Biomaterials for meniscus and cartilage in knee surgery: state of the art

Meniscus and cartilage injuries of the knee joint lead to cartilage degeneration and osteoarthritis (OA). The research on biomaterials and artificial implants as substitutes in reconstruction and regeneration has become a main international focus in order to solve clinical problems such as irreparable meniscus injury, postmeniscectomy syndrome, osteochondral lesions and generalised chronic OA. In this review, we provide a summary of biomaterials currently used in clinical practice as well as state-of-the-art tissue engineering strategies and technologies that are developed for articular cartilage and meniscus repair and regeneration. The literature was reviewed over the last 5 years on clinically used meniscus and cartilage repair biomaterials, such as Collagen Meniscal Implant, Actifit, NUsurface, TruFit, Agili-C and MaioRegen. There are clinical advantages for these biomaterials and the application of these treatment options should be considered individually. Standardised evaluation protocols are needed for biological and mechanical assessment and comparison between different scaffolds, and long-term randomised independent clinical trials with large study numbers are needed to provide more insight into the use of these biomaterials. Surgeons should become familiar and stay up to date with evolving repair options to improve their armamentarium for meniscal and cartilage defects.

Impact of Hyaluronic Acid on the Viability of Mesenchymal Cells Derived from Adipose Tissue Grown in Collagen Type I/III Membrane

Objective  To evaluate in vitro the viability of mesenchymal stem cells derived from adipose tissue (AD-MSCs) in different commercial solutions of hyaluronic acid (HA) before and after being sowed in collagen I/III membrane. Methods  In the first stage, the interaction between AD-MSCs was analyzed with seven different commercial products of HA, phosphate buffered saline (PBS), and bovine fetal serum (BFS), performed by counting living and dead cells after 24, 48 and 72 hours. Five products with a higher number of living cells were selected and the interaction between HA with AD-MSCs and type I/III collagen membrane was evaluated by counting living and dead cells in the same time interval (24, 48 and 72 hours). Results  In both situations analyzed (HA + AD-MSCs and HA + AD-MSCs + membrane), BFS presented the highest percentage of living cells after 24, 48 and 72 hours, a result higher than that of HA. Conclusion  The association of HA with AD-MSCs, with or without membrane, showed no superiority in cell viability when compared with BFS.

All-Cause Failure Rates Increase With Time Following Meniscal Repair Despite Favorable Outcomes: A Systematic Review and Meta-analysis

PURPOSE

The purpose of this review is to perform a meta-analysis of studies reporting meniscus repair outcomes. Pooled analyses of such studies will provide an accurate estimate of the outcomes that can be expected following meniscal repair at various postoperative time points.

METHODS

A meta-analysis of meniscal repair failure (defined as persistent symptoms, lack of healing on magnetic resonance imaging or revision surgery) and other clinical outcomes was performed following meniscal repair. Patients included had traumatic, nondegenerative meniscal tears, were skeletally mature, and had specific time-points after surgery. Repairs included were performed either in isolation, or with concomitant ACL reconstruction. Because of the inherent heterogeneity of single-arm meta-analyses, pooled analyses were performed using a random-effects model.

RESULTS

Rates of all-cause meniscal repair failure was pooled to be 12% at 0-1 years (95% CI: .09-.16), 15% at 2-3 years (95% CI: .11-.20), and 19% at 4-6 years (95% CI: .13-.24). Sensitivity analysis for studies performing meniscal repair entirely on patients with concomitant ACL reconstruction (ACLR) showed comparable rates of failure at similar time intervals. Development of osteoarthritis, in patients with knees previously free from articular pathologies, was 4% at 2-3 years (95% CI: .02-.07), and 10% at 4-6 years (95% CI: .03-.25).

CONCLUSION

Meniscus repair for traumatic injuries have an all-cause failure rate that increases from 12% to 19% through a time period ranging from 1-6 years following surgery. The failure rates were comparable for patients with meniscal repairs performed with concomitant ACLRs.

LEVEL OF EVIDENCE

IV; Systematic Review of Level II-IV Studies.

Does the Fight Profile Interfere with Orthopedic Injuries in Brazilian Jiu-Jitsu?

Purpose

To evaluate the prevalence and characteristics of orthopedic injuries associated with the technical-tactical profiles of Brazilian Jiu-Jitsu (BJJ) fighters, according to the fighters’ graduation level (beginner and advanced).

Patients and Methods

Cross-sectional study, which included the participation of amateur and professional BJJ athletes, aged between 18 and 60 years and practitioners of the sport for at least six months. All answered a mixed self-reported morbidity questionnaire. Participants were divided into four groups, according to the technical-tactical profile in the fight (keeper and passer) and the fighter’s graduation level (beginner and advanced), and also into four subgroups, divided by joining the groups in pairs above. Descriptive and analytical statistical procedures were used, with a level of statistical significance set at 5% (p < 0.05).

Results

A total of 198 participants were included in the study. There was a higher prevalence of musculoskeletal injuries in advanced fighters (p<0.001), with no significant difference between the profiles of guard and passer fighters. Sprains were the most common type of injury in all studied groups and subgroups. The anatomical segments knee and shoulder, respectively, were the most affected in all groups, and both segments showed significant associations of the athletes in the advanced and guard groups.

Conclusion

The study showed important data for creation of specifics injury prevention protocols, through the higher prevalence of injuries in athletes of the advanced profile and in the segments of the knee and shoulder, with emphasis on the guard fighters.

KNEE INJURIES PREVALENCE IN BRAZILIAN JIU-JITSU: EPIDEMIOLOGICAL STUDY

OBJECTIVE

To evaluate the epidemiological and clinical characteristics of knee injuries in Brazilian Jiu-Jitsu (BJJ) practitioners.

METHODS

Cross-sectional study, using a mixed questionnaire, based on the Referred Morbidity Index.

RESULTS

198 amateur and professional BJJ fighters, of both sexes, aged between 18 and 60 years, participated in the study. The majority (88%) of the fighters had only one knee injury (p < 0.001). In total, 29.8% proportion of knee injuries (p < 0.001) was identified, which were mainly from the medial collateral ligament (38%), caused by a sprain mechanism (86%) and conservative treatment (65%).

CONCLUSION

A high prevalence of knee injuries in JJB fighters was found, compared to other sports that also perform rotational movements and have great body contact, such as mixed martial arts (MMA), judo, soccer, basketball and handball. Some JJB strikes, such as the key and the projection, can cause greater knee joint stress, both in the attacking fighter and in the opponent. The knowledge of the epidemiological characteristics of sports injuries is important in the elaboration of prevention and training protocols more specific to the sport and for the understanding of the complex mechanisms involved with this outcome in sport. Level of Evidence IV, Case Series.

Medial meniscal extrusion greater than 4 mm reduces medial tibiofemoral compartment contact area: a biomechanical analysis of tibiofemoral contact area and pressures with varying amounts of meniscal extrusion

PURPOSE

The primary objective of this study is to evaluate the contact areas, contact pressures, and peak pressures in the medial compartment of the knee in six sequential testing conditions. The secondary objective is to establish how much the medial meniscus is able to extrude, secondary to soft tissue injury while keeping its roots intact.

