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xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n\u003Cp id=\u0022p-1\u0022\u003EDiagnosis remains the key to choosing the treatment that will help to ensure the best outcome. Clinicians must also know about new therapies that are on the horizon. Issues including diagnosing and treating medial and lateral meniscus tears, using clinical practice guidelines in the \u201creal world,\u201d and the potential for stem cell therapy were discussed.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eknee surgery\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eosteoarthritis\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Emedial meniscus\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Elateral meniscus\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Emeniscectomy\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Estem cells\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eroot tears\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EACL reconstruction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eminimum clinically important improvement\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eclinical practice guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eorthopedics \u0026amp; sports medicine guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ehip \u0026amp; knee conditions\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eorthopedic procedures\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n\n\u003Cp id=\u0022p-2\u0022\u003EDuring a session on knee surgery sponsored by the Arthroscopy Association of North America, specialists discussed new concepts in diagnosis and treatment in arthroscopic practice, with a special emphasis on surgical methods and technical pearls that enhance practice performance and patient outcomes. The session opened with a presentation on identifying and treating posterior root tears of the medial meniscus (MM), followed by a discussion of the difference between lateral meniscus (LM) and MM root tears and the different approaches to repair. These practical topics were followed by a discussion of whether clinical practice guidelines (CPGs) have led to lost opportunity for some procedures. The session closed with discussions on the use and regulation of stem cells in orthopedics.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n\u003Ch2 class=\u0022\u0022\u003EAnatomic Repair of Posterior MM Root Tears\u003C\/h2\u003E\n\u003Cp id=\u0022p-3\u0022\u003EAnatomic repair of posterior MM root tears produces near-intact contact area and minimizes increases in mean and peak contact pressures compared with nonanatomic repair [LaPrade CM et al. \u003Cem\u003EAm J Sports Med.\u003C\/em\u003E 2015]. According to Robert F. LaPrade, MD, PhD, Steadman Philippon Research Institute, Vail, Colorado, USA, there are several ways to find these tears and guidelines on when to fix them. Most patients with a posterior MM tear describe a \u201cpop\u201d associated with a deep squat, pain with deep flexion, joint line pain, or palpable extrusion. On x-ray, it is sometimes possible to see a meniscal ossicle; on magnetic resonance imaging (MRI), a ghost sign, extrusion, and insufficiency fractures may be noted. Dr LaPrade cautioned that since spontaneous osteonecrosis of the knee is often associated with a meniscal root tear, a posterior meniscal root tear should be considered before diagnosing a patient with spontaneous osteonecrosis of the knee, particularly in the presence of significant bone marrow edema.\u003C\/p\u003E\n\u003Cp id=\u0022p-4\u0022\u003ESurgery is appropriate for type II MM tears with extrusion, bone marrow edema, and lower grade cartilage lesions, as well as LM type II tears with extrusion and torn meniscofemoral ligaments. MM root tears have been successfully repaired with arthroscopic pullout suture surgery [Lee JH et al. \u003Cem\u003EArthroscopy.\u003C\/em\u003E 2009], which is associated with significantly improved clinical and radiologic results compared with meniscectomy (\u003Cem\u003EP\u003C\/em\u003E\u2005\u0026lt;\u2005.05) [Kim SB et al. \u003Cem\u003EArthroscopy.\u003C\/em\u003E 2011]. Dr LaPrade anticipates that new devices, the use of biologics, and improved physical therapy will augment healing.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n\u003Ch2 class=\u0022\u0022\u003ERepair Approaches in MM vs LM Root Tears\u003C\/h2\u003E\n\u003Cp id=\u0022p-5\u0022\u003EThere are clear and important differences between MM and LM root tears, noted K. Donald Shelbourne, MD, Shelbourne Knee Center, Indianapolis, Indiana, USA. LM tears are almost always associated with anterior cruciate ligament (ACL) tears and are usually associated with acute injury. Although joint space narrowing (JSN) is not common with LM tears, medial tears almost always occur secondary to JSN that causes extrusion. Patients who had MM tears were 5.8 times more likely to have articular cartilage degeneration [Matheny LM et al. \u003Cem\u003EKnee Surg Sports Traumatol Arthrosc.\u003C\/em\u003E 2014].