Suture-only fixation technique leads to a higher degree of extrusion than bony fixation in meniscal allograft transplantation

BACKGROUND

Most of the published series of transplanted menisci have consistently shown some degree of allograft extrusion. The speculation is that this meniscal extrusion may be caused by the soft tissue technique used to fix the allograft.

HYPOTHESIS

The percentage of extruded meniscal graft would be higher if the allograft were only fixed with sutures rather than with associated bony fixation.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

We performed a prospective series of 88 meniscal allograft transplantations. Thirty-three of the grafts were fixed with the suture-only technique (group A). The remaining 55 cases were performed with the bone plug method (group B). All patients were studied with magnetic resonance imaging (MRI) at a minimum 3 years' follow-up to determine the degree of meniscal extrusion. The time between surgery and MRI evaluation was 40 months (range, 36-48 months) in both groups. Meniscal extrusion was measured on coronal MRI. The percentage of the meniscal body width that was extruded was calculated. The average percentage of extrusion for each group was compared. The Lysholm score was analyzed in relation to the fixation method and degree of meniscal extrusion. Tears of the allograft that required surgical intervention were also reported.

RESULTS

The average percentage of meniscal tissue extruded in group A was 36.3% ± 13.7% without differences between the medial (35.9% ± 18.1%) and lateral (38.3% ± 14.4%) compartments (P = .84). Group B had a mean 28.13% ± 12.2% of the meniscal body extruded without differences between the medial (25.8% ± 16.2%) and lateral (30.14% ± 13.5%) compartments. A higher percentage of extruded meniscal tissue was found in group A than in group B (P < .001). No association between the degree of meniscal extrusion and the functional score was observed (P = .4). Graft tears were observed in 21.4% of the cases in group A and in 7.3% of the cases in group B (P = .09).

CONCLUSION

A meniscal allograft fixed with the suture-only technique showed a significantly higher degree of extruded meniscal body than that fixed with the bony fixation method, with no influence on the functional outcome. There was also a considerably higher rate of graft tears observed in those menisci fixed only with sutures, although this difference was not statistically significant with the numbers available.

Surgical treatment for early osteoarthritis. Part II: allografts and concurrent procedures

Young patients with early osteoarthritis (OA) represent a challenging population due to a combination of high functional demands and limited treatment options. Conservative measures such as injection and physical therapy can provide short-term pain relief but are only palliative in nature. Joint replacement, a successful procedure in the older population, is controversial in younger patients, who are less satisfied and experience higher failure rates. Therefore, while traditionally not indicated for the treatment of OA, cartilage repair has become a focus of increased interest due to its potential to provide pain relief and alter the progression of degenerative disease, with the hope of delaying or obviating the need for joint replacement. The field of cartilage repair is seeing the rapid development of new technologies that promise greater ease of application, less demanding rehabilitation and better outcomes. Concurrent procedures such as meniscal transplantation and osteotomy, however, remain of crucial importance to provide a normalized biomechanical environment for these new technologies.

LEVEL OF EVIDENCE

Systematic review, Level II.

Topical and intravenous tranexamic acid reduce blood loss compared to routine hemostasis in total knee arthroplasty: a multicenter, randomized, controlled trial

INTRODUCTION

Tranexamic acid (TXA) is becoming widely used in orthopedic surgery to reduce blood loss and transfusion requirements, but consensus is lacking regarding the optimal route and dose of administration. The aim of this study was to compare the efficacy and safety of topical and intravenous routes of TXA with routine hemostasis in patients undergoing primary total knee arthroplasty (TKA).

MATERIALS AND METHODS

We performed a randomized, multicenter, parallel, open-label clinical trial in adult patients undergoing primary TKA. Patients were divided into three groups of 50 patients each: Group 1 received 1 g topical TXA, Group 2 received 2 g intravenous TXA, and Group 3 (control group) had routine hemostasis. The primary outcome was total blood loss. Secondary outcomes were hidden blood loss, blood collected in drains, transfusion rate, number of blood units transfused, adverse events, and mortality.

