Incidence of Intraoperative and Postoperative Complications After Posterolateral Corner Reconstruction or Repair: A Systematic Review of the Current Literature

Drilling the tibial tunnel in an arthroscopic popliteus bypass from the anteromedial tibial cortex decreases risk of popliteal vascular injury

Purpose

Drilling the tibial tunnel in tibiofibular-based posterolateral corner (PLC) reconstructions is usually performed with a starting point from Gerdy's tubercle. Drilling the tunnel starting from the anteromedial tibial cortex could reduce the risk of popliteal neurovascular (PNV) injury. The purpose of this study is to assess the distance on Magnetic Resonance Imaging Scans (MRI) of the PNV bundle and peroneal nerve (PN) to these two different tunnel trajectories.

Methods

A total of 87 MRI scans were assessed. The ideal exit point of the tibial tunnel in PLC reconstructions was marked. We added 10 mm from this point in a straight posterior and in an oblique trajectory, mimicking the two different tunnel trajectories and measured the distance to the PNV bundle and PN from these two points.

Results

The mean distance of the tip of the guide wire drilled with a trajectory from Gerdy's tubercle to the PNV bundle and the peroneal nerve was respectively 13.2 mm (SD = 3.96) and 17.7 mm (SD = 4.39). The mean distance of the tip of the guide wire drilled with a trajectory from the anteromedial tibial cortex to the PNV bundle and the PN was respectively 19.6 mm (SD = 4.19) and 12.2 mm (SD = 3.96).). Drilling in a trajectory from the anteromedial tibial cortex significantly increases the distance to the PNV bundle (p < 0.001).

Conclusion

Tibial tunnel drilling in a tibiofibular based PLC reconstruction from the anteromedial tibial cortex significantly increases the distance to the popliteal artery but with a decreased distance to the peroneal nerve.

Level of evidence

level IV.

The presence of an aberrant anterior tibial artery does not depend on the patient's morphotype

PURPOSE

The aberrant anterior tibial artery (ATA) runs along the posterior surface of the tibial cortex making it, particularly, at risk during high tibial osteotomy (HTO). This study aimed to analyze the prevalence of the ATA according to global morphotype and its anatomical features in consideration of knee surgery.

METHODS

This retrospective study included 1589 knees on magnetic resonance imaging (MRI) studies with long-leg radiographs. The anatomical characteristics of the ATA, its distance in surgical areas at risk and its lumen were defined on MRI. Its presence according to the patient's morphotype (varus, valgus or neutral) was assessed using a χ2 test.

RESULTS

The ATA was present in 33 of 1589 knees, resulting in a prevalence of 2.1%. The anteroposterior distance of the ATA to the tibial head was 6.6 ± 2.5 mm at the height of the tibial plateau, 2.7 ± 1.6 mm at the footprint of the posterior cruciate ligament and 1.0 ± 0.6 mm under the top of the fibula (p < 0.01). For these three levels, the ratio between the distance from the ATA to the lateral tibial border and the total tibial width decreases progressively (p < 0.001). The mean lumen area of the ATA was 4.2 ± 2.5 mm2, and the lumen of the popliteal artery was 9.2 ± 3.6 mm2, representing a ratio of 49.4 ± 27.0%. The prevalence of ATA was similar between varus and valgus patients (n.s).

CONCLUSION

The presence of an ATA is rare, found in one out of 50 cases, but can be easily identified on MRI in patients before knee surgery, especially before HTO. The patient's morphotype did not influence its presence, the lumen diameter is highly variable and its clinical impact has yet to be determined.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

Ligament augmentation and reconstruction system (LARS) synthetic grafts are safe and effective for medial collateral ligament and posterolateral corner reconstructions in elite athletes

PURPOSE

This study documents the efficacy and safety of using a Ligament Augmentation and Reconstruction System (LARS) ligament graft to augment extra-articular knee ligament reconstructions in elite athletes by reporting return-to-play (RTP) rates and levels, career longevity and complications.

METHODS

A consecutive series of all extra-articular knee ligament reconstructions augmented by LARS ligaments in elite athletes undertaken by three specialist sports knee surgeons between 2013 and 2020 were reviewed. Seventy-six elite athletes, aged over 16 years old, and more than 2 years postsurgery were included. RTP was defined as competing at professional level or national/international level in amateur sport.