METHODS

Ten cadaveric knees were dissected and tested in six conditions: (1) intact meniscus, (2) 2 mm extrusion, (3) 3 mm extrusion, (4) 4 mm extrusion, (5) maximum extrusion, (6) capsular based meniscal repair. Knees were loaded with a 1000-N axial compressive force at 0°, 30°, 60°, and 90° for each condition. Medial compartment contact area, average contact pressure, and peak contact pressure data were recorded.

RESULTS

When compared to the intact state, there was no statistically significant difference in medial compartment contact area at 2 mm of extrusion or 3 mm of extrusion (n.s.). There was a statistically significant decrease in contact area compared to the intact state at 4 mm (p = 0.015) and maximum extrusion (p < 0.001). The repair state was able to improve medial compartment contact area, and there was no statistically significant difference between the repair and the intact states (n.s.). No significant differences were found in the average contact pressure between the repair, intact, or maximum extrusion conditions at any flexion angle (n.s.). No significant differences were found in the peak contact pressure between the repair, intact, or maximum extrusion conditions at any flexion angle (n.s.).

CONCLUSION

In this in vitro model, medial meniscus extrusion greater than 4 mm reduced medial compartment contact area, but meniscal extrusion did not significantly increase pressure in the medial compartment. Additionally, meniscal centralization was effective in restoring the medial tibiofemoral contact area to intact state when the meniscal extrusion was secondary to meniscotibial ligament injury. The diagnosis of meniscal extrusion may not necessarily involve meniscal root injury. Since it is known that meniscal extrusion greater than 3 or 4 mm has a biomechanical impact on tibiofemoral compartment contact area and pressures, specific treatments can be established. Centralization restored medial compartment contact area to the intact state.

Chemical Ablation of Genicular Nerve with Phenol for Pain Relief in Patients with Knee Osteoarthritis: A Prospective Study

BACKGROUND

Radiofrequency ablation of the genicular nerve is performed for knee osteoarthritis (KOA) when conservative treatment is not effective. Chemical ablation may be an alternative, but its effectiveness and safety have not been examined. The objective of this prospective open-label cohort study is to evaluate the effectiveness and safety of ultrasound-guided chemical neurolysis for genicular nerves with phenol to treat patients with chronic pain from KOA.

METHODS

Forty-three patients with KOA with pain intensity score (Numeric Rating Scale, NRS) ≥ 4, and duration of pain of more than 6 months were considered for enrollment. Ultrasound-guided diagnostic blocks of genicular nerves (superomedial, inferomedial, and superolateral) with 1.5 mL of 0.25% bupivacaine at each site were performed. Those who reported more than 50% reduction in NRS went on to undergo chemical neurolysis, using 1.5 mL 7% glycerated phenol in each genicular nerve. NRS and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were assessed before intervention and at 2 weeks and 1, 2, 3, and 6 months following the intervention.

RESULTS

NRS and WOMAC scores improved at all time points. Mean pain intensity improved from 7.2 (95% confidence interval [CI]: 6.8 to 7.7) at baseline to 4.2 (95%CI: 3.5 to 5.0) at 6-month follow-up (P < 0.001). Composite WOMAC score improved from 48.7 (95%CI: 43.3 to 54.2) at baseline to 20.7 (95%CI: 16.6 to 24.7) at 6-month follow-up (P < 0.001). Adverse events did not persist beyond 1 month and included local pain, hypoesthesia, swelling, and bruise.

CONCLUSION

Chemical neurolysis of genicular nerves with phenol provided efficacious analgesia and functional improvement for at least 6 months in most patients with a low incidence of adverse effects.

Radiographic Methods Are as Accurate as Magnetic Resonance Imaging for Graft Sizing Before Lateral Meniscal Transplantation

BACKGROUND

Accurate allograft matching is deemed critical for meniscal transplantation; thus, precise measurements are essential to correctly calculate meniscal size. Several methods for meniscal sizing have been described, but there remains a discussion on which is the most accurate for the lateral meniscus.

PURPOSE

To compare the accuracy of radiographic, anthropometric, and magnetic resonance imaging (MRI) methods of determining width and length of the lateral meniscus with actual dimensions after anatomic dissection.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten fresh-frozen human cadaveric knees without any evidence of meniscal or ligamentous injury were primarily imaged using radiography and MRI and subsequently underwent dissection to assess the anatomic size of each meniscus. Four methods were used to predict the size of the lateral menisci: anthropometric, radiographic (Pollard and Yoon), and MRI. Absolute differences in length and width between actual and predicted sizes were determined.

RESULTS

The anatomic lateral meniscal width and length were 33.01 ± 4.25 mm (mean ± SD; range, 24.84-40.18 mm) and 31.41 ± 5.06 mm (range, 25.2-40.05 mm), respectively. Regarding width, the anthropometric method demonstrated an absolute difference from anatomic measurement significantly greater when compared with the Pollard technique and MRI (P = .002). Regarding length, the Pollard method presented an absolute difference significantly greater than all other techniques (P = .003). In terms of the ability to measure width and length, MRI accurately predicted meniscal size within 10% of the anatomic size in 65% of measurements, the Yoon method in 54%, and the Pollard method in 20% (P = .01). Radiographs tended to overestimate the true size of the lateral meniscus, while the anthropometric technique overestimated width in all specimens.

CONCLUSION

This study demonstrated that MRI and the Yoon radiographic method are comparable in terms of accuracy for graft sizing before lateral meniscal transplantation. While MRI is useful, a contralateral MRI is required, which makes the Yoon radiographic method recommended given the ease and cost advantage. The original Pollard technique and the anthropometric method are not recommended.

CLINICAL RELEVANCE

Over- and undersizing of meniscal transplants has been implicated in graft failure. Therefore, increasing the reliability of preoperative meniscal measurements is deemed important for the success of meniscal allograft transplantation.

Higher Axial Tibiofemoral Rotation and Functional Outcomes with Mobile-Bearing Compared with Fixed-Bearing Total Knee Arthroplasty at 1- but Not at 2-Year Follow-Up-A Randomized Clinical Trial

The objective of this study was to determine in vivo knee kinematics and clinical outcomes of patients who underwent fixed- and mobile-bearing total knee arthroplasty (TKA) at 1- and 2-year follow-up. This prospective double-blinded randomized controlled trial was performed from November 2011 to December 2012. A total of 64 patients were randomized to fixed- and mobile-bearing TKA groups (32 patients in each group). All patients were evaluated with the following: three-dimensional in vivo knee kinematics analysis during gait, stepping up and stepping down stair steps, and getting up from and sitting on a chair; and knee range of motion and patient-reported outcome measures (Knee Outcome Survey Activities of Daily Living Scale [KOS-ADLS] and pain visual analog scale [VAS]) at 1- and 2-year follow-up. Descriptive statistics (means, standard deviations, and percentages) were calculated for all variables. The Kolmogorov-Smirnov test was used to test if variables were normally distributed. A Student's t-test was used to compare continuous variables between patients in the two groups. The chi-square test was used to compare the groups with respect to categorical variables. The α level for statistical significance was set at p < 0.05. The mean axial tibiofemoral rotation in patients who underwent mobile-bearing TKA was significantly higher during gait (13.3 vs. 10.7), stepping up (12.8 vs. 10) stair steps, and getting up (16.1 vs. 12.1) from a chair compared with fixed-bearing TKA patients at 1-year follow-up (p < 0.05). KOS-ADLS function score was significantly higher in the mobile-bearing compared with the fixed-bearing TKA group (32 vs. 27.7) at 1-year follow-up (p < 0.05). No significant difference in kinematics and clinical outcomes between fixed- and mobile-bearing TKA groups was observed at 2-year follow-up (p > 0.05). Based on the results of this study, mobile-bearing TKA allowed a higher degree of rotation when walking, stepping up stair steps, and standing up from a chair, and had higher functional outcomes compared with fixed-bearing TKA at 1-year follow-up. However, no difference in in vivo kinematics or in clinical outcomes was observed between fixed- and mobile-bearing prostheses at 2-year follow-up.