RESULTS

One hundred and fifty patients were included. Total blood loss was 1021.57 (481.09) mL in Group 1, 817.54 (324.82) mL in Group 2 and 1415.72 (595.11) mL in Group 3 (control group). Differences in total blood loss between the TXA groups and the control group were clinically and statistically significant (p < 0.001). In an exploratory analysis differences between the two TXA groups were not statistically significant (p = 0.073) Seventeen patients were transfused. Transfusion requirements were significantly higher in Group 3 (p = 0.005). No significant differences were found between groups regarding adverse events.

CONCLUSION

We found that 1 g of topical TXA and 2 g of intravenous TXA were both safe strategies and more effective than routine hemostasis to reduce blood loss and transfusion requirements after primary TKA.

LEVEL OF EVIDENCE

I.

How to improve the prediction of quadrupled semitendinosus and gracilis autograft sizes with magnetic resonance imaging and ultrasonography

BACKGROUND

Hamstring tendon grafts may have an unacceptable size for use in anterior cruciate ligament (ACL) reconstruction. Magnetic resonance imaging (MRI) has been proposed to predict the diameters of hamstring tendon grafts.

HYPOTHESIS

Preoperative ultrasonography (US) might reliably anticipate intraoperative 4-strand semitendinosus and gracilis tendon (4ST-GT) graft sizes similarly to MRI. An MRI evaluation of the hamstring tendons with a higher magnification may improve the accuracy of the method.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

A total of 33 patients undergoing ACL reconstruction with a 4ST-GT graft and MRI performed at our institution were included. The cross-sectional area (CSA) of each semitendinosus tendon (ST) and gracilis tendon (GT) was calculated preoperatively with US and with MRI under 2× and 4× magnification. Intraoperative measurement of the final diameter of the 4ST-GT using a closed-hole sizing block with 0.5-mm increments was made. Pearson correlation coefficients were calculated to determine the relationship between the final intraoperative graft diameter of the 4ST-GT and the CSA of the ST and GT measured with US and MRI with 2× and 4× magnification. Simple linear regression was also calculated to attempt to predict the graft diameter based on given measurements.

RESULTS

There were statistically significant correlations between the measured CSA with US and both MRI magnifications with the 4ST-GT diameter. However, MRI under 4× magnification showed a much higer correlation (0.86) than MRI under 2× magnification (0.54) or US (0.51). Final graft diameters ≥8 mm were observed in 80.8% of patients with a CSA >14 mm(2), in 76.9% of patients with a CSA >25 mm2, and in 96.2% of patients with a CSA >17 mm2 measured with US, 2× magnification of MRI, and 4× magnification of MRI, respectively.

CONCLUSION

Preoperative calculation of the CSA of the hamstring tendons with MRI and US can help to reliably estimate 4ST-GT grafts. In terms of correlation of the CSA with graft diameter, US was comparable to 2× MRI, but 4× MRI showed a much greater accuracy. Threshold values of the CSA of the ST and GT of 25 mm2, 17 mm2, and 14 mm2 with the 2× MRI, 4× MRI, and US methods, respectively, are needed to reliably predict a 4ST-GT graft with a minimum diameter of 8 mm.

Meniscal allograft transplantation without bone blocks: a 5- to 8-year follow-up of 33 patients

PURPOSE

The purpose of this study was to evaluate the functional and radiographic results on a midterm basis, as well as complications, in an initial series of meniscal allograft transplantations performed with suture fixation without any bone block.

METHODS

A series of 33 meniscal allograft transplantations were performed at our institution from January 2001 to October 2003. Inclusion criteria were patients with compartmental joint line pain due to a previous meniscectomy. There were 24 men and 9 women with a mean age of 38.8 years (range, 21 to 54 years). The functional outcomes were evaluated by use of Lysholm and Tegner scores at a mean and minimum follow-up of 6.5 years and 5 years, respectively. A visual analog scale for pain was also used. Radiographic assessment included joint space narrowing on the Rosenberg view and magnetic resonance imaging evaluation.

