Background: Focal chondral defects of the knee are a common condition. These lesions have a limited ability to heal and may progress to osteoarthritis. this presents an especially difficult clinical problem in young, high-demand patients. Autologous osteochondral grafting is an excellent method of biological resurfacing of focal chondral and osteochondral defects of the weight-bearing surface of the knee. Patients and Methods: This is a prospective clinical study performed between March 2017 to May 2021 in Menoufia University Hospitals. 30 patients with 30 knees, Mean Age 28 years, had focal chondral or osteochondral defects of the weight-bearing surface of the knee joint, 90% in the medial femoral condyle. (OATS) Was used in all cases. The mean ± SD defect size was 2.55±0.48 cm2 with ranged 1.2 -3 cm2. All patients were analyzed using the (IKDC) evaluation form with at least two years follow up period. Results: In the present study, OCD was the most common cause (80%) followed by Localized degenerative (13.3%) and traumatic (6.7%) causes. There was a statistically significant difference (p<0.001) between the mean of the preoperative (52.54±6.02) and Post-operative subjective IKDC scores (86.91±7.16%) indicating marked improvement of the postoperative Subjective IKDC score. Conclusions: The OATS is safe, efficient and cost-effective for the treatment of focal chondral lesions. the graft transferred should be flushed, radial and delivered gently. Maximum coverage and stability (press-fit) should be obtained. this technique should be limited to a chondral defect less than 3cm2. Keywords; knee; chondral lesions; Osteochondral fracture; OATS Level of evidence: IV

Introduction. Osteoarthritis - leading cause of disability worldwide. Existing treatments are not regenerative. The stromal vascular fraction contains mesenchymal stem cells, and has been shown to be effective in cartilage repair.
Purpose of the study. Assess the clinical efficacy of autologous cells of the stromal vascular fraction of adipose tissue (SVF) in patients with osteoarthritis of the knee.
Methods. A total of 15 patients with knee osteoarthritis (Kellgren–Lawrence I-IV) were included to the study. Initially arthroscopy of the knee joint was performed to carry out debridement and determine the initial state of the joint. Then lipoaspirate from the anterior abdominal wall after double centrifugation and the addition of platelet-rich plasma was injected into the cavity of the injured knee by intra-articular injection. Knee society score (KSS), visual analog scale (VAS), osteoarthritis outcome score (KOOS) were used for clinical evaluations function of the knee. The follow-up time 8 month.
Results. There are 9 women, mean age was 49.3 years (±28). At the same time, all 15 patients showed an increase in the range of motion, pain relief and significantly improved patient reported KSS, KOOS and VAS scores. In one case, there was an increase body temperature and ESR in the general blood test up to 14 mm/h temporary after injection.
Conclusion. The collected clinical results offer that SVF may represent a safe and effective treatment for OA symptoms, suggesting minimally invasive treatment. Further studies are needed to confirm clinical effect of SVF.
Key words: knee, adipose-tissue stromal-vascular fraction, regenerative medicine, osteoarthritis.

Introduction: Treatment of osteochondral defects (OCDs) of the knee joint remains challenging. The purpose of this study was to evaluate the clinical and radiological results of osteochondral regeneration following intra-articular injections of autologous peripheral blood stem cells (PBSCs) plus hyaluronic acid (HA) after arthroscopic subchondral drilling into OCDs of the knee joint. Methods: Five patients with OCDs of the knee joint were treated with arthroscopic subchondral drilling followed by postoperative intra-articular injections of autologous PBSCs plus HA. Autologous PBSCs were harvested one week after surgery and patients received five weekly intra-articular injections. Three additional intra-articular injections were administered weekly at intervals of 6, 12, 18 and 24 months after surgery. Subjective International Knee Documentation Committee (IKDC) scores and MRI scans were obtained preoperatively and postoperatively at serial visits. Results: At follow-ups of more than 5 years, the mean preoperative and postoperative IKDC scores were 47.2 and 80.7 respectively (p=0.005). IKDC scores for all patients exceeded the minimal clinically important difference values of 8.3, indicating clinical significance. Serial MRI scans charted the repair and regeneration of the OCDs with evidence of bone growth filling-in the base of the defects, followed by reformation of the subchondral bone plate and regeneration of the overlying articular cartilage. There were no significant adverse events, complications nor infections. Conclusion: Arthroscopic subchondral drilling into OCDs of the knee joint followed by postoperative intra-articular injections of autologous PBSCs plus HA has the ability to repair and regenerate both the osseous and articular cartilage components with clinical significance.