RESULTS

There were 64 medial collateral ligament (MCL) and 12 posterolateral corner (PLC) reconstructions. Fifty-two (68.4%) underwent concomitant autograft cruciate ligament(s) reconstruction. The mean age was 25.1 years (SD ± 4.5). Most were football (35, 46.1%) or rugby players (35, 46.1%). Sixty-seven athletes (88.2%) RTP with 65 (97.0%) of these playing at the same or higher Tegner level. Fifty-six (83.6%) of the athletes that RTP were still playing at 2 years postsurgery. Twenty (57.1%) of those who had RTP and were more than 5 years postsurgery were still playing at 5 years. Six (7.9%) players required further surgery relating to the LARS/metalwork. One case had soft tissue inflammation adjacent to the proximal end of the synthetic graft, but it is unknown if this was mechanical irritation or a biological reaction. One MCL reruptured 4 years after RTP.

CONCLUSION

Utilising LARS to augment extra-articular knee ligament reconstructions allows 88.2% of athletes with a variety of knee ligament injuries to return to elite sport. The low morbidity rates coupled with 57% of athletes still playing 5 years postsurgery demonstrates that the LARS is safe and effective in these cases. Although there are reports of LARS ligaments being used in MCL and PLC reconstructions, there is very little evidence investigating if they are safe and effective. This study demonstrates that LARS synthetic grafts can be safely used for MCL and PLC reconstructions in elite athletes and they permit a high RTP with a low risk of complications.

LEVEL OF EVIDENCE

Level IV.

There Is No Difference in Clinical Outcomes of Tibial-Based Versus Fibular-Based Posterolateral Corner Reconstruction: A Systematic Review

PURPOSE

To evaluate and analyze the current literature regarding clinical outcomes after posterolateral corner reconstruction (PLCR) using fibular-based and tibial-based techniques.

METHODS

A systematic review of the literature was performed to evaluate patient-reported outcomes after PLCR. Embase, PubMed, and Scopus were searched from their respective inception through October 25, 2022. Studies containing patient-reported outcome scores of tibial and fibular-based PLCR were included. Outcomes collected from each study were summarized using t tests for consistently reported Tegner, Lysholm, and International Knee Documentation Committee Score.

RESULTS

Twenty-four studies (16 with level of evidence IV, 6 with Level III, and 2 with Level II) met the inclusion criteria and included 669 patients in total. Four studies comprising 111 patients directly compared the results of tibial- and fibular-based PLCR. Mean clinical follow-up across all studies was 3.3 years. The 4 studies that reported on both tibial and fibular-based PLCR were found to have no significant differences in patient-reported outcomes with P values ranging from .0561 to .9881.

CONCLUSIONS

Analysis of the available literature regarding tibial- and fibular-based posterolateral corner reconstruction suggests no clinical differences.

LEVEL OF EVIDENCE

Level II-IV, review of systematic studies.

The distance between the fibular collateral ligament tunnel and the common peroneal nerve allows a posterolateral corner reconstruction without neurolysis

PURPOSE

The most popular knee posterolateral corner (PLC) reconstruction techniques describe that a common peroneal nerve (CPN) neurolysis must be done to safely address the posterolateral aspect of the knee. The purpose of this study was to measure the distance between the CPN and the fibular insertion of the FCL in different degrees of knee flexion in cadaveric specimens, to identify if tunnel drilling could be done anatomically and safely without a CPN neurolysis.

METHODS

Ex vivo experimental analytical study. Ten fresh frozen human knees were dissected leaving FCL and CPN in situ. Shortest distance from the centre of the FCL distal tunnel and CPN was measured (antero-posterior and proximal-distal wire-nerve distances) at 90°, 60°, 30°, and 0° of knee flexion. Measurements between different flexion angles were compared and correlation between knee flexion angle and distance was identified.

RESULTS

The mean distance between the FCL tunnel and the CPN at 90° were 21.15 ± 6.74 mm posteriorly (95% CI: 16.33-25.97) and 13.01 ± 3.55 mm distally (95% CI: 10.47-15.55). The minimum values were 9.8 mm posteriorly and 8.9 mm, respectively. These distances were smaller at 0° (p ≤ 0.017). At 90° of knee flexion, the mean distance from the fibular tip to the CPN distally was 23.46 ± 4.13 mm (20.51-26.41).

CONCLUSION

Anatomic localization and orientation of fibular tunnels can be done safely while avoiding nerve neurolysis. Further studies should aim to in vivo measurements and results.

