Greg Janes

Purpose: To investigate factors associated with 10‐year clinical scores after matrix‐induced autologous chondrocyte implantation (MACI). Methods: This retrospective case series included 143 MACI patients with 10‐year clinical and radiological follow‐up. Clinical assessment included the Knee Injury and Osteoarthritis Outcome Score (KOOS) quality of life (KOOS‐QOL) and sport and recreation (KOOS‐Sport/Rec) subscales, and patient satisfaction. Regression analysis investigated the contribution of patient (age, sex, body mass index and preoperative physical health), surgical (symptom duration, prior surgeries, defect size and location) and postoperative variables, such as knee extensor strength and a magnetic resonance imaging (MRI) composite graft score, to 10‐year clinical scores and being ‘very satisfied’. Results: The KOOS‐QOL ( p < 0.001) and KOOS‐Sport/Rec ( p < 0.0001) improved from baseline to 10 years, with 88 (61.5%) patients ‘very satisfied’ with their outcome. A lower number of prior surgical procedures, greater knee extensor strength, and a better 10‐year MRI score contributed significantly to a higher KOOS‐QOL. For the KOOS‐Sport/Rec, a lower number of prior surgical procedures, undergoing tibiofemoral (versus patellofemoral) MACI, greater preoperative physical health and a better 10‐year MRI score contributed significantly to a better score. Finally, a lower number of prior procedures and greater preoperative physical health contributed to a patient being ‘very satisfied’. Conclusion: Factors including the number of prior procedures, defect location, preoperative physical health, postoperative quadriceps strength and MRI‐based graft integrity were associated with improved 10‐year clinical scores. This information will permit more tailored patient discussion, along with the setting of realistic, longer‐term expectations for outcomes. Level of Evidence: Level IV.

Introduction Advanced hip imaging and surgical findings have demonstrated that a common cause of greater trochanteric pain syndrome (GTPS) is hip abductor tendon (HAT) tears. Traditionally, these patients have been managed non-operatively, often with temporary pain relief. More recently, there has been an increase in published work presenting the results of surgical intervention. A variety of open and endoscopic transtendinous, transosseous and/or bone anchored suture surgical techniques have been reported, with and without the use of tendon augmentation for repair reinforcement. While patient outcomes have demonstrated improvements in pain, symptoms and function, post-operative rehabilitation guidelines are often vague and underreported, providing no guidance to therapists. Materials and methods A systematic search of the literature was initially undertaken to identify published clinical studies on patients undergoing HAT repair, over a 3-year period up until May 2020. Following the application of strict inclusion and exclusion criteria, studies were identified and the detail relevant to rehabilitation was synthesized and presented. Published detail was combined with the authors clinical experience, with a detailed overview of rehabilitation proposed for this patient cohort. Results A total of 17 studies were included, reporting varied detail on components of rehabilitation including post-operative weight bearing (WB) restrictions, the initiation of passive/active hip range of motion (ROM) and resistance exercises. A detailed rehabilitation guide is proposed. Conclusion In combining the current published literature on rehabilitation after HAT repair and our own clinical experience in the surgical management and post-operative rehabilitation of these patients, we present an evidence-based, structured rehabilitation protocol to better assist surgeons and therapists in treating these patients. This rehabilitation protocol has been implemented for several years through our institutions with encouraging published clinical outcomes.

Context: The importance of rehabilitation and evaluation prior to return to sport (RTS) in patients undergoing anterior cruciate ligament reconstruction has been reported. Objective: This study sought to investigate current perspectives of Australian orthopedic surgeons on rehabilitation and RTS evaluation. Design: Survey. Participants: Members of the Australian Knee Society. Main Outcome Measures: A 14-question survey was disseminated to Australian Knee Society members (orthopedic surgeons) to investigate (1) preferred graft choice, (2) estimated retear rate, (3) importance of preoperative and postoperative rehabilitation, and (4) preferred timing of RTS and evaluation prior to RTS discharge. Results: Of all 85 Australian Knee Society members contacted, 86% (n = 73) responded. Overall, 66 respondents (90.4%) preferentially used hamstring tendon autografts. All surgeons estimated their retear rate to be ≤15%, with 31 (42.5%) Conclusions: This survey revealed variation in beliefs and practices surrounding rehabilitation and RTS evaluation. This is despite the current evidence demonstrating the benefit of preoperative and postoperative rehabilitation, as well as the emerging potential of RTS assessments consisting of strength and functional measures to reduce reinjury rates.