Ramp lesions are tears of the peripheral attachment of the posterior horn of the medial meniscus at the meniscocapsular junction and/or the meniscotibial ligament. This peripheral area is well-vascularized and theoretically has a good potential for spontaneous healing. During 6 months, all anterior cruciate ligament (ACL) reconstructions were recorded. Revision ACL ligament reconstruction were excluded. The population included 40 patients, all men, age average 23.3. 6 ramp lesions were observed (15%): 2 healed ramp lesions, 4 underwent repair with a suture hook device through a posteromedial portal. All these 6 patients displayed a grade III pivot shift under anesthesia before surgery. 9 months postoperatively, all patients restored the pivot shift to normal. Ramp lesions most commonly occurs in association with ACL tears with reported incidence of 9.3%-24%, which is in line with our study. Its pathophysiology has been debated with cadaveric studies. Hughston's theory of semimembranosus capsular tendon contraction remains accepted. Recent biomechanical studies reported negative effects of untreated ramp lesions on knee kinematics, based on an increased risk of persistent instability and reconstruction graft failure. Some authors insisted on the surgical repair of all ramp lesions at the time of ACL reconstruction. However, given the capsule vascularization and the meniscus red-red zone, some studies reported the potential for ramp lesions to heal without surgical treatment, as presented in 2 of our patients. Magnetic resonance imaging has a low sensitivity for detecting ramp lesions, making essential the routinely inspection of this “hidden” area in order to not miss this diagnosis.

Due to increasing popularity of arthroscopic procedures, a significant number of specific instruments have been developed. The standard arthroscopic burr or drill driver has become increasingly useful for drilling, shaving, and generally making depressions in intra articular areas where there is limited space. However, situations may arise when it is desirable for the surgeon to steer the active working end of the blade to multiple locations inside the joint during joint arthroscopy, including to areas where the opposite joint surface acts as an overhang which obstructs access. Micro-fracture is a common procedure that is used to encourage bleeding from the joint surface. It has largely been replaced by Micro-drilling as it is a procedure that encourages more consistent cartilage island formation. Achieving this end result using currently available hand piece drilling and cutting burrs is challenging and time consuming for the surgeon. Due to mechanical limitations of currently available designs, the blades must be large to remain robust and, as a result, cannot access the joint pervasively. Since a fluted drill bit design may be significantly more efficacious than a burr or rotating sharpened edge for drilling applications, a fluted drill design may be desirable for applications that require significant drilling. In this presentation, we describe the development of a specially designed arthroscopic drill for insertion into a human joint. A review of the existing drill designs is also presented along with the technical specifications and development steps undertaken to conceptualize, design and deploy our drill for use in patients.

Mesenchymal stem cell-derived exosomes (MSC-Exos) have been utilized as medicinal agents or as delivery vehicles in cartilage injuries and cartilage-based diseases. Given the ongoing emergence of evidence on the effector mechanisms and methods of the utility of the MSC-Exos in knee osteoarthritis, a comprehensive review of the current evidence is the need of the hour. Hence, in this article, we review the current understanding of the role of MSC-Exos in the management of knee osteoarthritis in view of their classification, characterization, biogenesis, mechanism of action, pathways involved in their therapeutic action, in-vitro evidence on cartilage regeneration, in-vivo evidence in OA knee models and recent advances in using MSC-Exos to better streamline future research from bench to bedside for OA knee.

Meniscal root tears have shown superior clinical outcomes after repair comparing to meniscectomy. High-cost materials represent a limitation for orthopedic surgeons that are willing to perform meniscal root repair using all-inside devices. Alternatives involving accessible instruments are crucial, in terms of expenses, especially in public hospitals. The technique involving combined use of anterior portals and transtibial tunnels with epidural needle was proven to be efficient. Thus, the present study aims to present technical orientations and tips to increase the efficiency related to meniscal root repair using the aforementioned technique in the setting of Brazilian public hospitals.

