Short graft anterior cruciate ligament reconstruction: Current concepts

Short graft anterior cruciate igament reconstruction is increasing in popularity for performing a primary ACLR. The short graft coupled with the all-inside technique using closed sockets and suspensory fixation at both femoral and tibial ends are its defining features. The outcomes of this technique have been comparable to well established transportal ACLR techniques. It has the benefits of preserved hamstring strength and less pain attributed to transtibial drilling. However, there is a learning curve involved and will require time before mastery of the technique. Furthermore, in combined osteotomy or multiligament surgery, the use of short graft anterior cruciate ligament reconstruction with sockets preserve bone stock and the single tendon harvest spares the other tendons for use in other ligament reconstruction.

Safety, Efficacy, and Cost-Effectiveness of Simultaneous Bilateral Arthroscopic Bankart Repair for Bilateral Shoulder Instability

Background:

Bilateral shoulder instability and Bankart lesions are not rare and frequently require surgical treatment. Bilateral instability may be treated with either a single-stage, simultaneous bilateral Bankart repair or 2-stage surgery.

Purpose/Hypothesis:

To compare simultaneous bilateral arthroscopic Bankart repair to 2-stage repair in terms of clinical outcomes and hospitalization costs. It was hypothesized that simultaneous repair would provide clinical outcomes similar to those of 2-stage Bankart repair while yielding lower hospitalization costs.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients who underwent simultaneous bilateral arthroscopic Bankart repair (group 1) were matched by age, sex, and injury type to control patients who had unilateral Bankart repair (group 2). All patients were operated on by the same surgeon in the same institution between 2007 and 2017 and had a minimum follow-up duration of 24 months. Patients with inflammatory arthritis, metabolic/malignant disease, previous shoulder surgery, a glenoid bone loss ≥25%, or off-track Hill-Sachs lesion were excluded. The 2 groups were compared in terms of pre- and postoperative Western Ontario Shoulder Instability Index (WOSI) scores, hospitalization costs, complications, and recurrent instability. The hospitalization cost of group 2 was multiplied by 2 to create a projection of the estimated cost of 2 sequential unilateral Bankart repairs.

Results:

The study population comprised 48 patients (38 men [79.17%] and 10 women [20.83%]; mean age, 25.5 years at surgery and 22.75 years at first dislocation). Group 1 included 32 shoulders in 16 patients, while group 2 consisted of 32 shoulders in 32 patients. The mean hospitalization cost (in 2020 US dollars) was $26,010 ± $1455 for group 1 and $33,591 ± $1574 for group 2 (P < .001). Both groups had improved WOSI scores after surgery and achieved similar scores at the latest follow-up. There was 1 redislocation in each group (3.13%). No surgery- or anesthesia-related/medical complications were recorded in either group.

Conclusion:

For bilateral shoulder instability, clinical outcomes of simultaneous bilateral arthroscopic Bankart repair were similar to those of 2-stage repair; however, lower hospitalization costs were seen after simultaneous bilateral repair compared with 2-stage surgery.

Endoscopic resection of a localized tenosynovial giant cell tumor causing posterior ankle impingement in a 15-year-old athlete: A case report

Tenosynovial giant cell tumor (TGCT) is a systematically benign but locally aggressive lesion arising from the synovium, tendon sheath or joint bursae. Even in athletes, soft tissue tumors may be the underlying reason or a component of posterior ankle impingement, although the most common mechanism is forceful and repetitive plantar flexion. In this article, we present a case of localized TGCT in a 15-year-old female patient presenting with symptoms of posterior ankle impingement. The preferred technique for treatment was complete local resection via posterior ankle endoscopy. The patient returned to sports at three months and no recurrence was observed on the last follow-up at the first postoperative year. Although rare, soft tissue tumors should be taken into consideration in posterior ankle impingement in athletes. Such benign soft tissue tumors in the posterior ankle can be treated safely and effectively via two-portal posterior endoscopic approach.

Does the Application of Platelet-Rich Fibrin in Anterior Cruciate Ligament Reconstruction Enhance Graft Healing and Maturation? A Comparative MRI Study of 44 Cases

Background:

Anterior cruciate ligament (ACL) reconstruction performed with growth factors and activated platelets has been suggested to accelerate tendon ligamentization, leading to earlier return to daily activities and sports.

