or obviating the need for joint replacement. The field of cartilage repair is seeing the rapid development of new technologies that promise greater ease of application, less demanding rehabilitation and better outcomes. Concurrent procedures such as meniscal transplantation and osteotomy, however, remain of crucial importance to provide a normalized biomechanical environment for these new technologies. Systematic review, Level II.

Surgical treatment for early osteoarthritis, part II: allografts and concurrent procedures

The etiology of osteochondritis dissecans and the results of treating the early stages with arthroscopic fixation using cannulated screws is discussed. Arthroscopic surgery was performed on 14 patients with osteochondritis dissecans, and the osteochondral fragment was fixed with one or two screws. A second arthroscopic procedure was necessary to assess the lesion and remove the screws. Ambulation without weight bearing is allowed during the first 2 months postoperatively. Full range of motion is encouraged. The results indicate that all patients returned to their previous sport 3-11 months postsurgery. The authors conclude that fixation with cannulated screws is the ideal method of treating osteochondritis dissecans when the osteochondral fragment is still in its bed.

Osteochondritis dissecans: A historical review and its treatment with cannulated screws

Purpose
Septic arthritis after an ACL reconstruction is a rare but serious complication. Functional outcomes of these patients have not been studied in depth in large series. The aim of this study was to determine the prevalence and management of knee joint infection following ACL reconstruction and to assess the functional outcomes.

Juan Carlos Monllau

Papers

Outcome After Partial Medial Meniscus Substitution With the Collagen Meniscal Implant at a Minimum of 10 Years' Follow-up

Suture-Only Fixation Technique Leads to a Higher Degree of Extrusion Than Bony Fixation in Meniscal Allograft Transplantation

Surgical treatment for early osteoarthritis, part II: allografts and concurrent procedures

Osteochondritis dissecans: A historical review and its treatment with cannulated screws

Knee joint infection after ACL reconstruction: prevalence, management and functional outcomes