Introduction: Medial meniscal extrusion (MME) after ACL reconstruction (ACLR) is an important factor in predicting future osteoarthritis progression. This study aims to investigate factors influencing MME after ACLR using multiple regression analysis. Methods: This study included 103 patients who underwent ACLR at our institution. The analysis was performed on 84 patients, excluding four patients with PCLR, three patients with re-operation, two patients with re-tears, and ten patients without MRI at one year (mean Age 27.8, 51 females, BMI 22.7, 44 left, 26 MM sutures). Pre- and postoperative MME were measured on MRI and compared by paired t-test. Multiple linear regression was calculated to predict postoperative MME based on age, gender, BMI, preoperative MME, and presence of MM suture. Results: The preoperative MME was 2.40±0.98 mm and the MME at one year postoperatively was 2.48±0.88 mm (p=0.48). Participants' predicted postoperative MME is equal to 1.03 + 0.015 (age) – 0.21 (gender) + 0.002 (BMI) + 0.32 (preoperative MME) + 0.99 (presence of MM suture), where age is measured as years, BMI as kg/m2, and preoperative MME as mm; sex is coded as: 1 = male, 0 = female and presence of MM suture as: 1 = yes, 0 = no. Age (p<0.05), preoperative MME (p<0.001), and presence of MM suture (p<0.001) were significant predictors of postoperative MME. Conclusion: MME after ACLR was positively correlated with age and preoperative MME and was significantly greater in cases with MM suture.

Background:The iliotibial band together with its attachment to the distal femur, known eponymously as the Kaplan fibers has been shown to contribute to anterolateral rotatory stability of
the knee. However, there remains paucity of data regarding the detailed anatomy of the Kaplan fibers to aid us in anatomical based surgical reconstruction of these structures. The aim of our study was to identify and compare the presence and quantitative anatomy of the Kaplan fibers in Caucasian and Asian cadavers. Methods: 20 paired fresh-frozen Asian and 20 unpaired embalmed Caucasian cadaveric knees were dissected using a standard outside-in technique. The presence, qualitative and quantitative measurements of any distal femoral attachments of the iliotibial band were
recorded. Mean values of its dimensions were calculated and compared between the Caucasian and Asian groups. Results: A consistent supracondylar attachment of the iliotibial band was found in all Caucasian knees and in 19 of 20 Asian knees. The fibres were noted to have two variations with regards to its insertion to the distal femur, either as a single limb or as a double limb attachment, averaging between 30mm to 40mm from the lateral femoral epicondyle. No statistically significant difference was noted in dimensions of the fibres between the
Caucasian and Asian group. Conclusions: The Kaplan fibres are a consistent attachment of the iliotibial band at the distal femur in both Caucasian and Asian knees with two different patterns of insertion. Surgical reconstructions should aim to recreate these attachments to be as anatomical based as possible.

Lateral patella dislocations are a fairly common knee injury in teenagers and young adults accounting for 2-3% of all knee injuries. Avulsion fractures are less frequent (7% of all dislocations) and are sometimes overlooked in the initial assessment of the patient following an acute patella dislocation. Patella dislocation may result from a direct blow to the knee or twisting of the femur with a fixed tibia. After reduction, an X-ray is performed in AP/lateral view but also a merchant view, osteochondral lesions may only become apparent using this projection. An MRI to assess other associated injuries should be the following exam, however it is not often an available exam in the emergency department. Surgical repair or excision of the fragment should be performed as well as removal of loose intraarticular bodies. We present 4 cases of fragment repair using bioabsorbable darts/screws and 1 case of fragment excision because of its inferior size (intraoperative photos and videos available). Diagnostic arthroscopy was initially performed to diagnosed and treat any other associated injury as well as reinforcing the MPFL with an anchor suture. Postoperatively, patients are fitted with a knee brace to allow 0-30º ROM for the first two weeks and then progressed to gradually regain full ROM. Radiologically osteochondral avulsion fractures exhibit signs of healing. It is important to perform early diagnosis and treatment of avulsion fractures of the patella after dislocation. Excision and fixation are accepted options whilst the preferred method of fixation is not yet clear.