To compare the histological and immunohistochemical characteristics of matrix-assisted chondrocyte implantation (MACI) grafts between patients with revision surgery and patients with total joint arthroplasty. Biopsies of MACI grafts from patients with revision and total joint arthroplasty. The graft tissue characteristics and subchondral bone were examined by qualitative histology, ICRS (International Cartilage Repair Society) II scoring and semiquantitative immunohistochemistry using antibodies specific to type I and type II collagen. A total of 31 biopsies were available, 10 undergoing total knee arthroplasty (TKA) and 21 patients undergoing revision surgery. Patients in the clinically failed group were significantly older (46.3 years) than patients in the revision group (36.6 years) (P = 0.007). Histologically, the predominant tissue in both groups was of fibrocartilaginous nature, although a higher percentage of specimens in the revision group contained a hyaline-like repair tissue. The percentages of type I collagen (52.9% and 61.0%) and type II collagen (66.3% and 42.2%) were not significantly different between clinically failed and revised MACI, respectively. The talar dome contained the best and patella the worst repair tissue. Subchondral bone pathology was present in all clinically failed patients and consisted of bone marrow lesions, including edema, necrosis and fibrosis, intralesional osteophyte formation, subchondral bone plate elevation, intralesional osteophyte formation, subchondral bone cyst formation, or combinations thereof. MACI grafts in patients with revision and total joint arthroplasty were predominantly fibrocartilage in repair type, did not differ in composition and were histologically dissimilar to healthy cartilage. Clinically failed cases showed evidence of osteochondral unit failure, rather than merely cartilage repair tissue failure. The role of the subchondral bone in relation to pain and failure and the pathogenesis warrants further investigation.

Objectives: Matrix-induced autologous chondrocyte implantation (MACI) has demonstrated encouraging clinical outcomes in the treatment of symptomatic knee chondral defects. However, longer term results are still lacking and post-operative management has traditionally been conservative, with little available evidence on how best to progressively increase weight bearing (WB) and rehabilitation post-surgery. This study sought to investigate the longer term clinical and radiological outcomes following an accelerated (versus conservative) WB protocol after MACI. Methods: A randomized controlled study design was used to investigate outcomes in 70 patients who underwent MACI to the medial or lateral femoral condyle between November 2005 and November 2007, in conjunction with either an accelerated (AR, n=34, 8 weeks to full WB) or conservative (CR, n=36, 12 weeks to full WB) approach to post-operative WB rehabilitation. Patients were evaluated pre-surgery and at 3, 6, 12 and 24 months, as well as 5 years post-surgery. At minimum 10 year follow up (range 10.5-11.5 years), 60 patients (86%, AR=31, CR=29) were available for review. Clinical outcomes included the IKDC, KOOS, Lysholm, Cincinnati, Tegner, SF-36, Satisfaction, maximal isokinetic knee extensor and flexor strength and functional hop capacity. Limb Symmetry Indicies (LSIs) comparing the operated and non-operated limbs were calculated for strength and functional measures. High resolution magnetic resonance imaging (MRI) was undertaken to assess the quality and quantity of repair tissue as per the magnetic resonance observation of cartilage repair tissue (MOCART) scoring system. A combined MRI composite score was also evalauted. ANOVA investigated group differecnes over time. Results: While the AR group reported significantly less knee pain in the earlier post-operative timeline, no significant differences (p>0.05) were observed in patient demographics or injury/surgery characteristics between groups, nor clinical and MRI-based scores, at minimum 10 year post-operative follow up. All clinical scores across both groups significantly improved (p<0.001) to 5 years, maintained to 10 years. At minimum 10 years, no differences were observed in mean LSIs for maximal isokinetic knee extension strength (AR=96.8%, CR=97.9%), or the single (AR=95.5%, CR=98.9%) and triple hop (AR=96.7%, CR=99.6%) tests for distance. At a minimum 10 years 82.4% and 83.3% of patients in the AR and CR groups, respectively, demonstrated a good-excellent MRI composite score, while 79.4% and 83.3% demonstrated good-excellent tissue infill, as per the MOCART score. Graft failure was observed on MRI in 5 patients (8.3%, AR=2, CR=3) at 10 years post-surgery. At 10 years, 93.3% of patients were satisfied with MACI for relieving their pain, with 83.4% satisfied with their ability to participate in sport. Conclusion: MACI provided high levels of patient satisfaction and tissue durability beyond 10 years. The outcomes of this randomized trial demonstrate a safe and effective accelerated WB rehabilitation protocol, with improved early patient outcomes albeit comparable longer term results.