Hypotheses:

Platelet-rich fibrin (PRF) will result in improved graft maturation and healing as evaluated by magnetic resonance imaging (MRI) in patients undergoing hamstring ACL reconstruction. Hemostatic and analgesic properties of PRF will lead to less postoperative blood loss and pain.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 44 patients with isolated ACL injuries who underwent arthroscopic all-inside anatomic single-bundle ACL reconstruction with semitendinosus tendon graft were enrolled. Group 1 included 23 patients who had PRF sprayed to the surface of the graft; group 2 included 21 patients for whom no PRF was used. Patients were discharged after 24 hours and examined for hemarthrosis that needed to be aspirated. MRI was performed at the fifth postoperative month. A blinded radiologist evaluated graft maturation according to its signal intensity and the presence of synovial fluid at the tunnel-graft interface.

Results:

PRF-treated grafts demonstrated lower MRI signal intensity and less fluid in the graft-tunnel interface as compared with controls for the entire length of the graft. The mean full-length MRI signal intensities were 9.19 versus 16.59 (P = .047) for groups 1 and 2, respectively. Subgroup analysis of the semitendinosus grafts demonstrated a signal intensity of 11.57 versus 23.98 (P = .044) for the proximal third, 9.53 versus 13.83 (P = .237) for the midbody, and 6.48 versus 11.98 (P = .087) for the distal third. Synovial fluid at the graft-tunnel interface was detected in 1 patient in group 1 (4.3%) and 3 patients in group 2 (14.3%; P < .001). Patients in group 1 had significantly less hemarthrosis that needed to be aspirated (P = .003), while postoperative analgesia requirements were similar in both groups (P = .08). No clinical benefit of PRF could be demonstrated in clinical outcomes.

Conclusion:

Application of PRF led to superior graft integration and maturation in the proximal third of the ACL graft. There was no significant difference in MRI signal intensity in the midbody or distal tibial graft. Application of PRF also resulted in significantly lower rates of postoperative hemarthrosis that needed to be aspirated.

Biological Response Following Inlay Arthroplasty of the Knee: Cartilage Flow Over the Implant

Objective Inlay arthroplasty (IA) has seen growing interest as a new primary arthroplasty intervention for patients that need to transition from biology to joint replacement. The purpose of this study was to investigate the biological response to this procedure. Design Patients presenting with symptomatic mono- or bicompartmental arthrosis and varus malalignment underwent IA and concurrent medial open wedge high tibial osteotomy (HTO). A subset of patients required hardware removal and consented to second-look arthroscopy without biopsy allowing for assessment of IA components and compartment-specific findings related to implant fixation, cartilage flow, propagation of lesions, and opposing tibial surfaces. Results In a series of 41 knees (35 patients) treated with combined IA and HTO (mean varus >7°), 26 knees (23 patients, 18 male, 5 female) with a mean age of 52 years (range = 43-67) required HTO plate removal. Concurrent second look arthroscopy was performed at a mean of 14 months (range = 12-19) following the index procedure. On probing, all arthroplasty components showed solid fixation without gap formation. On the medial femoral condyle, 15 mm implants ( n = 14) showed a peripheral cartilage flow of 12% (range = 5% to 25%), 20 mm implants ( n = 12) of 9% (range 5% to 15%), and trochlear implants ( n = 12) of 20% (range 10% to 40%). No progressive deterioration of the index defects or progression of tibial and retropatellar grades were seen. Conclusion Joint surface reconstruction using IA showed stable fixation with peripheral cartilage coverage ranging from 9% to 20% and no further chondral damage on opposing surfaces. Future clinical effectiveness studies are required to support the positive biological integration.

Treatment of Osgood-Schlatter disease: review of the literature

BACKGROUND

Osgood-Schlatter disease (OSD) is a self-limiting condition which occurs commonly in adolescence.

PURPOSE

The objective of this article is to review published literature regarding pathophysiology, diagnosis and treatment of OSD.

METHODS

A search of the literature was performed on the electronic databases PubMed, Cochrane and SCOPUS databases between 1962 and 2016 for pathophysiology, diagnosis and treatment of Osgood-Schlatter disease.