RESULTS

The Lysholm and Tegner scores significantly improved from 65.4 to 88.6 (P < .001) and from 3.1 to 5.5 (P < .001), respectively, after surgery. The visual analog scale score significantly dropped from 6.4 to 1.5 (P < .001). The radiographic evaluation did not show any joint space narrowing (P = .38). Meniscal extrusion was a constant finding, averaging 36.3% of total meniscal size. According to the Van Arkel criteria, the survival rate was 87.8% at 6.5 years. The rate of complications was 33%.

CONCLUSIONS

This study suggests that this procedure provides significant pain relief and functional improvement in selected symptomatic individuals on a midterm basis. However, there was a high rate of complications (33%) and revision surgery.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Efficacy and safety of fibrin glue and tranexamic acid to prevent postoperative blood loss in total knee arthroplasty: a randomized controlled clinical trial

BACKGROUND

Postoperative blood loss in patients after total knee arthroplasty may cause local and systemic complications and influence clinical outcome. The aim of this study was to assess whether fibrin glue or tranexamic acid reduced blood loss compared with routine hemostasis in patients undergoing total knee arthroplasty.

METHODS

A randomized, single-center, parallel, open clinical trial was performed in adult patients undergoing primary total knee arthroplasty. Patients were divided into four groups. Group 1 received fibrin glue manufactured by the Blood and Tissue Bank of Catalonia, Group 2 received Tissucol (fibrinogen and thrombin), Group 3 received intravenous tranexamic acid, and Group 4 (control) had no treatment other than routine hemostasis. The primary outcome was total blood loss collected in drains after surgery. Secondary outcomes were the calculated hidden blood loss, transfusion rate, preoperative and postoperative hemoglobin, number of blood units transfused, adverse events, and mortality.

RESULTS

One hundred and seventy-two patients were included. The mean total blood loss (and standard deviation) collected in drains was 553.9 ± 321.5 mL for Group 1, 567.8 ± 299.3 mL for Group 2, 244.1 ± 223.4 mL for Group 3, and 563.5 ± 269.7 mL for Group 4. In comparison with the control group, Group 3 had significantly lower total blood loss (p < 0.001), but it was not significantly lower in Groups 1 and 2. The overall rate of patients who had a blood transfusion was 21.1% (thirty-five of 166 patients analyzed per protocol). Two patients required transfusion in Group 3 compared with twelve patients in Group 4 (p = 0.015). No significant difference was observed between the two fibrin glue groups and the control group with regard to the need for transfusion. There was no difference between groups with regard to the percentage of adverse events.

CONCLUSIONS

Neither type of fibrin glue was more effective than routine hemostasis in reducing postoperative bleeding and transfusion requirements, and we no longer use them. However, this trial supports findings from previous studies showing that intravenous tranexamic acid can decrease postoperative blood loss.

Clinical results after ultrasound-guided intratissue percutaneous electrolysis (EPI®) and eccentric exercise in the treatment of patellar tendinopathy

PURPOSE

To investigate the outcome of ultrasound (US)-guided intratissue percutaneous electrolysis (EPI(®)) and eccentric exercise in the treatment of patellar tendinopathy during a long-term follow-up.

METHODS

Forty patients with patellar tendinopathy were prospectively evaluated over a 10-year follow-up period. Pain and function were evaluated before treatment, at 3 months and at 2, 5 and 10 years using the Victorian Institute of Sport Assessment-Patella (VISA-P) score, the Tegner score and Blazina's classification. According to VISA-P score at baseline, patients were also dichotomized into Group 1 (<50 points) and Group 2 (≥50 points). There were 21 patients in Group 1 and 19 in Group 2. Patient satisfaction was measured according to the Roles and Maudsley score.