The first meniscal suture was performed in 1885 and it took about a century to become popular worldwide. Currently, all-inside meniscal repair devices are widely used. Nonetheless, this technique has the disadvantage of being a method dependent on specific devices, presenting a higher cost than other known techniques. The elevated costs limit the use of all-inside devices, especially in public hospitals in developing countries. The purpose of this technical note is to describe an all-inside meniscal suture using a 40x12mm disposable procedure needle. The authors believe that the modified technique presented might become widespread, permitting its use mainly in resource-limited settings (RLS).

Introduction: tibial spine avulsion fractures (TSAF) are uncommon knee injuries among adults. Several techniques of arthroscopic treatment have been described in the literature.
This study aims to describe our tension band wiring (TBW) fixation technique and to evaluate clinical and radiological outcomes of these lesions. Methods: We carried out a retrospective study including 5 patients (2019-2021) treated using our arthroscopic TBW technique ( fixation with two k-wires and cerclage with a wire loop). Clinical outcomes were evaluated by Lysholm score. Radiological outcomes were also reported. Results: The mean age was 36 years. 2 patients had non-reducible McKeever type II avulsion fracture and3 had type III. At the final follow-up ( average of 16 months), All fractures showed union. All patients achieved full range of movement knee.No clinical sagittal laxity was found. The mean Lysholm score was 97.2 (92,2-100).Conclusion: Arthroscopic reduction and fixation of tibial spine avulsion fractures by tension band wiring technique can achieve excellent clinical and radiological results in type II and III. It is a simple, reproducible, and low-cost surgical option.

Background
This study aimed to describe outcomes of patients who had undergone medial patellofemoral ligament reconstruction (MPFLr) to treat PF instability following TKA.

Methods
This is a retrospective case-series of consecutive patients treated at a single institution for PFI post TKA. Patients were included is they had either clinical or radiographic documentation of patella dislocation or subluxation, and component position was deemed adequate on pre-operative imaging. In all cases, MPFLr was performed using a quadriceps tendon autograft. The graft was fixed to the femur in a bone tunnel, with either interference screw or additional suspensory fixation to obtain cortical reinforcement. Patients were assessed clinically with Kujala and international knee score (IKS) scores at a minimum 12-month follow-up, and radiographically to measure Caton-Deschamp index (CDI), patella-tilt (PT) and patella-shift (PS).

Results
A total of 22 patients (23 procedures) were included. Mean follow-up was 38 months (range 12-72). At the last follow-up, mean IKS knee score was 79.57/100 ± 13.4, the mean IKS function score was 73.38/100 ± 26.1 and the mean Kujala score was 57.42/100 ± 18.7. There was 1 mechanical failure, which occurred in the isolated MPFL with a screw fixation group and 7 complications (30.4%) overall. MPFLr had a patella lowering effect, 0.97 pre-operatively to 0.74 post-operatively (p=0.069).

Conclusion
MPFL reconstruction, with the addition of TTO in appropriately selected patients is a satisfactory option to treat PF instability following TKA.

Introduction: Multiligamentous knee injury is a complex and challenging problem, not only because it is difficult to diagnose, but reconstruction procedures need expertise itself. A high level of suspicion and a comprehensive clinical and radiographic examination are required to identify all injured structures.In multi-ligamentous reconstruction, several technical aspects that require consideration are important, such as graft choice, the sequence of ligament reconstruction, and tunnel position. The purpose of our study is to analyze a single institution’s experience with multi-ligamentous knee injuries using autologous grafts.
Method: Clinical data of thirty-five patients, who underwent for surgical treatment from January 2017 to July 2020 were enrolled in the study. All the surgical intervention done at Liaquat National Hospital. A detailed performa was designed to collect the demographic data, type, and degree of injury, radiological findings, and surgical technique. Patients were evaluated at follow up of 6 months, 1 year and 2 Years using Lysholm score and The International Knee Documentation Committee score (IKDC).
Results: All patients included in the study had mean age, 31.62 SD±6.89, BMI 21.67 SD1.7. In our study, all patients were male gender and all patients had trauma to the knee. The overall Lysholm score averaged 85.0±3.66 points (range, 85-100 points). According to the IKDC evaluation, 16 patients was graded as A, 6 patient were graded as B, 3 patient with ACL/PCL/PLC was graded as C and none of the patients were graded D. At 2 years we found a significant association with Lysholm score having p value <0.0001