Medial Opening Wedge High Tibial Osteotomy Decreases Medial Meniscal Extrusion and Improves Clinical Outcomes and Return to Activity

Background:

Medial meniscal extrusion (MME) is defined as displacement of the meniscus that extends beyond the tibial margin. Knee varus malalignment increases MME.

Purpose/Hypothesis:

The purpose of this study was to quantify MME before and after medial opening wedge high tibial osteotomy (HTO) and to correlate the reduction of MME with clinical outcomes and return to activity. It was hypothesized that MME would decrease after HTO and that patients with lower MME after surgery would have improved clinical outcomes and return to activity at short-term follow-up.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study included 66 patients who underwent HTO to correct the anatomic axis with a minimum follow-up of 2 years. MME was measured using magnetic resonance imaging preoperatively and 6 weeks after surgery (study protocol). Patients were assessed preoperatively and postoperatively with the Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) score for pain, and Tegner score.

Results:

The mean ± SD preoperative and postoperative MME values were 3.9 ± 0.6 mm and 0.9 ± 0.5 mm, respectively. At 2 years after surgery, KOOS, pain VAS, and Tegner scores were higher than those found preoperatively (P < .001). Patients with less than 1.5 mm of MME after surgery had better clinical outcomes and return to activity compared with patients who had MME of 1.5 mm or more (P < .05).

Conclusion:

Medial opening wedge HTO decreased MME after 6 weeks and improved clinical outcomes and return to activity at a minimum 2-year follow-up. Additionally, patients with postoperative MME of less than 1.5 mm had better clinical outcomes and return to activity compared with patients who had postoperative MME of 1.5 mm or more.

Pediatric Anterior Cruciate Ligament Reruptures Are Related to Lower Functional Scores at the Time of Return to Activity: A Prospective, Midterm Follow-up Study

Background:

Skeletally immature patients show a higher rate of anterior cruciate ligament (ACL) reruptures. A better understanding of the risk factors for an ACL rerupture in this population is critical.

Purpose/Hypothesis:

The objective of this study was to analyze preoperative, intraoperative, and postoperative characteristics of pediatric patients undergoing ACL reconstruction and determine the relationship of these factors with an ACL rerupture. It was hypothesized that patients with worse activity scores and knee function at the time of return to activity would have a higher rate of ACL reruptures at midterm follow-up. Additionally, it was hypothesized that most ACL reruptures would occur before age 20 years in the study population.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

A total of 65 skeletally immature patients (age <16 years) with ACL ruptures underwent reconstruction with a quadruple hamstring tendon graft between 2002 and 2016. Of these patients, 52 were available for the study. Patient characteristics, surgical details, Tegner and Lysholm scores, and ACL reconstruction outcomes were recorded. Patients were analyzed and compared according to ACL rerupture occurrence.

Results:

Of the 52 patients, 18 (34.6%) experienced an ACL rerupture after reconstruction. The majority of reruptures (77.8%) occurred before age 20 years. There were 2 patients who sustained ACL reruptures during the rehabilitation period before they returned to activity. The majority of reruptures occurred after 12 months (83.2%), with 66.6% occurring after 24 months. Upon returning to activity between 6 and 9 months postoperatively, patients who ended up with intact ACL grafts reported 69% higher mean Tegner scores (P = .006) and 64% higher mean Lysholm scores than patients who sustained ACL reruptures (P < .001). Within the limits of this study, we could identify no statistical relationship between the rate of ACL reruptures and different sport types, surgical techniques, or associated injuries (P > .05).

Conclusion:

Skeletally immature patients who underwent ACL reconstruction and sustained ACL reruptures had lower Tegner and Lysholm scores upon returning to activity than patients without ACL reruptures. In addition, most ACL reruptures occurred in patients younger than 20 years (77.8%) and after 24 months postoperatively (66.6%).

Evaluation and Management of Subchondral Calcium Phosphate Injection Technique to Treat Bone Marrow Lesion

PURPOSE

This study aimed to compile available data in medical literature about subchondral calcium phosphate injection, comparing results obtained with this technique, as well as indications, complications, and other important factors in treatment of bone marrow lesions.

DESIGNS

A literature review using PubMed and Medline database in order to identify works with terms "subchondral calcium phosphate injection," " subchondroplasty®," "bone marrow lesion," and "knee." Eight relevant articles were found.

RESULTS

A total of 164 patients with bone marrow lesion mainly on femoral condyle and tibial plateau recovered with significant functional improvement of knee after subchondral calcium phosphate treatment. Although 25% of them still had some type of pain complaint, they also showed improvement. There were few complications reported and return to activities occurred after 3 months on average.

CONCLUSIONS

Few studies evaluate the result of using subchondral calcium phosphate injection technique. However, all presented favorable results regarding pain and improvement of knee function. In addition, within 2 years, there was a 70% reduction in conversion to total knee arthroplasty in patients with previous surgical indication who choose calcium phosphate treatment.

The development of the anterior cruciate ligament in the paediatric population

PURPOSE

The aim of this study was to retrospectively compile normative data on the anterior cruciate ligament (ACL) in the paediatric population with magnetic resonance imaging, emphasizing the differences between men and women.

METHODS

In this retrospective study, musculoskeletal radiologists evaluated length, area, coronal and sagittal inclination of the ACL and inclination of the intercondylar notch. A total of 253 MR examinations (130 males and 123 females between 6 and 18 years of age) were included. The association between measurements, sex and age was considered. Linear and fractional polynomial regression models were used to evaluate the relationships between measurements.

RESULTS

ACL length showed significant progressive growth (p < 0.001) with age in men and women, without characterization of growth peaks. ACL area in women showed more pronounced growth up to 11 years, stabilized from 11 to 14 years and then sustained a slight reduction. In men, ACL area showed more pronounced growth up to 12 years, stabilized from 12 to 15 years and then sustained slight reduction. Coronal and sagittal inclination of the ACL showed a significant progressive increase (p < 0.001) with age in both sexes, progressively verticalizing. The intercondylar roof inclination angle showed significant progressive reduction (p < 0.001) with age in both sexes.

CONCLUSION

The area of the ACL does not accompany skeletal maturation, interrupting its growth around 11-12 years. Progressive verticalization of the ACL as well as of the intercondylar notch roof in the evaluated ages was also observed. The clinical relevance of this study is that the ACL presents different angular and morphologic changes during growth in the paediatric population. Since ACL repair is now being performed on younger children, recognition of the normal developmental changes of the ACL is of utmost importance for successful ACL graft placement.