RESULTS

The VISA-P score improved globally by 41.2 points (p < 0.01) after a mean 4.1 procedures. In Group 1, VISA-P score improved from 33.1 ± 13 to 78.9 ± 14.4 at 3-month and to 88.8 ± 10.1 at 10-year follow-up (p < 0.001). In Group 2, VISA-P score improved from 69.3 ± 10.5 to 84.9 ± 9 at 3-month and to 96.0 ± 4.3 at 10-year follow-up (p < 0.001). After 10 years, 91.2 % of the patients had a VISA-P score >80 points. The same level (80 % of patients) or the Tegner score at no more than one level lower (20 % of patients) was restored, and 97.5 % of the patients were satisfied with the procedure.

CONCLUSION

Treatment with the US-guided EPI(®) technique and eccentric exercises in patellar tendinopathy resulted in a great improvement in knee function and a rapid return to the previous level of activity after few sessions. The procedure has proved to be safe with no recurrences on a long-term basis.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Osteochondritis dissecans: a historical review and its treatment with cannulated screws

The etiology of osteochondritis dissecans and the results of treating the early stages with arthroscopic fixation using cannulated screws is discussed. Arthroscopic surgery was performed on 14 patients with osteochondritis dissecans, and the osteochondral fragment was fixed with one or two screws. A second arthroscopic procedure was necessary to assess the lesion and remove the screws. Ambulation without weight bearing is allowed during the first 2 months postoperatively. Full range of motion is encouraged. The results indicate that all patients returned to their previous sport 3-11 months postsurgery. The authors conclude that fixation with cannulated screws is the ideal method of treating osteochondritis dissecans when the osteochondral fragment is still in its bed.

Ring-shaped lateral meniscus

The existence of abnormal-shaped menisci has been long recognized. The presence of discoid menisci in the human knee is considered to be a congenital malformation with a very low rate of incidence except in Asian populations. Since the publication of Watanabe's Atlas, three types of lateral meniscal abnormalities are generally accepted: the complete and incomplete discoid, as well as the Wrisberg-ligament type meniscus. The present case is the second description of a ring-shaped meniscus on the lateral side of the knee and we propose that this variant be included as a fourth variant in a future classification.

Freezing causes changes in the meniscus collagen net: a new ultrastructural meniscus disarray scale

Alterations in meniscal permeability leading to nutritional deficit have been suggested as a cause of shrinkage in meniscal transplantation. The purpose of this study was to ascertain how freezing, one of the most common procedures used to preserve meniscal allografts, alters the collagen's architecture. Twenty-six fresh human external menisci were analyzed with transmission electron microscopy. Thirteen of them were previously frozen at -80 degrees C while the rest were used as controls. A new scale of the collagen meniscal architecture was proposed according to the collagen's periodicity and degree of disruption, loss of banding, degree of collagen packing, fibril size variability and its intrafibrilar oedema. Each meniscus was scored from 0 to 7. Subsequently they were classified in grades ranging from a normal state (grade I; 0-2 points) to severe disarray (grade III; 5-7 points). The fibril collagen diameters of those menisci which had been previously frozen showed an average size in the longitudinal section of 14.26 nm, whereas it was 17.28 nm in the menisci used as controls (p=0.019). In the transverse section, the frozen menisci averaged 13.14 and 16.93 nm in the controls (p=0.003). Samples of the 13 previously frozen menisci were classified as grade III in 61.54% of the cases. In the control group, all the menisci were classified either as grade I or II. The frozen menisci averaged 4.85 points, whereas the control group did so at 2.46 (p<0.001). The fibril diameters in frozen menisci showed a thinner diameter and had a higher degree of disarray. Therefore, the results suggest that the freezing process alters the menisci's collagen net. This could partially explain the pathological changes found in shrunken menisci after transplantation.