RESULTS

OSD, also known as apophysitis of the tibial tubercle, is a common disease with most cases resolving spontaneously with skeletal maturity. In pathophysiology, the most accepted theory is repetitive knee extensor mechanism contraction. The pain is localized to the anterior aspect of the proximal tibia over the tibial tuberosity. They may describe a dull ache exacerbated by jumping or stair climbing. Radiological evaluation may indicate superficial ossicle in the patellar tendon. Osgood-Schlatter is a self-limited disease and generally ceases with skeletal maturity. Treatment is usually symptomatic. Adults with continued symptoms may need surgical treatment if they fail to respond to conservative treatment. Surgical procedures include open, bursoscopic and arthroscopic technique. Arthroscopic surgery is beneficial over an open procedure due to early postoperative recovery, no incisional scar in front of the tuberosity that usually causes discomfort in kneeling with a better cosmetic result and the ability to address concomitant intra-articular pathology.

CONCLUSION

Osgood-Schlatter syndrome runs a self-limiting course, and usually complete recovery is expected with closure of the tibial growth plate. Overall prognosis for Osgood-Schlatter syndrome is good, except for some discomfort in kneeling and activity restriction in a few cases. Arthroscopic techniques seem to be the best choice of treatment of unresolved Osgood-Schlatter lesions.

Simultaneous ACL-PCL reconstructions with high tibial osteotomy: salvage for an unstable arthritic knee

We present a case of a 28-year-old man with a severe osteoarthritic varus knee after a neglected multiligamentous injury sustained 10 years prior. Simultaneous anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstructions with high tibial osteotomy (HTO) were performed at a single stage. Five years after surgery, there were no signs of effusion and no instability, and the patient could easily kneel down without any discomfort. We think that salvage procedures and biological reconstructions would be the primary choice of surgical treatment in young patients to delay arthroplasty, and it is possible to perform simultaneous reconstructions of ACL and PCL with HTO in a single stage.

Superior Labrum Anterior Posterior Lesions and Associated Injuries: Return to Play in Elite Athletes

Background:

Superior labrum anterior posterior (SLAP) lesions often cause shoulder pain, dysfunction, and instability. Professional athletes require a high level of shoulder function for competition and overhead activities.

Purpose:

To evaluate elite athletes who had arthroscopic surgery for common shoulder pathologies and SLAP lesions with a follow-up of more than 3 years. The associated intra-articular pathologies and return to play were documented.

Study Design:

Case series; Level of evidence, 4.

Methods:

Thirty-five shoulders in 34 elite athletes (4 women and 30 men; mean age, 25 years [range, 18-32 years]) had arthroscopic repair of SLAP lesions and accompanying Bankart or rotator cuff tears between January 2008 and November 2011. The documentation included patient symptoms, physical examination, radiological analysis with radiographs, and magnetic resonance imaging. Shoulder function was evaluated preoperatively and at follow-up using American Shoulder and Elbow Surgeons (ASES) and Kerlan Jobe Orthopaedic Clinic (KJOC) scores. The mean follow-up was 52 months.

Results:

Isolated SLAP lesions were seen in 17.1% of patients, SLAP lesions and partial cuff tear occurred in 25.7%, associated Bankart lesions in 37.1%, full-thickness rotator cuff tears in 8.6%, Bankart and posterior labrum lesions in 8.6%, and Bankart and full-thickness rotator cuff tears in 2.9%. Return to play was a mean 6.4 ± 1.5 months. The mean postoperative ASES and KJOC scores were 89.6 ± 4.6 and 80.9 ± 6.8, respectively, compared with preoperative scores of 64.0 ± 7.2 and 50.5 ± 10.3 (t test, P < .01).

Conclusion:

The majority (88.2%) of professional athletes returned to their preinjury levels. SLAP lesions may frequently occur with Bankart lesions and rotator cuff tears. A high rate of return to sport at the same level of athletic performance can be achieved by anatomic repair and effective rehabilitation.

Matrix-induced autologous chondrocyte implantation for a large chondral defect in a professional football player: a case report

Introduction

Matrix-assisted autologous chondrocyte implantation is a well-known procedure for the treatment of cartilage defects, which aims to establish a regenerative milieu and restore hyaline cartilage. However, much less is known about third-generation autologous chondrocyte implantation application in high-level athletes. We report on the two-year follow-up outcome after matrix-assisted autologous chondrocyte implantation to treat a large cartilage lesion of the lateral femoral condyle in a male Caucasian professional football player.