LEVEL OF EVIDENCE

III.

Epidemiology of injuries due to ankle sprain diagnosed in an orthopedic emergency room

Objective

To use magnetic resonance imaging to assess the prevalence of foot and ankle ligament injuries and fractures associated with ankle sprain and not diagnosed by x-ray.

Methods

We included 180 consecutive patients with a history of ankle sprain, assessed at a primary care service in a 12-month period. Magnetic resonance imaging findings were recorded and described.

Results

Approximately 92% of patients had some type of injury shown on the magnetic resonance imaging. We found 379 ligament injuries, 9 osteochondral injuries, 19 tendinous injuries and 51 fractures. Only 14 magnetic resonance imaging tests (7.8%) did not show any sort of injury. We observed a positive relation between injuries of the lateral complex, syndesmosis and medial ligaments. However, there was a negative correlation between ankle ligament injuries and midfoot injuries.

Conclusion

There was a high rate of injuries secondary to ankle sprains. We found correlation between lateral ligament injuries and syndesmosis and deltoid injuries. We did not observe a relation between deltoid and syndesmosis injuries or between lateral ligamentous and subtalar injuries. Similarly, no relation was found between ankle and midfoot injuries.

Biomechanical Comparison of Vertical Mattress and Cross-stitch Suture Techniques and Single- and Double-Row Configurations for the Treatment of Bucket-Handle Medial Meniscal Tears

BACKGROUND

Given the variety of suturing techniques for bucket-handle meniscal repair, it is important to assess which suturing technique best restores native biomechanics.

PURPOSE/HYPOTHESIS

To biomechanically compare vertical mattress and cross-stitch suture techniques, in single- and double-row configurations, in their ability to restore native knee kinematics in a bucket-handle medial meniscal tear model. The hypothesis was that there would be no difference between the vertical mattress and cross-stitch double-row suture techniques but that the double-row technique would provide significantly improved biomechanical parameters versus the single-row technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten matched pairs of human cadaver knees were randomly assigned to the vertical mattress (n = 10) or cross-stitch (n = 10) repair group. Each knee underwent 4 consecutive testing conditions: (1) intact, (2) displaced bucket-handle tear, (3) single-row suture configuration on the femoral meniscus surface, and (4) double-row suture configuration (repair of femoral and tibial meniscus surfaces). Knees were loaded with a 1000-N axial compressive force at 0°, 30°, 60°, 90°, and 120° of flexion for each condition. Resultant medial compartment contact area, average contact pressure, and peak contact pressure data were recorded.

RESULTS

Intact state contact area was not restored at 0° ( P = .027) for the vertical double-row configuration and at 0° ( P = .032), 60° ( P < .001), and 90° ( P = .007) of flexion for the cross-stitch double-row configuration. No significant differences were found in the average contact pressure and peak contact pressure between the intact state and the vertical mattress and cross-stitch repairs with single- and double-row configurations at any flexion angles. When the vertical and cross-stich repairs were compared across all flexion angles, no significant differences were observed in single-row configurations, but in double-row configurations, cross-stitch repair resulted in a significantly decreased contact area, average contact pressure, and peak contact pressure (all P < .001).

CONCLUSION

Single- and double-row configurations of the vertical mattress and cross-stitch inside-out meniscal repair techniques restored native tibiofemoral pressure after a medial meniscal bucket-handle tear at all assessed knee flexion angles. Despite decreased contact area with a double-row configuration, mainly related to the cross-stitch repair, in comparison with the intact state, the cross-stitch double-row repair led to decreased pressure as compared with the vertical double-row repair. These findings are applicable only at the time of the surgery, as the biological effects of healing were not considered.

CLINICAL RELEVANCE

Medial meniscal bucket-handle tears may be repaired with the single- or double-row configuration of vertical mattress or cross-stitch sutures.

ASSESSMENT OF THE REGENERATION CAPACITY OF SEMITENDINOSUS AND GRACILIS TENDONS

Objectives:

To evaluate the regenerative capacity of gracilis (G) and semitendinosus (ST) tendons, to examine the sensitivity and specificity of signs and symptoms in the assessment of hamstring tendons, and to assess the thickness and insertion site of regenerated tendons.

Methods:

Thirty sequential knees were subjected to anterior cruciate ligament reconstruction with semitendinosus and gracilis tendons. After surgery, the patients were followed up clinically with physical examination and magnetic resonance imaging (MRI).

Results:

Overall, 36.66% of the tendons were visible on MRI, whereas 83.33% were palpable. On MRI, the distal insertion site of the regenerated semitendinosus tendon was visible proximal to the landmark of the medial femoral condyle in 28%, at the same level in 16%, and distally in 56% of the cases. Gracilis tendon insertion was visible proximally in 36.66% of cases, at the same level in 10%, and distally in 53.33%. Eleven knees exhibited complete regeneration.

Conclusion:

Partial or total regeneration of the ST and G tendons was apparent on MRI. Palpation is effective for evaluating regeneration of the ST and G tendons; however, MRI is still the gold standard. ST and G tendons regenerated completely in only a small percentage of patients, limiting reuse as a graft in cases with new ligament injuries of the knee. Level of Evidence II, Prospective comparative study.

Hydrogel implant is as effective as osteochondral autologous transplantation for treating focal cartilage knee injury in 24 months

PURPOSE

The treatment approach for a patient with knee joint focal cartilage lesion is a difficult decision. To date, there has been no randomized clinical trial involving Hydrogel (Cartiva™). This study evaluated and compared the results of a hydrogel implant (Cartiva™) with autologous osteochondral transplantation (AOT) for treating knee joint focal cartilage lesions.

METHODS

Thirty-eight symptomatic patients, with a focal cartilage lesion of Outerbridge grades III or IV, were randomized into one of two groups according to the inclusion and exclusion criteria. Group I underwent AOT, and Group II was treated with a Hydrogel implant. Patients were evaluated preoperatively and again postoperatively at 6, 12, and 24 months using the subjective International Knee Documentation Committee (IKDC) scores, Visual Analog Scale for Pain (VAS Pain), Activities of Daily Living Scale (ADLS) and Lysholm score.

RESULTS

Both groups showed significant improvements from baseline (pre-surgery) to post-surgery (6, 12, and 24 months; p < 0.05), but there was no difference between the groups. Regarding complications, prolonged pain was observed in four patients (10.5%), two from each group, with a regression of symptoms within 1 year.

CONCLUSION

The Hydrogel implant showed similar efficiency as the autologous osteochondral graft for treating knee joint focal cartilage lesions. Both techniques showed satisfactory results compared to preoperative status. The Hydrogel implant was safe and effective, and it provided good stability and joint function at 2-year follow-up.

LEVEL OF EVIDENCE

I.

Knee isokinetic performance following anterior cruciate ligament reconstruction: patellar tendon versus hamstrings graft

OBJECTIVE

To compare knee isokinetic performance six months after reconstruction of the anterior cruciate ligament using grafts from either the patellar tendon or the hamstrings among patients who underwent the same rehabilitation protocol.