Pressure algometry is a useful tool to quantify pain in the medial part of the knee: an intra- and inter-reliability study in healthy subjects

PURPOSE

Pain quantification is essential for diagnostic and pain monitoring purposes in disorders around the knee. Pressure algometry is a method described to determine pressure pain threshold (PPT) by applying controlled pressure to a given body point. The purpose of this study was to determine the reliability of this method when it was applied to the medial part of the proximal tibia metaphysis and to evaluate the PPT levels between genders.

METHODS

Fifty healthy (mean age; 46.9) volunteers were recruited, 25 men and 25 women. Pressure algometry was applied to a 1 cm(2)-probe area on the medial part of the knee by 2 raters. Intra- and interclass correlation (ICC) was obtained and differences between genders were evaluated. Bland-Altman plots were performed to evaluate the variability of the measures.

RESULTS

The mean values of PPT obtained by rater 1 and 2 were 497.5 Kpa and 489 Kpa respectively. The intrarater reliability values (95% IC) for rater 1 and 2 were 0.97 (0.95-0.98) and 0.84 (0.73-0.90) respectively. With regard to interrater reliability, the ICC (95% IC) for the first measurement was 0.92 (0.87-0.95) and 0.86 (0.78-0.92) for the second one. Women showed significant lower values of PPT than men. The Bland-Altmand plots showed excellent agreement.

CONCLUSIONS

Pressure algometry has excellent reliability when it is applied to the medial part of the proximal metaphysis of the tibia. Women have lower values of PTT than men. The high reliability of the PA in an individual volunteer makes it a more valuable tool for longitudinal assessment of a given patient than for comparison between them.

LEVEL OF EVIDENCE

Level III. Prospective study.

A comparison of risk between the lateral decubitus and the beach-chair position when establishing an anteroinferior shoulder portal: a cadaveric study

PURPOSE

The purpose of this study was to assess, using a technique that minimally distorts the normal anatomy, the risk of injury when establishing a 5 o'clock shoulder portal in the lateral decubitus versus beach-chair position.

METHODS

The anteroinferior portal was simulated with Kirschner wires (K-w) drilled orthogonally at the 5 o'clock position in 13 fresh frozen human cadaveric shoulders. The neighboring neurovascular structures were identified through an anteroinferior window made in the inferior glenohumeral ligament. Their relations to the K-w and surrounding structures were recorded in both positions.

RESULTS

The median distance from the musculocutaneous nerve to the K-w was shorter in the lateral decubitus position than in the beach chair position (13.16 mm v 20.49 mm, P = .011). The cephalic vein was closer to the portal in the beach-chair position than in the lateral decubitus position (median 8.48 mm v 9.93 mm, P = .039). The axillary nerve was closer to the K-w in the lateral decubitus position than in the beach-chair position (median 21.15 mm v 25.54 mm, P = .03). No differences in the distances from the K-w to the subscapular and anterior circumflex arteries were found when comparing both positions. The mean percentage of subscapular muscle height from its superior border to the K-w was 53.03%.

CONCLUSIONS

This study showed the risk of injury establishing a transubscapular portal in either position. The musculocutaneous nerve and the cephalic vein are the most prone to injury. In general, the beach-chair position proved to be safer.

CLINICAL RELEVANCE

Inserting anchor devices orthogonally would permit stronger fixation but presents the risk of damaging neurovascular structures. This study focused on showing the neurovascular risk of performing full orthogonal insertion. Considering the good results reported with the usual superior-anterior portals, we do not recommend performing a transubscapular portal in routine shoulder arthroscopy.