Functional Hydrogels for Delivery of the Proteolytic Enzyme Serratiopeptidase

Hydrogels are superior wound dressings because they can provide protection and hydration of the wound, as well as the controlled release of therapeutic substances to aid tissue regeneration and the healing process. Hydrogels obtained from natural precursors are preferred because of their low cost, biocompatibility, and biodegradability. We describe the synthesis of novel functional hydrogels based on two natural products-citric acid (CA) and pentane-1,2,5-triol (PT, a product from lignocellulose processing) and poly(ethylene glycol) (PEG-600)-via an environment friendly approach. The hydrogels were prepared via monomer crosslinking through a polycondensation reaction at an elevated temperature in the absence of any solvent. The reagents were blended at three different compositions with molar ratios of hydroxyl (from PT and PEG) to carboxyl (from CA) groups of 1:1, 1:1.4, and 1.4:1, respectively. The effect of the composition on the physicomechanical properties of materials was investigated. All hydrogels exhibited pH-sensitive behavior, while the swelling degree and elastic modulus were dependent on the composition of the polymer network. The proteolytic enzyme serratiopeptidase (SER) was loaded into a hydrogel via physical absorption as a model drug. The release profile of SER and the effects of the enzyme on healthy skin cells were assessed. The results showed that the hydrogel carrier could provide the complete release of the loaded enzyme.

High tibial osteotomy for acute correction and subsequent gradual tensioning of the posterolateral knee ligament complex in treating genu varum combined with a lateral thrust using the Ilizarov technique in adults: surgical technique and early results

OBJECTIVE

To report the early results of using the Ilizarov technique in performing medial wedge opening high tibial osteotomy (MWOHTO) combined with gradual tensioning of the posterolateral corner in adult patients presenting with genu varum (GV) and lateral thrust.

METHODS

A prospective case series study included 12 adult patients with a mean age of 25.2 ± 8.1 years who presented with GV deformity associated with lateral thrust. They were evaluated clinically using the "hospital for special surgery" (HSS) knee scoring system. Radiological evaluation was performed using long film from hip to knee to ankle (HKA) radiographs; the overall mechanical alignment was measured as the HKA angle, the upper tibial deformity was measured as the medial proximal tibial angle (MPTA), and the joint line convergence angle (JLCA) was measured. Surgical technique included using Ilizarov for MWOHTO below the level of the tibial tubercle, acute correction of the GV deformity, fibular osteotomy, and gradual distalization of the proximal fibula.

RESULTS

After a mean follow-up of 26.3 ± 6.4 months, all osteotomies were united. All patients achieved fibular osteotomy site bony union except two with a fibrous union. The HSS score showed improvement from a mean preoperative score of 88.7 ± 7.6 to a postoperative 97.3 ± 3.9 (P < 0.05). The overall mechanical lower limb alignment improved significantly from a mean preoperative HKA of 164.5 ± 3.2 to a postoperative 178.9 ± 1.6 (P < 0.05). The MPTA improved significantly from 74.6 ± 4.1 to 88.9 ± 2.3, as well as the JLCA from 12.17 ± 1.9 to 2.3 ± 1.7 (P < 0.05). Grade 1 pin tract infection was developed in four patients and was treated conservatively. In two patients, mild pain over the fibular osteotomy site was relieved over time. The lateral thrust reoccurred at the last follow-up evaluation in the two poliomyelitis patients.

CONCLUSION

MWOHTO, concomitant with tensioning the knee lateral soft tissue structure at the same setting through applying an Ilizarov apparatus, showed promising functional and radiological outcomes.

Three-dimensional-printed patient-specific instrumentation is an accurate tool to reproduce femoral bone tunnels in multiple-ligament knee injuries

PURPOSE

Multiple-ligament knee reconstruction techniques often involve the creation of several bone tunnels for various reconstruction grafts. A critical step in this procedure is to avoid short tunnels or convergences among them. Currently, no specific template guide to reproduce these angulations has been reported in the literature, and the success of the technique still depends on the experience of the surgeon. The aim of this study is to analyze the accuracy and reliability of 3D-printed patient-specific instrumentation (PSI) for lateral and medial anatomical knee reconstructions.

