Jonathan C. Riboh

While numerous randomized controlled trials have compared surgical treatments for cartilage defects of the knee, the comparative efficacy of these treatments is still poorly understood. The goal of this network meta-analysis was to synthesize these randomized data into a comprehensive model allowing pairwise comparisons of all treatment options and treatment rankings based on multiple measures of efficacy. We hypothesized that advanced chondral procedures would have improved outcomes when compared to microfracture.

Amniotic membrane (AM)–derived products have been successfully used in ophthalmology, plastic surgery, and wound care, but little is known about their potential applications in orthopaedic sports medicine. To provide an updated review of the basic science and preclinical and clinical data supporting the use of AM-derived products and to review their current applications in sports medicine. Systematic review. A systematic search of the literature was conducted using the Medline, EMBASE, and Cochrane databases. The search term amniotic membrane was used alone and in conjunction with stem cell, orthopaedic, tissue engineering, scaffold, and sports medicine. The search identified 6870 articles, 80 of which, after screening of the titles and abstracts, were considered relevant to this study. Fifty-five articles described the anatomy, basic science, and nonorthopaedic applications of AM-derived products. Twenty-five articles described preclinical and clinical trials of AM-derived products for orthopaedic sports medicine. Because the level of evidence obtained from this search was not adequate for systematic review or meta-analysis, a current concepts review on the anatomy, physiology, and clinical uses of AM-derived products is presented. Amniotic membranes have many promising applications in sports medicine. They are a source of pluripotent cells, highly organized collagen, antifibrotic and anti-inflammatory cytokines, immunomodulators, and matrix proteins. These properties may make it beneficial when applied as tissue engineering scaffolds, improving tissue organization in healing, and treatment of the arthritic joint. The current body of evidence in sports medicine is heavily biased toward in vitro and animal studies, with little to no human clinical data. Nonetheless, 14 companies or distributors offer commercial AM products. The preparation and formulation of these products alter their biological and mechanical properties, and a thorough understanding of these differences will help guide the use of AM-derived products in sports medicine research.

Purpose: To report the results of meniscal allograft transplantation (MAT) with minimum 2‐year follow‐up in an active adolescent population. Methods: After institutional review board approval, all patients aged 16 years or younger who underwent MAT and had more than 2 years' clinical follow‐up were identified from a prospectively collected database. Demographic data were collected and summary statistics calculated. Functional outcome scores were collected preoperatively and at 6 months, 1 year, 2 years, and final follow‐up. Differences between scores at each time point were calculated using a mixed‐model repeated‐measures analysis of variance. All prior procedures and reoperations were documented. Results: Thirty‐seven MAT procedures were performed in 36 children (84% lateral and 16% medial). For 32 of these procedures (86%), the patients met the inclusion criteria with minimum 2‐year follow‐up. The mean age was 15.4 ± 1.04 years (range, 13 to 16 years). All patients had undergone prior knee surgery. Of the 32 patients, 23 (72%) were girls and 9 (28%) were boys. Eleven patients had open physes. Forty‐eight percent of patients underwent concomitant procedures, mainly for chondral defects. The mean length of clinical follow‐up was 7.2 ± 3.2 years (range, 2 to 15 years). MAT resulted in significant improvements in the Knee Injury and Osteoarthritis Outcome Score, Lysholm score, International Knee Documentation Committee subjective score, Western Ontario and McMaster Universities Osteoarthritis Index pain score, Western Ontario and McMaster Universities Osteoarthritis Index function score, and Short Form 12 physical score. After MAT, 7 patients (22%) underwent 8 surgical procedures, most of which were for chondral disease. The meniscal reoperation rate was 6%. No revision MAT procedures were required. No angular deformities or limb‐length inequalities were reported. Conclusions: MAT resulted in predictable improvements in functional outcomes in the adolescent population. The meniscal reoperation rate was low (6%), no revision MAT procedures were required, and no growth complications were reported. Chondral disease remains the primary reason for reoperation after MAT. Level of Evidence: Level IV, therapeutic case series.

Injury to the glenohumeral capsulolabral complex is the critical lesion in anterior shoulder instability. Various injury patterns have been described including the classic Bankart lesion, the bony Bankart lesion, and humeral avulsion of the glenohumeral ligament. A rare injury variant is a glenoid avulsion of the glenohumeral ligament (GAGL lesion). Careful patient setup and surgical technique are required to identify and arthroscopically repair these lesions. We describe a suture anchor–based arthroscopic GAGL repair performed with the patient in the lateral decubitus position through standard anterior and posterior portals and an accessory posterolateral 7‐o'clock portal. Technique Video: video See video under supplementary data.

The treatment of focal cartilage defects in the knee remains a challenging clinical problem. One relatively new unique treatment option is particulated articular cartilage, which includes autograft and off-the-shelf allogeneic juvenile grafts. The use of particulated cartilage has the advantage of being a single-stage procedure. In the case of autograft, it is cost efficient, while in the juvenile allograft form, it may have increased proliferative and restorative potentials. Laboratory and clinical data are limited for particulated cartilage grafts; however, there are promising histologic and clinical outcomes. This review provides a summary of the indications, surgical technique, and most up-to-date research on particulated cartilage for the repair of symptomatic chondral defects in the knee.

Background: Leukocyte-poor platelet-rich plasma (LP-PRP) is hypothesized to be more suitable for intra-articular injection than leukocyte-rich PRP (LR-PRP) in the treatment of knee osteoarthritis. Purpose: To compare clinical outcomes and rates of adverse reactions between LP-PRP and LR-PRP for this application. Study Design: Meta-analysis. Methods: The MEDLINE, EMBASE, and Cochrane databases were reviewed. The primary outcome was the incidence of local adverse reactions. Secondary outcomes were the changes in International Knee Documentation Committee (IKDC) subjective score and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score between baseline and final follow-up measurements. A Bayesian network meta-analysis was performed, with a post hoc meta-regression to correct for baseline differences in WOMAC scores. Treatment rankings were based on surface under the cumulative ranking (SUCRA) probabilities. Results: Included in the analysis were 6 randomized controlled trials (evidence level 1) and 3 prospective comparative studies (evidence level 2) with a total of 1055 patients. Injection of LP-PRP resulted in significantly better WOMAC scores than did injection of hyaluronic acid (mean difference, −21.14; 95% CI, −39.63 to −2.65) or placebo (mean difference, −17.84; 95% CI, −34.95 to −0.73). No such difference was observed with LR-PRP (mean difference, −14.28; 95% CI, −44.80 to 16.25). All treatment groups resulted in equivalent IKDC subjective scores. The SUCRA analysis showed that LP-PRP was the highest ranked treatment for both measures of clinical efficacy (WOMAC and IKDC). Finally, PRP injections resulted in a higher incidence of adverse reactions than hyaluronic acid (odds ratio, 5.63; 95% CI, 1.38-22.90), but there was no difference between LR-PRP and LP-PRP (odds ratio, 0.78; 95% CI, 0.05-11.93). These reactions were nearly always local swelling and pain, with a single study reporting medical side effects including syncope, dizziness, headache, gastritis, and tachycardia (17/1055 total patients). Conclusion: LP-PRP results in improved functional outcome scores compared with hyaluronic acid and placebo when used for treatment of knee osteoarthritis. LP-PRP and LR-PRP have similar safety profiles, although both induce more transient reactions than does hyaluronic acid. Adverse reactions to PRP may not be directly related to leukocyte concentration.