A porous PCL scaffold promotes the human chondrocytes redifferentiation and hyaline-specific extracellular matrix protein synthesis

The redifferentiation, proliferation, and hyaline-specific extracellular matrix (ECM) protein synthesis of chondrocytes cultured in a polycaprolactone (PCL) scaffold were analyzed. Gene expression of the type II collagen and aggrecan was assessed by real-time PCR in cells from PCL scaffolds, monolayer, and pellet cultures. The proliferative activity was assessed using Ki-67 immunodetection, and the chondrocytic differentiation was evaluated using S-100 immunodetection. The synthesis and deposition into scaffold pores of type II collagen and glycosaminoglycan were analyzed by immunohistochemistry and Alcian blue staining, respectively. All parameters were assessed throughout 28 days of cultures maintained in either fetal bovine serum-containing medium (FCM) or Insulin-Transferrin-Selenium-containing medium (ICM). Expression of the type II collagen gene was lower in FCM cultures than in ICM cultures for all culture systems (p < 0.05). Moreover, PCL scaffolds cultured in ICM were able to induce collagen gene expression more efficiently than pellet and monolayer cultures. Aggrecan gene expression did not vary significantly between mediums and three-dimensional system cultures, but in ICM cultures, the monolayer cultures had significantly higher levels of aggrecan gene expression than did either the PCL or pellet cultures. Chondrocytes cultured in PCL scaffolds or pellets with FCM did not proliferate to a great extent but did maintain their differentiated phenotype for 28 days. Levels of cartilage ECM protein synthesis and deposition into the scaffold pores were similar among PCL and pellet cultures grown in FCM and in ICM. In conclusion, chondrocytes seeded into PCL scaffolds, cultured in ICM, efficiently maintained their differentiated phenotype and were able to synthesize cartilage-specific ECM proteins.

The posteromedial corner of the knee: an international expert consensus statement on diagnosis, classification, treatment, and rehabilitation

PURPOSE

To establish recommendations for diagnosis, classification, treatment, and rehabilitation of posteromedial corner (PMC) knee injuries using a modified Delphi technique.

METHODS

A list of statements concerning the diagnosis, classification, treatment and rehabilitation of PMC injuries was created by a working group of four individuals. Using a modified Delphi technique, a group of 35 surgeons with expertise in PMC injuries was surveyed, on three occasions, to establish consensus on the inclusion or exclusion of each statement. Experts were encouraged to propose further suggestions or modifications following each round. Pre-defined criteria were used to refine item lists after each survey. The final document included statements reaching consensus in round three.

RESULTS

Thirty-five experts had a 100% response rate for all three rounds. A total of 53 items achieved over 75% consensus. The overall rate of consensus was 82.8%. Statements pertaining to PMC reconstruction and those regarding the treatment of combined cruciate and PMC injuries reached 100% consensus. Consensus was reached for 85.7% of the statements on anatomy of the PMC, 90% for those relating to diagnosis, 70% relating to classification, 64.3% relating to the treatment of isolated PMC injuries, and 83.3% relating to rehabilitation after PMC reconstruction.

CONCLUSION

A modified Delphi technique was applied to generate an expert consensus statement concerning the diagnosis, classification, treatment, and rehabilitation practices for PMC injuries of the knee with high levels of expert agreement. Though the majority of statements pertaining to anatomy, diagnosis, and rehabilitation reached consensus, there remains inconsistency as to the optimal approach to treating isolated PMC injuries. Additionally, there is a need for improved PMC injury classification.

LEVEL OF EVIDENCE

Level V.

Combined Anterior Cruciate Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis Better Restores Knee Stability and Reduces Failure Rates Than Isolated Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

BACKGROUND

The increase in anterior cruciate ligament (ACL) injuries in pediatric patients and the high failure rate reported in the literature in this population are driving surgeons to search for specific techniques to better restore knee stability. Recent literature has reported that the combination of lateral extra-articular tenodesis (LET) and ACL reconstruction improves outcomes in high-risk patients. However, such advantages in pediatric patients have been infrequently evaluated.