\u003C\/p\u003E\n\u003Cp id=\u0022p-6\u0022\u003EThe data on repair of LM root tears in conjunction with ACL reconstruction tend to support leaving the tear in situ when the meniscofemoral ligaments are intact. One MRI-based study reported no improvement in extrusion in the coronal plane but significant improvement in the sagittal plane 8 months after all-inside repair surgery (\u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.007) [Ahn JH et al. \u003Cem\u003EArthroscopy.\u003C\/em\u003E 2010]. Another study reported no statistically significant difference in International Knee Documentation Committee subjective scores (\u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.09) after 10 years between patients with LM root tears left in situ compared with patients with no meniscus tears, but these patients did have further JSN indicating some progression of arthritis [Shelbourne KD et al. \u003Cem\u003EAm J Sports Med.\u003C\/em\u003E 2011].\u003C\/p\u003E\n\u003Cp id=\u0022p-7\u0022\u003EAlthough biomechanical studies have shown that repair of MM root tears can restore joint mechanics [Marzo JM, Gurske-DePerio J. \u003Cem\u003EAm J Sports Med.\u003C\/em\u003E 2009; Allaire R et al. \u003Cem\u003EJ Bone Joint Surg Am\u003C\/em\u003E. 2008], laboratory studies do not accurately reflect \u201creal-world\u201d patients. Patients with an MM tear have JSN on x-ray and extrusion on MRI. Although repair seems appropriate, the meniscus is extruded because of JSN and it is technically difficult to pull it back into a narrowed joint. More importantly, extrusion has been shown to significantly increase after repair (\u003Cem\u003EP\u2005\u003C\/em\u003E\u0026lt;\u2005.001) [Moon HK et al. \u003Cem\u003EAm J Sports Med.\u003C\/em\u003E 2012]. Dr Shelbourne approaches MM root tears nonoperatively. He recommends injections to get the patient through the initial painful period then rehabilitation to improve range of motion, leg control, and function.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n\u003Ch2 class=\u0022\u0022\u003EAAOS CPGs Questioned\u003C\/h2\u003E\n\u003Cp id=\u0022p-8\u0022\u003EJack M. Bert, MD, Minnesota Bone \u0026amp; Joint Specialists, St Paul, Minnesota, USA, questioned whether some CPGs may interfere with the evolving goal of improved treatment and management of orthopedic conditions. He cited 3 areas where he feels the CPGs have failed by limiting the use of procedures: rotator cuff repair (RCR), arthroscopic debridement of osteoarthritis (OA), and viscosupplementation.\u003C\/p\u003E\n\u003Cp id=\u0022p-9\u0022\u003EAs background, Dr Bert noted that following the publication of several studies between 2002 and 2008 in which debridement was shown to be no better than sham surgery for knee OA [Kirkley A et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2008; Moseley JB et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2002], there was a 39% reduction in the adjusted population-based rate of in knee arthroscopy [Holmes R et al. \u003Cem\u003EAm J Sports Med\u003C\/em\u003E. 2013]. Yet, in a review of \u0026gt;\u2005273\u2005000 patients that had arthroscopy for knee OA, overall, only 4.1% of patients aged \u0026lt;\u200565 years were converted to total knee arthroplasty (TKA) [Fedorka CJ et al. \u003Cem\u003EJ Arthroplasty.\u003C\/em\u003E 2014] and in another study, 32.5% of patients with arthropathy had TKA at 9 years from the index arthroscopy indicating that arthroscopy debridement may contribute to a significant delay in TKA (\u003Cem\u003EP\u003C\/em\u003E\u2005\u0026lt;\u2005.0001) [Johanson NA et al. \u003Cem\u003EJ Arthroplasty.\u003C\/em\u003E 2011].\u003C\/p\u003E\n\u003Cp id=\u0022p-10\u0022\u003EHowever, a strong recommendation against arthroscopy with lavage or debridement in patients with a primary diagnosis of symptomatic knee OA was issued in the 2013 American Academy of Orthopaedic Surgeons (AAOS) Evidence-Based Guideline on Treatment of Osteoarthritis of the Knee [Jevsevar DS et al. \u003Cem\u003EJ Bone Joint Surg Am\u003C\/em\u003E. 2013]. A closer look at the recommendation, however, shows that it does not to apply to patients with knee OA and a primary diagnosis of meniscal tear, loose body, or other mechanical derangement. Similar difficulties exist with the CPGs for RCR [Lubowitz JH et al. \u003Cem\u003EArthroscopy\u003C\/em\u003E. 2012].\u003C\/p\u003E\n\u003Cp id=\u0022p-11\u0022\u003EDr Bert cautioned that arthroscopic debridement should be performed for the right reasons (ie, mechanical symptoms from a torn meniscus or loose body) and should be coded appropriately for the procedure performed. He furthermore believes that the recommendation against the use of viscosupplementation should be ignored since it was based on the AAOS\u2019s misuse of the minimal clinically important difference and improvement metrics.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\n\u003Ch2 class=\u0022\u0022\u003EThe Future: MSC Use in Humans\u003C\/h2\u003E\n\u003Cp id=\u0022p-12\u0022\u003EThe use of mesenchymal stem cells (MSCs) to repair large, full-thickness defects of the articular cartilage in animals was successfully performed \u0026gt;\u200520 years ago. Constance R. Chu, MD, Stanford University, Stanford, California, USA, discussed recent studies that are expected to expand this procedure in humans.