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Use of allografts in knee reconstruction: II. Surgical considerations.

The first allograft used in the knee was articular cartilage. The need to use fresh grafts and the absence of proper instruments for shaping and sizing implants have prevented widespread usage of articular cartilage allografts. Patient selection is very important; young, active, well-motivated individuals with defects smaller than 4 cm2 caused by trauma or osteochondritis dissecans have the best results. Failure is evidenced by crumbling of the supporting bone and fragmentation of the graft, a process identical to that seen in osteonecrosis. The use of allografts to reconstruct knee ligaments has gained wider acceptance. The availability of high-quality tissue from modern tissue banks, excellent preservation methods, a decrease in short-term surgical morbidity, and results at 2- to 5-year follow-up that are essentially equivalent to those obtained with autogenous grafts have combined to make allografts an alternative to using the patient's own tissue. However, long-term stability results are needed for comparison with autogenous grafts. Replacing an unsalvageable meniscus with an allograft is an appealing concept, with the potential for restoring normal load distribution, lubrication, and stability in the knee. Healing of the grafts and pain reduction have been reported by several investigators, but concerns about graft shrinkage, central hypocellularity, and long-term functional survival remain.

Use of allografts in knee reconstruction: I. Basic science aspects and current status.

Allografts were first used in reconstructive surgery of the knee early in this century. Their widespread use and acceptance paralleled the development of modern tissue banks and our increased understanding of the immune system. Advantages of allogeneic tissue use include less surgical morbidity, shorter surgical time, smaller incisions, and the wider selection of graft sizes and types of tissue. Disadvantages include the risk of disease transmission, a slower biologic remodeling process, and the potential for a subclinical immune response. Allografts can be obtained in several forms, including fresh, fresh-frozen, freeze-dried, and cryopreserved, each with its own advantages and disadvantages. Graft sterility is most commonly ensured by aseptic techniques of harvest and procurement. Other methods, such as irradiation and chemical sterilization, have the potential to damage the collagen structure of the graft and must be used with care. Surgeons who use allografts should make sure that the tissue bank supplying their graft adheres to any applicable guidelines of the Food and Drug Administration and the American Association of Tissue Banks, and uses top-quality testing procedures. In addition, the physician should thoroughly understand the structural and biologic influence of the preservation technique used for that tissue.

Hip Resurfacing Arthroplasty

Surface replacement is currently recognized as a viable alternative to conventional total hip arthroplasty for young patients with end-stage osteoarthritis of the hip. The procedure involves either a hemiresurfacing of the femoral head or a total surface replacement of both the femoral head and the acetabular surface. Indications for hip surface replacement include degenerative conditions that irretrievably destroy the articular surface of the hip, resulting in pain and disability. Common conditions include osteoarthritis, posttraumatic arthritis, femoral head osteonecrosis, as well as degenerative sequelae of childhood hip disorders such as slipped capital femoral epiphysis or developmental hip dysplasia. This article presents a concise description of our metal-on-metal hip resurfacing arthroplasty using the Conserve®Plus implant.

Anterolateral Approach to Hip Resurfacing Arthroplasty: 10 Tips for the New Surgeon

Hip resurfacing is an alternative to total hip replacement that at medium-term follow-up has had high rates of clinical success and prosthesis survival when done by experienced surgeons in appropriately selected patients. Traditional selection criteria for hip resurfacing suggest that it is most successful in active men younger than 55 years, most of whom have a diagnosis of osteoarthritic hip pain. Recent reports have suggested that high survivorships of resurfaced hips can also be achieved in wider settings, such as those of active older patients and those with osteonecrosis or developmental dysplasia of the hip. Advantages of hip resurfacing as compared with total hip arthroplasty include improved load transfer to the proximal femur, a greater range of motion of the hip joint, and more natural gait mechanics of walking. Some sources also suggest that because the proximal femoral bone is retained, conversion of a failed resurfaced hip is less demanding than revision of a total hip arthroplasty. Despite these advantages, hip resurfacing is a technically demanding procedure that requires extensive training and has a well-documented learning curve. To assist the progress along this learning curve for orthopaedic surgeons unfamiliar with hip resurfacing, this article outlines the indications for and contraindications to hip resurfacing, and offers surgical tips and techniques that can help improve the outcome of this procedure.

Arthroscopic Capsular Plication for Multidirectional Instability

Multidirectional shoulder instability (MDI) is a challenging entity for the clinician to treat. The presenting complaint may range from pain to episodes of subluxation or dislocation in the affected shoulder. There is often no history of major trauma or only minor trauma. Athletes involved in repetitive overhead activities are often affected, as are patients with generalized ligamentous laxity. The mainstay of treatment of MDI is conservative, with a focus on physical therapy. Patients whose symptoms are refractory to conservative measures may benefit from surgical treatment. Traditionally, MDI has been treated with an open capsular shift. More recent reports have described successful arthroscopic capsular plication techniques. This article reviews the diagnosis and treatment options for MDI, and the technique of arthroscopic capsular plication is reviewed in detail.