PURPOSE

To assess whether adding LET to ACL reconstruction can significantly improve knee stability, clinical outcomes, and failure rates in pediatric patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A multicentric study involving 3 orthopaedic teaching centers was conducted to evaluate pediatric patients aged between 12 and 16 years who had undergone primary ACL reconstruction using a physeal-sparing femoral tunnel drilling technique. A minimum 2-year follow-up evaluation was required. Based on the surgical technique performed, the patients were divided into 2 group. The patients in group 1 underwent an isolated arthroscopic ACL reconstruction, while the patients in group 2 had an arthroscopic ACL reconstruction in combination with a modified Lemaire LET procedure. Group 1 was a historical control cohort of patients, whereas group 2 was prospectively enrolled. All the patients included in the present study were clinically evaluated using the Pediatric International Knee Documentation Committee (Pedi-IKDC) subjective score and the Pediatric Functional Activity Brief Scale (Pedi-FABS) score. Anteroposterior knee stability was measured using the KT-1000 knee ligament arthrometer, and the objective pivot-shift evaluation was documented using a triaxial accelerometer (Kinematic Rapid Assessment [KiRA]). The included patients also underwent a standardized radiological protocol to evaluate leg-length discrepancies, axial deviation, and degenerative signs preoperatively and at last follow-up.

RESULTS

This study included 66 pediatric patients with an anatomic hybrid ACL reconstruction using an autologous 4-strand hamstring graft. In group 1, there were 34 patients (mean age, 13.5 ± 1.2 years), while 32 patients (mean age, 13.8 ± 1.4 years) were included in group 2. The clinical outcome scores showed no difference between the 2 groups (Pedi-IKDC, P = .072; Pedi-FABS, P = .180). Nevertheless, the patients in group 2 had better anteroposterior stability measured using a KT-1000 arthrometer (1.9 ± 1.1 mm in group 1 vs 0.8 ± 0.8 mm in group 2; P = .031), as well as better rotational stability measured using the KiRA (-0.59 ± 1.05 m/s² in group 2 vs 0.98 ± 1.12 m/s² in group 1; P = .012). The patients in group 1 returned to sports at the same competitive level at a rate of 82.4%, while patients included in group 2 returned at the same competitive level in 90.6% of the cases without a significant difference between the 2 groups (P = .059). No leg-length discrepancies were found between the 2 groups at last follow-up (P = .881). Two patients displayed an increased valgus deformity of 3° on the operated limb at last follow-up (1 patient in group 1 and 1 patient in group 2). Group 1 had a significatively higher cumulative failure rate (14.7% vs 6.3%; P = .021). No intra- or postoperative complications was observed between the 2 groups.

CONCLUSION

Performing a modified Lemaire LET along with an ACL reconstruction with hamstring graft in pediatric patients reduced the cumulative failure rate and improved objective stability with no increase in intra- or postoperative complications. No significant difference was found between the 2 groups in terms of patient-reported outcomes or in the return-to-sports activity.

Cell-free cartilage engineering approach using hyaluronic acid–polycaprolactone scaffolds: A study in vivo

Polycaprolactone scaffolds modified with cross-linked hyaluronic acid were prepared in order to establish whether a more hydrophilic and biomimetic microenvironment benefits the progenitor cells arriving from bone marrow in a cell-free tissue-engineering approach. The polycaprolactone and polycaprolactone/hyaluronic acid scaffolds were characterized in terms of morphology and water absorption capacity. The polycaprolactone and polycaprolactone/hyaluronic acid samples were implanted in a chondral defect in rabbits; bleeding of the subchondral bone was provoked to generate a spontaneous healing response. Repair at 1, 4, 12, and 24 weeks was assessed macroscopically using the International Cartilage Repair Society score and the Oswestry Arthroscopy Score and microscopically using immunohistological staining for collagen type I and type II, and for Ki-67. The presence of hyaluronic acid improves scaffold performance, which supports a good repair response without biomaterial pre-seeding.

Femoral tunnel drilling angles for the posterolateral corner in multiligamentary knee reconstructions: computed tomography evaluation in a cadaveric model

PURPOSE

The goal of this study was to determine the best angle at which to drill the femoral tunnels of the popliteus tendon (PT) and fibular collateral ligament (FCL) in combined reconstructive procedures so as to avoid either short tunnels or tunnel collisions with the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) femoral tunnels.