Case presentation

A 27-year-old male Caucasian professional football player was previously treated for cartilage problems of his left knee with two failed microfracture procedures resulting in a 9 cm² Outerbridge Grade 4 chondral lesion at his lateral femoral condyle. Preoperative Tegner-Lysholm and Brittberg-Peterson scores were 64 and 58, and by the second year they were 91 and 6. An evaluation with magnetic resonance imaging demonstrated filling of the defect with the signal intensity of the repair tissue resembling healthy cartilage. Second-look arthroscopy revealed robust, smooth cartilage covering his lateral femoral condyle. He returned to his former competitive level without restrictions or complaints one year after the procedure.

Conclusions

This case illustrates that robust cartilage tissue can be obtained with a matrix-assisted autologous chondrocyte implantation procedure even after two failed microfracture procedures in a large (9 cm²) cartilage defect. To the best of our knowledge, this is the first case report on the application of the third-generation cell therapy treatment technique, matrix-assisted autologous chondrocyte implantation, in a professional football player.

Cytotoxicity of local anesthetics to rats' articular cartilage: an experimental study

OBJECTIVE

The aim of this study was to evaluate the effects of both in vivo and in vitro bupivacaine, levobupivacaine and tramadol on articular cartilage and chondrocytes in experimental rat models.

METHODS

Thirty mature Sprague Dawley rats weighing 230-300 g were randomized into 3 groups. Bupivacaine (Group 1), levobupivacaine (Group 2) and tramadol (Group 3) were injected into the right knee joints and a physiological 0.9% saline into the left. From each group, 5 rats were executed 48 hours following drug administration after 5 and 10 days. The specimens were fixed, decalcified and stained with hematoxylin & eosin and toluidine blue. All samples were histopathologically evaluated according to the recommendation of ICRS' osteoarthritis and cartilage histopathology grading and staging system. Articular cartilage cells of the rats were cultured and seeded into cell culture flasks. Cartilage cell seeded samples (104 cells/ml) were incubated in three different anesthetic agents (0.5%); bupivacaine, levobupivacaine, and tramadol, respectively. CellTiter 96(®) Non-Radioactive Cell Proliferation (MTS) assay was used to determine the cell density on the samples.

RESULTS

Statistically significant higher OARSI grades and OA stage and scores were detected when comparing the group injected with levobupivacaine and executed after 10 days with the levobupivacaine injected group killed after 48 hours (p<0.01 [p=0.008]). Although, statistical analysis could not be done due to insufficient number of samples in the in vitro part of the experiment, it can be concluded that tramadol is cytotoxic to rat chondrocyte in vitro after 30 min of exposure. Additionally, cell numbers in both the bupivacaine and levobupivacaine treated wells showed decrease throughout 15, 30 and 60 minute exposures.

CONCLUSION

Although chondrotoxicity of bupivacaine was less harmful than levobupivacaine and tramadol, these findings suggest that local anesthetics may negatively affect articular cartilage and chondrocytes.

Arthroscopic excision of an ununited ossicle due to Osgood-Schlatter disease

Surgical excision of the ossicles has been suggested for unresolved sequelae of Osgood-Schlatter disease in adults resistant to conservative measures. A 24-year-old, male semiprofessional soccer player had anterior knee pain during sports activity and climbing stairs that had been treated conservatively for 2 years. On physical examination, there was a permanent tibial tubercle with pain. On radiographic examination, an ununited ossicle was seen beneath the patellar tendon. Arthroscopy was performed through the standard low anterolateral and anteromedial portals close to the patellar tendon. Soft tissue at the retropatellar surface and the inflamed infrapatellar fat pad beneath the patellar tendon were debrided with a motorized shaver. Localization of the ununited ossicle was performed by use of an image intensifier. The ossicle was separated from the surrounding soft tissue with a motorized shaver and removed by use of a grasper. After excision of the ossicle, the inflamed surface of the retropatellar tendon was also debrided. The contouring of the irregular surface of the tibial tubercle was performed by use of a motorized bur. After 6 weeks, the patient returned to sports activities without any restrictions. This study showed that all of the described procedures might be done arthroscopically and sports activity may be allowed earlier.