METHODS

Thirty-four patients were evaluated (17 with grafts from the patellar tendon and 17 with grafts from the hamstrings). Operated and non-operated knees were compared with regards to the variables of peak torque, work and the hamstring/quadriceps relationship at velocities of 60º/s and 180º/s and power of 180º/s after six months of surgery.

RESULTS

The patients with ACL reconstruction using the patellar tendon (BPTB) showed quadriceps deficits for all variables, but the flexor musculature was balanced. In the hamstring group, both the extensors and the flexors showed deficits for the variables analyzed, except for hamstring power at 180º/s.

CONCLUSION

Patients in the patellar tendon group had a greater quadriceps deficit compared with those in the hamstrings group. Patients in the hamstrings group had a greater muscular deficit in the flexor mechanism compared with the contralateral knee. An unbalanced H/Q ratio was observed regardless of graft type, but this was more evident in the BPTB group.

ASSOCIATION OF TOBACCO DEPENDENCE, ALCOHOLISM AND ANABOLIC STEROIDS WITH MENISCOLIGAMENTOUS INJURIES

OBJECTIVE

To determine a relationship between smoking, alcohol abuse and anabolic steroids and meniscoligamentous injuries.

METHODS

A total of 239 patients underwent surgical treatment of isolated anterior cruciate ligament (ACL) lesion, ACL associated with meniscal injury and isolated meniscal injury, and were inquired by a single team of surgeons about their habits: smoking, alcoholism and use of artificial anabolic agents. In addition, quality of life was assessed using the SF-36 questionnaire.

RESULTS

It was not possible to establish a direct relationship between habits and meniscal and ligamentous injuries, despite the finding that patients with ACL-associated lesions were more frequently smokers, and that patients with isolated meniscal injuries used more artificial anabolic agents. Regarding quality of life, there were no statistical differences in the habits between the groups; however, except for smokers with isolated meniscal injury, all patients who did not have the habits analyzed presented a better score in the SF-36 questionnaire.

CONCLUSION

There were no significant findings correlating smoking, alcohol abuse and artificial anabolic agents with the presence of injuries. In addition, six months after the surgical treatment, there was no difference in the quality of life between the groups evaluated. Level of Evidence III, Prospective case series.

One-incision versus two-incision techniques for arthroscopically assisted anterior cruciate ligament reconstruction in adults

BACKGROUND

Anterior cruciate ligament (ACL) tears are serious knee injuries that are frequently treated surgically in the form of arthroscopically assisted reconstruction with grafts from the patella or hamstrings tendons. We reviewed the evidence for the choice of arthroscopically assisted ACL reconstruction technique in terms of whether it should involve one incision (femoral tunnel drilled from inside the knee joint under arthroscopic visualisation) or two incisions (femoral tunnel drilled from outside to inside the knee joint).

OBJECTIVES

To assess the effects (benefits and harms) of one-incision versus two-incision techniques for arthroscopically assisted ACL reconstruction in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Latin American and Caribbean Health Sciences (LILACS), the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, reference lists, and conference abstracts. The date of the search was 16 August 2017.

SELECTION CRITERIA

Randomised and quasi-randomised controlled clinical trials evaluating one-incision versus two-incision techniques for arthroscopically assisted ACL reconstruction in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched and selected studies, and extracted data and assessed the risk of bias of the eligible studies. We undertook limited pooling of data using the fixed-effect model.

MAIN RESULTS

We included five trials (four randomised and one quasi-randomised) evaluating a total of 320 participants who were mainly in their 20s. All participants underwent ACL reconstruction with patella tendon grafts. All five included trials were at a high risk of bias, particularly performance bias. Based on these limitations and the insufficiency of the available data resulting in imprecision of effect estimates, we judged the quality of the evidence as very low for all outcomes. This means that we are uncertain of the findings of the review.We found very low-quality evidence of no clinically important differences between the two techniques in self reported knee function, measured using the Lysholm knee score (scale 0 to 100: best outcome), at short-term (3 months) (mean difference (MD) 2.73 favours one-incision technique, 95% confidence interval (CI) -2.70 to 8.15; 79 participants, 2 studies), intermediate-term (12 months) (MD -3.68 favours two-incision technique, 95% CI -6.61 to -0.75; 79 participants, 2 studies), and long-term follow-up. The data available for long-term follow-up (2 to 5 years) was expressed in terms of the numbers of participants with excellent Lysholm scores (90 points or more); we found no difference between the two groups (42/45 versus 36/40; risk ratio (RR) 1.04, 95% CI 0.91 to 1.18; 1 study). There were no data for quality of life measures or for overall numbers of participants incurring an adverse event. We found very low-quality evidence of little between-group differences in individual adverse events such as infection, knee stiffness, reoperation, and graft failure.We found very low-quality evidence from one study (59 participants) of little difference between the two groups in activity levels measured using Tegner scores (scale 0 to 10: highest sport activity) at two years (MD -0.80 favours two-incision technique, 95% CI -1.90 to 0.30). There was very low-quality evidence from four studies of minimal between-group difference in the number of participants with normal or nearly normal objectively measured knee function (International Knee Documentation Committee objective assessment grading) at intermediate follow-up (means 12 to 28 months): 56/78 versus 63/89; RR 1.01, 95% CI 0.85 to 1.21; 167 participants).

AUTHORS' CONCLUSIONS

The very low-quality and often absent evidence means that we are uncertain whether one-incision arthroscopically assisted ACL reconstruction techniques yield better, worse, or equivalent results compared with two-incision techniques in terms of short-, intermediate-, or long-term subjective function, quality of life, adverse outcomes, activity levels, and objectively rated knee function. The evidence was available only for single-bundle ACL reconstruction using patella tendon grafts.When considering priorities for high-quality randomised trials on techniques for ACL reconstruction, it is important to note the insufficiency of the evidence available to inform this key comparison.

Increased Femoral Anteversion Influence Over Surgically Treated Recurrent Patellar Instability Patients

PURPOSE

To verify the influence that increased femoral anteversion (FA) has on patients with recurrent patellar instability (RPI) treated by anteromedialization tibial tubercle osteotomy (TTO) combined with medial patellofemoral ligament reconstruction (MPFLR) and to present the midterm outcomes of these patients.

METHODS

From January 2008 to August 2013, skeletally mature patients with RPI and tibial tubercle (TT)-trochlear groove (TG) ≥ 17 mm who underwent anteromedialization TTO combined with MPFLR were evaluated for J sign, patellar glide, apprehension test, increased FA, Caton index, trochlea dysplasia, TT-TG, Kujala, International Knee Documentation Committee subjective knee evaluation form, and Tegner. Increased FA was determined clinically by a difference of more than 30° between hip internal and external rotation, 70° or more of hip internal rotation, and 30° or more of femoral neck anteversion. A subgroup analysis involving increased FA was made.