\u003C\/p\u003E\n\u003Cp id=\u0022p-13\u0022\u003EIn 2007, investigators were able to achieve histologically superior cartilage repair by using an adeno-associated virus vector to deliver transforming growth factor-beta-1 to rats implanted with human bone marrow MSCs [Pagnotto MR et al. \u003Cem\u003EGene Ther\u003C\/em\u003E. 2007].\u003C\/p\u003E\n\u003Cp id=\u0022p-14\u0022\u003EHowever, because bone marrow MSCs are not readily available for use, attention has turned to the use of bone marrow concentrate (BMC). In an equine model, the use of BMC in addition to microfracture resulted in healing of acute full-thickness cartilage defects that was structurally superior to that seen with microfracture alone at 8 months (macroscopic scores, \u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.009; histological scores, \u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.02) [Fortier LA et al. \u003Cem\u003EJ Bone Joint Surg Am\u003C\/em\u003E. 2010]. Human studies with MSCs include a prospective case control study that failed to show clinical benefit after 5 years [Wakitani S et al. \u003Cem\u003EJ Bone Miner Metab.\u003C\/em\u003E 2008] and a 2013 meta-analysis of 11 studies using both MSCs and BMC, which showed limited evidence of benefit using clinical metrics [Pastides P et al. \u003Cem\u003EOsteoarthritis Cartilage.\u003C\/em\u003E 2013]. Clinical metrics are less sensitive than structural metrics as noted in another equine study showing improved arthroscopic appearance with no differences in clinical outcome metrics after injection of MSCs 1 month after microfracture [McIlwraith CW et al. \u003Cem\u003EArthroscopy\u003C\/em\u003E 2011]. Many questions related to issues, such as host factors and donor factors, remain regarding how best to employ stem cell therapy clinically. However, based on promising animal studies, Dr Chu is confident this therapy will play a role in the future of orthopedics.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-6\u0022\u003E\n\u003Ch2 class=\u0022\u0022\u003EFDA\u2019s Regulation of Stem Cells\u003C\/h2\u003E\n\u003Cp id=\u0022p-15\u0022\u003EBrian J. Cole, MD, MBA, Midwest Orthopaedics at Rush, Chicago, Illinois, USA, believes that overregulation by government, particularly the regulation of stem cells, presents a particular challenge to the development and implementation of emerging technology in the United States. Under the current FDA regulations stem cells are regulated as both a device and a biologic. Five orthopedic trials were withdrawn or canceled in 2013 due mainly to the inability to overcome the regulatory burden relating to study design and patient enrollment. There have been no new regulated products in \u0026gt;\u200516 years, due mostly to the conflicts between clinical reality and requirements set forth in the FDA Guidance Document.\u003C\/p\u003E\n\u003Cp id=\u0022p-16\u0022\u003EIn the only level 1 MSC study in the United States, adult human MSCs were delivered to the knee of 55 patients following partial medial meniscectomy [Vangsness CT Jr et al. \u003Cem\u003EJ Bone Joint Surg Am\u003C\/em\u003E. 2014]. Compared with controls, patients with OA who received MSCs experienced a greater reduction in pain along with evidence of meniscus regeneration at 2 years of follow-up (\u003Cem\u003EP\u2005\u003C\/em\u003E\u2264\u2005.05).\u003C\/p\u003E\n\u003Cp id=\u0022p-17\u0022\u003EHuman tissue and cellular and tissue-based products are placed into 3 categories: category 1 includes nonhuman tissue and cellular and tissue-based products; category 2 contains lower risk products (noncombination, minimal manipulated, nonsystemic effect, or autologous products labeled for homologous use only) such as allogeneic cartilage and minimally manipulated articular allografts; category 3 covers higher risk products such as placental cord blood and cultured bone marrow and fat stem cells [FDA. \u003Ca href=\u0022http:\/\/www.fda.gov\/biologicsbloodvaccines\/guidancecomplianceregulatoryinformation\/guidances\/tissue\/ucm427795.htm\u0022\u003Ehttp:\/\/www.fda.gov\/biologicsbloodvaccines\/guidancecomplianceregulatoryinformation\/guidances\/tissue\/ucm427795.htm\u003C\/a\u003E. Accessed April 2, 2015]. Each category is subject to specific regulations with regard to regulation and use.\u003C\/p\u003E\n\u003Cp id=\u0022p-18\u0022\u003EOne reason for the lack of studies has been the requirement for randomized controlled trials; however, a meta-analysis published in 2000 noted the lack of outcome differences between randomized clinical trials and well-designed observational studies; and the FDA has just approved an historical control trial using patient-level data on microfracture. Possible solutions to increase the number of trials include treating clinical solutions as an \u201corphan drug\u201d situation, the use of 2:1 vs 1:1 randomization, the allowance for clinical heterogeneity, the inclusion of phase 1 and 2 data, assessing for noninferiority, and the ability to use registry data.\u003C\/p\u003E\n\u003Cp id=\u0022p-19\u0022\u003EDr Cole sees progress with FDA approval of devices coming more quickly and more opportunities for studies on the biologics.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/15\/7\/2.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlpg1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}