Objectives: Proponents of minimally invasive knee replacements argue that retracting rather than everting the patella results in quicker postoperative recovery and improved function compared to the standard approach. We aimed to investigate this in a group of patients undergoing knee arthroplasty using a standard medial parapatellar approach. Methods: In a prospective randomized double-blinded study sixty-eight patients undergoing total knee arthroplasty through a standard medial parapatellar approach were assigned to either retraction or eversion of the patella. An independent observer assessed the flexion and secondary outcome measures of Oxford knee score, the SF12 score, visual analog pain scores, range of motion data and radiographs preoperatively, at three months and at one-year post surgery. Results: Early (3 month) follow-up showed no significant difference between eversion and subluxation in flexion (mean and 95%CI, 101°± 5.37 vs 102°±4.14) Oxford knee scores (25±3 vs 27±2.69), SF12 or visual analog pain scores (1.9±0.54 vs 1.1±0.44). A statistically significant improvement in extension was found (-3.9°±1.12 vs 2.0°±0.91 (p=0.034)) but this was not thought to be clinically significant. There was no difference in any outcomes at one year. There was a significant difference in implant malpositioning in the subluxation group with increased percentage lateral tibial overhang (0.45±0.39 vs 1.84±0.82 (p=0.005)) but this did not correlate with functional outcome. There was no statistical difference in alignment between the two groups (178.29°±0.84 vs 178.18°±0.78). There was no difference between the two groups in Insall-Salvati Ratio (1.15±0.06 vs 1.12±0.06) although there was a correlation to a reduction in the ratio and functional outcome. There were two partial divisions of the patella tendon in the retraction group, but no patella related complications in the eversion group. Conclusion: Retracting rather than everting the patella during total knee arthroplasty results in no significant clinical benefit in the early to medium term. There is no increase in patella tendon shortening as a result of eversion rather than subluxation.

Background: Proponents of minimally invasive total knee arthroplasty argue that retracting rather than everting the patella results in quicker postoperative recovery and improved function. We aimed to investigate this in patients undergoing knee arthroplasty through a standard medial parapatellar approach. Methods: In a prospective randomized double-blinded study, sixty-eight patients undergoing total knee arthroplasty through a standard medial parapatellar approach were assigned to either retraction or eversion of the patella. Postoperatively, at three months, and at one year after surgery, an independent observer assessed the primary outcome measure (i.e., knee flexion) and secondary outcome measures (i.e., Oxford knee score, Short Form-12 [SF-12] score, visual analog scale pain score, knee motion, and alignment and patellar height as measured on radiographs with use of the Insall-Salvati ratio). Results: Early (three-month) follow-up showed no significant difference between patellar eversion and subluxation in flexion (mean and 95% confidence interval [CI], 101° ± 5.37° versus 102° ± 4.14°, respectively), Oxford knee scores (25 ± 3 versus 27 ± 2.69, respectively), SF-12, or visual analog scale pain scores (1.9 ± 0.54 versus 1.1 ± 0.44, respectively). A significant improvement in extension was found (−3.9° ± 1.12° versus −2.0° ± 0.91°, respectively [p = 0.034]), but this was not clinically significant. There was no significant difference in any of the outcomes at one year. There was a significant difference in implant malpositioning between the eversion group and the subluxation group, with an increased percentage of lateral tibial overhang in the subluxation group (0.45 ± 0.39 versus 1.84 ± 0.82, respectively [p = 0.005]), but this did not correlate with functional outcome. There was no significant difference in alignment between the two groups (178.29° ± 0.84° versus 178.18° ± 0.78°). At one year after surgery, there was no difference between the two groups in Insall-Salvati ratio (1.15 ± 0.06 versus 1.12 ± 0.06) although there was a correlation between the percentage reduction in the ratio and functional outcome. There were two partial divisions of the patella tendon in the subluxation group, but no patella-related complications in the eversion group. Conclusions: The results of this trial showed that retracting rather than everting the patella during total knee arthroplasty resulted in no significant clinical benefit in the early to medium term. We observed no increase in patellar tendon shortening as a result of eversion rather than subluxation. Our findings did suggest that, with subluxation, there may be an increased risk of damage to the patellar tendon and reduced visualization of the lateral compartment, leading to an increase in implant malpositioning with lateral tibial overhang. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. Peer Review This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

We describe an augmented surgical repair technique for gluteus minimus and medius tears, along with a supportive case series. A consecutive series of 22 patients presenting with clinical and radiological findings consistent with hip abductor tears, who had undergone failed prior conservative treatments, were prospectively recruited. Patients underwent open bursectomy, Y-iliotibial release, debridement of the diseased tendon, decortication of the trochanteric foot-plate and reattachment augmented with a LARS ligament through a trans-osseous tunnel, together with suture anchors. All patients were assessed pre- and postoperatively to 12 months with the Oxford Hip Score (OHS), the Short-Form Health Survey (SF-36) and a Visual Analogue Pain Scale (VAS), while a satisfaction scale was employed at 12 months. A statistically significant improvement (p≤0.05) was observed for all patient reported outcome measures, while all patients were at least ‘satisfied’ with the procedure at 12 months. One patient reported some lateral hip discomfort at 10 months, and removal of the LARS interference screw provided immediate relief. One patient had a urological catheter-related complication. With no other complications and no clinical failures of the repair, we believe the technique to be safe and reliable, whilst reducing the incidence of re-tears as reported in the existing literature.