Intraarticular tramadol plus pericapsular incisional bupivacaine provides better analgesia than intraarticular plus pericapsular incisional bupivacaine after outpatient arthroscopic partial meniscectomy

Postoperative analgesic effects of intraarticular tramadol plus periarticular bupivacaine, and intraarticular plus periarticular bupivacaine injections after day-case arthroscopic partial meniscectomy were compared. Seventy-four ASA I/II patients undergoing arthroscopic partial meniscectomy, performed by a single surgeon under general anesthesia were assigned in a randomized, double-blinded manner into two groups: Group TB (n = 41) received intraarticular 100 mg of tramadol in 20 ml normal saline and periarticular incisional injection of 10 ml bupivacaine 0.5%. Group BB (n = 33) received intraarticular 20 ml 0.25% and periarticular incisional 10 ml 0.5% bupivacaine injections. The injections were performed immediately after the portal closures. Pain was assessed with visual analog scale (VAS) at 0, 15, 30 min and at 1, 2, 4 h at rest and active 90 degrees knee flexion by a blinded observer. The first additional analgesic requirement time was recorded. The patients were discharged the same day with a prescription for paracetamol as required, up to six tablets a day and questioned for analgesic use and pain score at 24 h. VAS scores at rest at 15, 30 min and at movement at 0, 15, 30 min were lower in group TB (P < 0.05). First time requiring additional analgesia was lower in group TB (17.1 +/- 21.9, 33.8 +/- 26.6) (P < 0.05) and total paracetamol dose at the end of 24 h was 1.2 +/- 1.5 g in group BB and 0.9 +/- 1.3 g in group TB (P < 0.05). Intraarticular tramadol plus periarticular bupivacaine combination provides better pain relief and less analgesic requirement following arthroscopic outpatient partial meniscectomy surgery.

[The effectiveness of dorsiflexion night splint added to conservative treatment for plantar fasciitis]

OBJECTIVES

We evaluated the effectiveness and results of night splint applications for the treatment of plantar fasciitis.

METHODS

The study included 44 patients (53 feet) with plantar fasciitis. The mean symptom duration was 7.2+/-5.9 weeks (range 1 to 24 weeks). Calcaneal spurs were detected in 12 feet. All the patients received classic conservative treatment and all were recommended to use a night splint that kept the ankle in 5-degree of dorsiflexion for eight weeks. Twenty-five patients (14 females, 11 males; 31 feet) did not accept to use a night splint, whereas 19 patients (12 females, 7 males; 22 feet) did. Evaluations were made with the AOFAS ankle-hindfoot rating scale and a visual analog scale (VAS) before and after two months of treatment. The mean follow-up periods were 33.8 months (range 12 to 54 months) and 32.7 months (range 13 to 53 months) for those who completed treatment with and without the use of a night splint, respectively.

RESULTS

Although there were no significant differences between the two groups with regard to the initial AOFAS and VAS scores, patients using a night splint exhibited significantly higher improvements in both scores at the end of the second month (p=0.01 and p=0.001, respectively). Heel pain recurred in three feet (13.6%) and in nine feet (29%) with and without night splint applications, respectively. Overall, the presence of a calcaneal spur, bilateral involvement, and body mass index were not correlated with patient satisfaction and recurrences. There was no correlation between the presence of a calcaneal spur and body mass index. However, symptom duration till treatment showed a significant correlation with recurrences (r=0.326, p=0.031).

CONCLUSION

Patients without previous treatments for plantar fasciitis obtain significant relief of heel pain in the short term with the use of a night splint incorporated into conservative methods; however, this application does not have a significant effect on prevention of recurrences after a two-year follow-up.

Functional latissimus dorsi island pedicle musculocutaneous flap to restore elbow flexion in replantation or revascularisation of above-elbow amputations

Two total and one subtotal above-elbow amputations had replantation or revascularization for their severely damaged upper extremities followed by functional latissimus dorsi island pedicle musculocutaneous flap to restore elbow flexion. The mean follow-up was 68 months (range: 14 to 121 months). At final follow-up examinations, the patients had sufficient range-of-motion of their elbows with good strength. Restoring elbow function eliminates one of the most important limiting factors for above-elbow replantations. Functional latissimus dorsi island pedicle musculocutaneous flap is very reliable, has minimal donor-site morbidity and offers a wider choice when deciding about arm replantation in the upper arm region by providing a chance of restoring functions.