Ankle arthroscopy has emerged as a viable treatment option for multiple ankle pathologies and continues to have expanding indications as technology and techniques improve. Historically, ankle arthroscopy used skeletal traction, and it has transitioned to noninvasive soft-tissue distraction because of high rates of iatrogenic complications. Although soft-tissue distraction has decreased complications, it continues to be both cumbersome and time-consuming. Thus we propose a simple cost effective , altruistic method of effective ankle distraction using the existing fracture tabe set up and sterile ankle strap.
We have achieved excellent distraction without neurovascular complication at the same time allowing for hindrance free view and movement of scope and instruments within the ankle joint , even in heavily arthritic joint.
Simple, cost-effective , efficient, reliable and safe distraction system of ankle joint. We could potentially save on the expensive distraction arm set up and can be set up in any orthopaedic theatre without the need for any other specialized hardware , thus saving n time and budget. The fracture table system allows us to control the fine as well as gross traction settings for an effective and safe visualization during the procedure. This set u can also be "swung away" from the table after simple decupling of foot from distraction strap , allowing for other procedures such as ankle fusion to proceed. This set up allows for easy C-arm integration as well

32yr male patient presented with anterolateral ankle pain since 1 yr. He had history of sprain. There was swelling in the anterolateral groove, locking sensation during dorsiflexion, Molloy test was positive & no instability.He had 2 MRI scans over this period. He was diagnosed to have grade 2 sprain of the ATFL along with ALAIS and OA. After informed consent, he underwent therapeutic ankle arthroscopy in supine position with manual traction. There was extensive synovitis in anterolateral gutter with hypertrophic soft tissue. Grade3/ 4 OA changes were present on the lateral talar dome and distal tibial articular surface. There were distal tibial anterior osteophytes as well. 50ml of Bone marrow aspirate (BMA) was taken from the anterior iliac crest. About 8ml of Bone
marrow aspirate concentrate (BMAC) was obtained after going through the clinical centrifuge. Synovectomy, debridement, chondroplasty, removal of loose chondral flaps, microfracture & excision of osteophytes with burr was done. He did not go near the ATFL in the lateral gutter arthroscopically as it could damage the ATFL while clearing the hypertrophic soft tissues on its superior edge. A mini open incision over ATFL to see it’s integrity was done and it was found to be intact. A dry scope was done and BMAC was inserted after closing the arthroscopic portals and the mini incision. The patient was mobilised non weight bearing with a Walker frame 5hrs after the procedure under physio supervision. The procedure was done as day care.

Introduction: Anterior Cruciate Ligament (ACL) is a key ligament involved in stabilising the knee joint. ACL injuries remain the most common injuries in soccer due to high velocity, frequent change in direction, pivots and rotation of lower limbs. This study investigates the incidence of ACL injuries in soccer based on playing positions (defenders, midfielder, forward and goalkeeper). Methods: Research papers on ACL injuries published in the last ten years were reviewed. PubMed and CINAHL database searches were performed using various combinations of the following keywords: ACL Injury, Knee Injury and Knee injury in soccer. Four out of 380 published papers were included in this study, with the primary focus being on playing positions. Results: Our study includes a review of 52542 soccer players. A total of 843 ACL injuries were recorded, and our data shows that defenders have the highest number of ACL injuries compared to other playing positions. Discussion: Our study shows that defenders are at the highest risk of sustaining ACL injuries. Studies show that majority of these injuries occur via contact mechanism while tackling and are more common in female soccer players as compared to their male counterparts. Conclusion: The results indicate that defenders are at the greatest risk of ACL injuries. Data from our study show that defenders sustained the highest percentage (37%) of ACL injuries compared to midfielders (29%), forwards (27%) and goalkeepers (5%). This study suggests prevention knee injuries become vital especially dealing with elite athletes.