RESULTS

Forty-eight patients composed the study group. Mean follow-up was 41.5 ± 11.05 months. The J-sign was present in 86% before surgery and none postoperatively (P < .001). All patients had a positive apprehension test or a patellar luxation at the patellar glide test rated as grade 4 before surgery. After surgery, the mean glide was 1.29 ± 0.45 with no apprehension (P < .001). Increased FA was present in 18.7%. Caton index before surgery was 1.11 ± 0.21 and 0.99 ± 0.11 postoperatively (P = .004). Trochlea dysplasia was present in all patients. TT-TG preoperatively was 20.77 ± 2.12 mm and 11.33 ± 1.24 mm postoperatively (P < .001). Functional scores improved preoperatively to postoperatively (P < .001) with Kujala and International Knee Documentation Committee means: 59.08 to 84.37; 52.6 to 85.5, respectively. Tegner preinjury score was 5.4 and postoperatively was 5.2 (P = .01). Increased FA group had worse Kujala compared with the normal FA group and worse Kujala improvement: 77.7 and 85.89 (P = .012), and 21.7 and 26.1, respectively (P < .001).

CONCLUSIONS

Increased FA in patients with RPI had a negative effect on the outcome of anteromedialization TTO combined with MPFLR. Combined anteromedialization TTO and MPFLR had good functional midterm outcomes in treating patients with RPI and TT-TG ≥ 17 mm.

LEVEL OF EVIDENCE

Level III, comparative study.

Posteromedial Versus Direct Posterior Approach for Posterior Cruciate Ligament Reinsertion

Avulsion fractures of the posterior cruciate ligament (PCL) are usually found in pediatric populations. This study investigated which of 2 approaches-posteromedial or direct posterior-enables easier PCL reinsertion. Ten fresh cadavers were studied using direct posterior (10 knees) and posteromedial (10 knees) approaches. In both, a guidewire was inserted into the tibial insertion of the PCL as perpendicular as possible to the coronal knee axis. Then, the angle between the guidewire and the horizontal plane of the table was measured. The mean angle of the guidewire was 8.6° (SD=7.3°) with the direct posterior approach and 36.6° (SD=14.3°) with the posteromedial approach (P=.005). The direct posterior approach allows a greater degree of freedom compared with the posteromedial approach to reach the PCL tibial insertion. [Orthopedics. 2016; 39(5):e1024-e1027.].

Bioabsorbable versus metallic interference screws for graft fixation in anterior cruciate ligament reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) tears are frequently treated with surgical reconstruction with grafts, frequently patella tendon or hamstrings. Interference screws are often used to secure the graft in bone tunnels in the femur and tibia. This review examines whether bioabsorbable interference screws give better results than metal interference screws when used for graft fixation in ACL reconstruction.

OBJECTIVES

To assess the effects (benefits and harms) of bioabsorbable versus metallic interference screws for graft fixation in ACL reconstruction.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, LILACS, trial registers and reference lists of articles. Date of search: January 2016.

SELECTION CRITERIA

We included randomised controlled trials and quasi-randomised trials comparing bioabsorbable with metallic interferences screws in ACL reconstruction. The main outcomes sought were subjective-rated knee function, failure of treatment, and activity level.

DATA COLLECTION AND ANALYSIS

At least two review authors selected eligible trials, independently assessed risk of bias, and cross-checked data. Data were pooled whenever relevant and possible. Requests for further information were sent to the original study authors.

MAIN RESULTS

We included 12 trials (11 randomised and one quasi-randomised) involving a total of 944 participants, and reporting follow-up results for 774. Participants in the 12 trials underwent ACL reconstruction with either hamstring tendon grafts (five trials) or patellar tendon grafts (seven trials). Trials participants were randomly allocated to bioabsorbable or metallic interference screws for graft fixation in both femur and tibia (seven trials); femur only (three trials); tibia only (one trial); location was not reported in the remaining trial. A variety of materials was used for the bioabsorbable screws, Poly-L-lactic acid (PLLA) being the most common. The metallic screws, where reported, were titanium.All trials were at high risk of bias, which invariably included performance bias. Seven trials were at high risk of attrition bias and eight at high risk of reporting bias. The quasi-randomised trial was assessed as being at high risk for selection bias. Based on these study limitations and insufficiency of the available data, we judged the quality of evidence for all outcomes was very low.The majority of the available data for patient-reported knee function was presented as Lysholm scores (0 to 100; higher scores = better function). There was very low quality but consistent evidence of no clinically important differences between the two groups in Lysholm scores at 12 months follow-up (mean difference (MD) -0.08, 95% confidence interval (CI) -1.48 to 1.32; three trials, 168 participants); 24 months (MD 0.35, 95% CI -1.27 to 1.98; three trials, 113 participants) or five or more years follow-up (MD 1.23, 95% CI -2.00 to 4.47; two trials, 71 participants). This lack of between-group differences was also reported for Lysholm scores in several trials that did not provide sufficient data for pooling as well as for other self-reported knee function scores reported in several trials.Treatment failure was represented by the summed data for implant breakage during surgery and major postoperative complications (implant failure, graft rupture, symptomatic foreign body reactions, effusion and treated arthrofibrosis and related conditions) that were usually described in the trial reports as requiring further substantive treatment. There is very low-quality evidence of greater treatment failure in the bioabsorbable screw group (60/451 versus 29/434; risk ratio (RR) 1.94 favouring metallic screw fixation, 95% CI 1.29 to 2.93; 885 participants, 11 studies). In a population with an assumed risk (based on the median control group risk) of 56 participants per 1000 having treatment failure after metallic screw fixation, this equates to 53 more (95% CI 17 to 108 more) per 1000 participants having treatment failure after bioabsorbable screw fixation. All 16 intraoperative complications in the bioabsorbable screw group were implant breakages upon screw insertion. Treatment failure defined as postoperative complications only still favoured the metallic screw group but the 95% CI also included the potential for a greater risk of treatment failure after metallic screw fixation: 44/451 versus 29/434; RR 1.44, 95% CI 0.93 to 2.23. Based on the assumed risk of 56 participants per 1000 having postoperative treatment failure after metallic screw fixation, this equates to 25 more (95% CI 4 fewer and 69 more) per 1000 participants having this outcome after bioabsorbable screw fixation.There was very low-quality evidence of very similar activity levels in the two groups at 12 and 24 months follow-up measured via the Tegner score (0 to 10; higher scores = greater activity): 12 months (MD 0.08, 95% CI -0.39 to 0.55; 122 participants, two studies); 24 months (MD 0.01, 95% CI -0.54 to 0.57; 72 participants, two studies).

AUTHORS' CONCLUSIONS

There is very low-quality evidence of no difference in self-reported knee function and levels of activity between bioabsorbable and metallic interference screws for graft fixation in ACL reconstruction. There is very low-quality evidence that bioabsorbable screws may be associated with more overall treatment failures, including implant breakage during surgery. Further research does not appear to be a priority, but if undertaken, should also examine costs.

Anterior cruciate ligament - updating article

This updating article on the anterior cruciate ligament (ACL) has the aim of addressing some of the most interesting current topics in this field. Within this stratified approach, it contains the following sections: ACL remnant; anterolateral ligament and combined intra and extra-articular reconstruction; fixation devices; and ACL femoral tunnel creation techniques.