METHODS

Ten cadaveric knees were scanned by computed tomography (CT). Using specific computer software, anatomical femoral attachments were identified: (1) on the lateral side the lateral collateral ligament (LCL) and the popliteal tendon (PT) and (2) on the medial side the medial collateral ligament (MCL) and the posterior oblique ligament (POL). Four bone tunnels were planned for each knee, and PSI with different directions were designed as templates to reproduce the planned tunnels during surgery. Twenty 3D-printed PSI were used: ten were tailored to the medial side for reconstructing MCL and POL tunnels, and the other ten were tailored to the lateral side for reconstructing LCL and PT tunnels. Postoperative CT scans were made for each cadaveric knee. The accuracy of the use of 3D-printed PSI was assessed by superimposing post-operative CT images onto pre-operative images and analyzing the deviation of tunnels performed based on the planning, specifically the entry point and the angular deviations.

RESULTS

The median entry point deviations for the tunnels were as follows: LCL tunnel, 1.88 mm (interquartile range (IQR) 2.2 mm); PT tunnel, 2.93 mm (IQR 1.17 mm); MCL tunnel, 1.93 mm (IQR 4.26 mm); and POL tunnel, 2.16 mm (IQR 2.39). The median angular deviations for the tunnels were as follows: LCL tunnel, 2.42° (IQR 6.49°); PT tunnel, 4.15° (IQR 6.68); MCL tunnel, 4.50° (IQR 6.34°); and POL tunnel, 4.69° (IQR 3.1°). No statistically significant differences were found in either the entry point or the angular deviation among the different bone tunnels.

CONCLUSION

The use of 3D-printed PSI for lateral and medial anatomical knee reconstructions provides accurate and reproducible results and may be a promising tool for use in clinical practice.

Superior Bone Microarchitecture in Anatomic Versus Nonanatomic Fibular Drill Tunnels for Reconstruction of the Posterolateral Corner of the Knee

Background:

Several fibula-based reconstruction techniques have been introduced to address ligamentous injuries of the posterolateral corner of the knee. These techniques involve a drill tunnel with auto- or allograft placement through the proximal fibula.

Purpose:

To determine the skeletal microarchitecture of the proximal fibula and its association with age and to compare the microarchitecture within the regions of different drill tunnel techniques for reconstruction of the posterolateral corner.

Study Design:

Descriptive laboratory study.

Methods:

A total of 30 human fibulae were analyzed in this cadaveric imaging study. High-resolution peripheral quantitative computed tomography measurements were performed in a 4.5 cm–long volume of interest at the proximal fibula. Three-dimensional microarchitectural data sets of cortical and trabecular compartments were evaluated using customized scripts. The quadrants representing the entry and exit drill tunnel positions corresponding to anatomic techniques (LaPrade/Arciero) and the Larson technique were analyzed. Linear regression models and group comparisons were applied.

Results:

Trabecular microarchitecture parameters declined significantly with age in women but not men. Analysis of subregions with respect to height revealed stable cortical and decreasing trabecular values from proximal to distal in both sexes. Along with a structural variability in axial slices, superior values were found for the densitometric and microarchitectural parameters corresponding to the fibular drill tunnels in the anatomic versus Larson technique (mean ± SD; bone volume to tissue volume at the entry position, 0.273 ± 0.079 vs 0.175 ± 0.063; P < .0001; cortical thickness at the entry position, 0.501 ± 0.138 vs 0.353 ± 0.081 mm; P < .0001).

Conclusion:

Age represented a relevant risk factor for impaired skeletal microarchitecture in the proximal fibula in women but not men. The region of drill tunnels according to anatomic techniques showed superior bone microarchitecture versus that according to the Larson technique.

Highly Water-Absorptive and Antibacterial Hydrogel Dressings for Rapid Postoperative Detumescence

Postoperative wound edema, infection, and pain burden the patient’s life. Therefore, the purpose of this study is to develop an effective antibacterial, multifunctional application to prevent postoperative edema and relieve postoperative pain by making full use of the dehydrating and analgesic effects of magnesium sulfate (MgSO₄), magnesium oxide (MgO), sodium alginate (SA), and sodium carboxymethyl cellulose (Na-CMC) to make a composite hydrogel, which can promote postoperative detumescence. MgSO_4//MgO/SA/Na-CMC composite hydrogel dressings have outstanding mechanical properties, high water absorption, and good biocompatibility. MgO endows the hydrogel dressing with excellent antibacterial properties and better antibacterial activity against common bacteria and multidrug-resistant bacteria. In addition, MgSO₄/MgO/SA/Na-CMC hydrogel dressing shows superior dehydration and analgesic properties in the postoperative nude mice model. This study shows that the multifunctional MgSO₄/MgO/SA/Na-CMC composite hydrogel dressing developed as a surgical incision dressing has broad prospects in the prevention of incision infection, postoperative edema, and analgesia.