Comprehensive selection of reference genes for expression studies in meniscus injury using quantitative real-time PCR

The meniscus plays critical roles in the knee function. Meniscal tears can lead to knee osteoarthritis. Gene expression analysis may be a useful tool for understanding meniscus tears, and reverse-transcription quantitative polymerase chain reaction (RT-qPCR) has become an effective method for such studies. However, this technique requires the use of suitable reference genes for data normalization. We evaluated the suitability of six reference genes (18S, ACTB, B2M, GAPDH, HPRT1 and TBP) using meniscus samples of (1) 19 patients with isolated meniscal tears, (2) 20 patients with meniscal tears and combined anterior cruciate ligament injury (ACL), and (3) 11 controls without meniscal tears. The stability of the candidate reference genes was determined using the NormFinder, geNorm, BestKeeper DataAssist and RefFinder software packages and comparative ΔCt method. Overall, HPRT1 was the best single reference gene. However, GenEx software demonstrated that two or more reference genes should be used for gene expression normalization, which was confirmed when we evaluated TGFβR1 expression using several reference gene combinations. HPRT1+TBP was the most frequently identified pair from the analysis of samples of (1) meniscal tear samples of patients with a concomitant ACL tears, (2) all meniscal tears, and (3) all samples. HPRT1+GAPDH was the most frequently identified pair from the analysis of samples of isolated meniscal tear samples and controls. In the analysis involving only controls, GAPDH+18S was the most frequently identified pair. In the analysis of only isolated meniscal tear samples and in the analysis of meniscal tear samples of patients with concomitant ACL tears and controls, both HPRT1+TBP and HPRT1+GAPDH were identified as suitable pairs. If the gene expression study aims to compare non-injured meniscus, isolated meniscal tears and meniscal tears of patients with ACL tears as three independent groups, the trio of HPRT1+TBP+GAPDH is the most suitable combination of reference genes.

Intraarticular hamstring graft diameter decreases with continuing knee growth after ACL reconstruction with open physes

PURPOSE

To evaluate the graft diameter size after one-year follow-up or more of patients Tanner II, III, and IV who were submitted to anterior cruciate ligament reconstruction.

METHODS

Ten patients [five males (mean age: 14.4 years) and five females (mean age: 13.6 years)] with open physis and anterior cruciate ligament tear were submitted to transphyseal anterior cruciate ligament reconstruction with quadruple hamstrings graft. During the procedure, graft and tunnel size were recorded. After last clinical follow-up (range 1-11 years), an MRI study was requested and their measurements near the tibial tunnel were compared with the graft diameter measured and used during primary procedure.

RESULTS

Four patients had Tanner stage II, four patients Tanner stage III, and two Tanner IV. There were statistically significant decreases in the quadruple hamstrings graft diameter size (average of 25.3%). Mean size at time of surgery was 7.9 mm (±0.87), and mean size measured at different points of follow-up evaluation was 5.9 mm (±0.65).

CONCLUSION

Diameter size of hamstring graft in skeletally immature patients is smaller in most cases. If there is a decrease in the diameter of the graft along postoperative time, the risk of a re-rupture is theoretically further increased. Quadruple hamstring graft decreases a mean 25.3% in diameter from time of anterior cruciate ligament reconstruction surgery until reassessment period in skeletally immature patients.

LEVEL OF EVIDENCE

IV.

Identification of Suitable Reference Genes for Investigating Gene Expression in Anterior Cruciate Ligament Injury by Using Reverse Transcription-Quantitative PCR

The anterior cruciate ligament (ACL) is one of the most frequently injured structures during high-impact sporting activities. Gene expression analysis may be a useful tool for understanding ACL tears and healing failure. Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) has emerged as an effective method for such studies. However, this technique requires the use of suitable reference genes for data normalization. Here, we evaluated the suitability of six reference genes (18S, ACTB, B2M, GAPDH, HPRT1, and TBP) by using ACL samples of 39 individuals with ACL tears (20 with isolated ACL tears and 19 with ACL tear and combined meniscal injury) and of 13 controls. The stability of the candidate reference genes was determined by using the NormFinder, geNorm, BestKeeper DataAssist, and RefFinder software packages and the comparative ΔCt method. ACTB was the best single reference gene and ACTB+TBP was the best gene pair. The GenEx software showed that the accumulated standard deviation is reduced when a larger number of reference genes is used for gene expression normalization. However, the use of a single reference gene may not be suitable. To identify the optimal combination of reference genes, we evaluated the expression of FN1 and PLOD1. We observed that at least 3 reference genes should be used. ACTB+HPRT1+18S is the best trio for the analyses involving isolated ACL tears and controls. Conversely, ACTB+TBP+18S is the best trio for the analyses involving (1) injured ACL tears and controls, and (2) ACL tears of patients with meniscal tears and controls. Therefore, if the gene expression study aims to compare non-injured ACL, isolated ACL tears and ACL tears from patients with meniscal tear as three independent groups ACTB+TBP+18S+HPRT1 should be used. In conclusion, 3 or more genes should be used as reference genes for analysis of ACL samples of individuals with and without ACL tears.

Updates in biological therapies for knee injuries: menisci

The preservation of meniscal tissue is paramount for long-term joint function, especially in younger patients who are athletically active. Many studies have reported encouraging results following the repair of meniscus tears, including both simple longitudinal tears located in the periphery and complex multiplanar tears that extend into the central third avascular region. However, most types of meniscal lesions are managed with a partial meniscectomy. Options to restore the meniscus range from an allograft transplantation to the use of synthetic and biological technologies. Recent studies have demonstrated good long-term outcomes with meniscal allograft transplantation, although the indications and techniques continue to evolve, and the long-term chondroprotective potential of this approach has yet to be determined. Several synthetic implants, most of which are approved in the European market, have shown some promise for replacing part of or the entire meniscus, including collagen meniscal implants, hydrogels, and polymer scaffolds. Currently, there is no ideal implant generated by means of tissue engineering. However, meniscus tissue engineering is a fast developing field that promises to develop an implant that mimics the histologic and biomechanical properties of a native meniscus.

Extension and flexion gap balancing and its correlation with alignment in navigated total knee arthroplasty

Computer-assisted surgery was developed to improve the results of conventional total knee arthroplasty (TKA). The authors investigated the preoperative varus/valgus deformity influence on the production of balanced extension and flexion gaps using computer-assisted surgery. This study evaluated data from a prospective case series. A total of 132 patients (107 women and 25 men) underwent navigated TKA. Patients were divided into the following 3 groups according to the degree of the initial varus/valgus deformity: group 1, 0° to 3°; group 2, 3° to 9°; and group 3, greater than 9°. The final lower limb mechanical axis (LLMA) and the final flexion and extension gaps were measured. Knees exhibiting up to 3° of deviation on the frontal plane and a difference of up to 3 mm between the lateral and medial gaps were considered to be aligned and balanced, respectively. Average LLMA deviation decreased from 5.58° (± 4.80°) to 1.87° (± 1.66°). For knees with varus deviation, the percentage of balancing relative to the flexion gaps was 97.8% and that relative to the extension gap was 100% (P>.05). For knees with valgus deviation, the percentage of balancing relative to the flexion gaps was 95.1% and that relative to the extension gap was 97.6% (P>.05). Approximately 92% of the LLMA alignment was achieved in the group with varus deformity, whereas 71.4% was observed in the group with valgus deformity (P<.05). Computer-assisted TKA could attain proper flexion and extension balance regardless of coronal plane malalignment magnitude. Severe valgus and varus knees are more difficult to align using navigation. No difference was found in the balance of flexion or extension gaps in valgus or varus knees, independent of the severity.

Total knee arthroplasty with computer-assisted navigation: an analysis of 200 cases

Objective

to evaluate the results from surgery with computer-assisted navigation in cases of total knee arthroplasty.

Method

a total of 196 patients who underwent total knee arthroplasty with computer-assisted navigation were evaluated. The extension and flexion spaces (gaps) were evaluated during the operation and the alignment after the operation was assessed. The Knee Society Score (KSS) questionnaire for assessing patient's function was applied preoperatively and postoperatively after a mean follow-up of 22 months.

Results

in all, 86.7% of the patients presented good alignment of the mechanical axis (less than 3° of varus or valgus in relation to the mechanical axis) and 96.4% of the patients presented balanced flexion and extension gaps. Before the operation, 97% of the patients presented poor or insufficient KSS, but after the operation, 77.6% presented good or excellent KSS.

Conclusion

the navigation system made it possible to achieve aligned and balanced implants, with notable functional improvement among the patients. It was found to be useful in assessing, understanding and improving knowledge in relation to performing arthroplasty procedures.

Meniscal repair by all-inside technique with Fast-Fix device

Objective

The objective of this study is to evaluate the results and effectiveness of the technique of meniscal repair type all-inside using Fast-Fix device.

Methods

A retrospective cohort study evaluating 22 patients with meniscal surgery between January 2004 and December 2010 underwent meniscal repair technique for all-inside with the Fast-Fix device with or without ACL reconstruction. Function and quality of life outcomes were chosen by the IKDC and Lysholm score, before and postoperatively, and reoperation rates, relying to the time of final follow-up. Statistical analysis was performed using the Student's t test.

Results

The mean follow-up was 59 months (16–84). The Lysholm score showed 72% (16 patients) of excellent and good results (84–100 points), 27% (6 patients) fair (65–83 points) and no cases classified as poor (<64 points). According to the IKDC: 81% (18 patients) of excellent and good results (75–100 points), 18% of cases regular (50–75 points) and no patient had poor results (<50 points). There were no failures or complications.

Conclusion

The technique of meniscal repair type all-inside using the Fast-Fix device is safe and effective for the treatment of meniscal lesions in the red zone or red-white with or without simultaneous ACL reconstruction, with good and excellent results in most patients Level 4 Study.

Is it safe the empirical distal femoral resection angle of 5° to 6° of valgus in the Brazilian geriatric population?

OBJECTIVE

The purpose of this study is to determine if there is a safe distal femoral resection angle to restore the normal axial alignment of the limb in total knee arthroplasty (TKA) in the Brazilian geriatric population with knee arthrosis.

METHOD

This study analyzed 99 pre-operative hip-knee-ankle radiographs of osteoarthritic knees of 66 patients (54 women, 12 men) with knee osteoarthritis. The distal femoral cut angle was determined based on the femoral mechanical-anatomical angle (FMA). Mean, median and standard deviation measurements of the distal femoral cut angle were calculated, differentiated by gender and side. The mean result of the distal femoral resection angle was compared to 5.7°, the mean average angle of previous and similar study based on European population of patients with knee arthrosis.

RESULTS

The mean average of the distal femoral resection angle of the study was 6.05 (range 3-9°). The distribution of this angle between genders showed a slight superior average of the male population (6.17°) compared to the female (6.02°), but with no statistically significant difference (p = 0.726). There was no statistically significant difference (p = 0.052) between the mean average of this study (6.05°) compared to the mean average of the literature (5.7°). However, considering 3° as the limit of acceptable error in the coronal plane, this empirical femoral resection angle would not be appropriated for 19.7% of the population.

CONCLUSION

The distal femoral resection angle of 5-6° is not completely safe for the Brazilian geriatric population.

A CT-based classification of prior ACL femoral tunnel location for planning revision ACL surgery

PURPOSE

The purposes of this study are to describe an ACL femoral tunnel classification system for use in planning revision ACL reconstruction based on 3-D computed tomography (CT) reconstructions and to evaluate its inter- and intra-rater reliability.

METHODS

A femoral tunnel classification system was developed based on the location of the femoral tunnel relative to the lateral intercondylar ridge. The femoral tunnel was classified as Type I if it was located entirely below and posterior to the ridge as viewed from distally, Type II if it was slightly malpositioned (either vertically, anteriorly, or both), and Type III if it was significantly malpositioned. To evaluate the reproducibility of the classification system, CT scans of 27 knees were obtained from patients scheduled for revision ACL reconstruction, and 3-D reconstructions were created. Four views of the 3-D reconstruction of each femur were then obtained, and inter- and intra-observer reliability was determined following classification of the tunnels by eight observers.

RESULTS

Twenty-five tunnels were classified as Type I (5 tunnels), Type II (9 tunnels), or type III (11 tunnels) by at least 5 of 8 observers, while insufficient agreement was noted to classify two tunnels. The interobserver reliability of tunnel classification as type I, II, or III yielded a κ coefficient of 0.57, while intra-observer reliability yielded a κ coefficient of 0.67. Subclassification of type II femoral tunnels into the subgroups anterior, vertical, and both was possible in four of the nine type II patients. The interobserver reliability of the complete classification system yielded a κ coefficient of 0.50, while the intra-observer reliability yielded a κ coefficient of 0.54.

CONCLUSION

Classification of the location of ACL femoral tunnels utilizing 3-D reconstructions of CT data yields moderate to substantial inter- and intra-observer reliability.

LEVEL OF EVIDENCE

Diagnostic Level III.

Lesões do aparelho locomotor nos acidentes com motocicleta

Estudo realizado no município de São Paulo entre janeiro de 2001 e julho de 2002 e tem como objetivo analisar o perfil do indivíduo envolvido em acidentes motociclísticos avaliando: o perfil do condutor, as circunstâncias dos acidentes, as lesões e o uso de equipamentos de segurança. Foram encontrados 387 pacientes sendo 354(91,0%) do sexo masculino, entre 16 e 44 anos e considerados os indivíduos que necessitaram somente do tratamento traumato-ortopédico. O mecanismo de trauma mais comum envolveu a colisão entre a moto com outro veículo (67,0%), numa velocidade entre 20-60km/h (73,0%), em pessoas com menor experiência (67,0%) na idade entre 21-24 anos (45,0%), nos quais 532 (53,9%) lesões ocorreram nos membros inferiores. Quanto ao tipo de lesão tivemos 393(39,8%) ferimentos, 314(31,8%) contusões e 212(21,5%) fraturas [ossos do pé 34(16%), fêmur 32(15,1%), tornozelo 27(12,7%), tíbia 25(11,8%)]. A reincidência foi observada em 231(60,0%) acidentes e somente 6,0% dos pacientes não usavam equipamentos de proteção.O aumento da velocidade relacionou-se à um índice maior de fraturas quando foi aplicado o teste de Mann-Whitney (p=0,001). Pesquisas de engenharia mecânica e de engenharia de tráfego, associadas à rigorosa fiscalização e conscientização da população, devem ser consideradas o método mais efetivo , que é o da prevenção.