METHODS

Eight cadaveric knees were studied. ACL/PCL femoral tunnels were arthroscopically drilled. PT and FCL tunnels were drilled at 0° and 30° axial and coronal angulations. They were scanned by computed tomography to document relations of the PT and FCL tunnels to the intercondylar notch and ACL/PCL tunnels. A minimum tunnel length of 25 mm was required.

RESULTS

Drilling the PT tunnel at 0° axial angulation was associated with an increased risk of tunnel collision with the ACL (P < .001). Interference with the PCL tunnel can be avoided only if the K-wire guiding the PT tunnel is drilled with 30° coronal angulations (P < .001). The minimum tunnel length of the PT could be obtained only with both axial and coronal angulations of 30° (P = .003). Sufficient tunnel lengths of the FCL were obtained at all angulations evaluated (P = .036). However, only the tunnels drilled at 30° axial and 0° coronal angulations did not collapse with the ACL tunnels (P < .001). No intersections between FCL and PT tunnels were observed.

CONCLUSIONS

When posterolateral reconstructions are performed in combination with concomitant anterior and posterior cruciate procedures, PT tunnels should be drilled at 30° axial and 30° coronal angulations. FCL tunnels should be drilled at 30° axial and 0° coronal angulations. These angulations should minimize such potential complications as short tunnels or collisions with the ACL/PCL tunnels.

CLINICAL RELEVANCE

Specific drilling angles are necessary to avoid short tunnels or collisions between the drilled tunnels when FCL and PT femoral tunnels are performed in multiligament knee reconstructions.

Magnetic resonance evaluation of TruFit® plugs for the treatment of osteochondral lesions of the knee shows the poor characteristics of the repair tissue

BACKGROUND

Treatment of osteochondral lesions of the knee with synthetic scaffolds seems to offer a good surgical option preventing donor site morbidity. The TruFit® plug has frequently been shown to not properly incorporate into.

OBJECTIVE

To evaluate the relationship between MRI findings and functional scores of patients with osteochondral lesions of the knee treated with TruFit®.

METHODS

Patients were evaluated with MOCART score for magnetic resonance imaging assessment of the repair tissue. KOOS, SF-36 and VAS were used for clinical evaluation. Correlation between size of the treated chondral defect and functional scores was also analyzed.

RESULTS

Fifty-seven patients with median follow-up of 44.8 months (range 24-73) were included. KOOS, SF-36 and VAS improved from a mean 58.5, 53.9 and 8.5 points to a mean 87.4, 86.6 and 1.2 at last follow-up (p<0.001). Larger lesions showed less improvement in KOOS (p=0.04) and SF-36 (p=0.029). Median Tegner values were restored to preinjury situation (5, range 2-10). Mean MOCART score was 43.2 ± 16.1. Although the cartilage layer had good integration, it showed high heterogeneity and no filling of the subchondral bone layer.

CONCLUSIONS

TruFit® failed to restore the normal MRI aspect of the subchondral bone and lamina in most cases. The appearance of the chondral layer in MRI was partially re-established. This unfavourable MRI appearance did not adversely influence the patient's outcome in the short time and they restored their previous level of activity. There was an inverse linear relationship between the size of the lesion and the functional scores.

LEVEL OF EVIDENCE

Therapeutic case series; level 4.

Minimizing the risk of graft failure after anterior cruciate ligament reconstruction in athletes. A narrative review of the current evidence

Anterior cruciate ligament (ACL) tear is one of the most common sport-related injuries and the request for ACL reconstructions is increasing nowadays. Unfortunately, ACL graft failures are reported in up to 34.2% in athletes, representing a traumatic and career-threatening event. It can be convenient to understand the various risk factors for ACL failure, in order to properly inform the patients about the expected outcomes and to minimize the chance of poor results. In literature, a multitude of studies have been performed on the failure risks after ACL reconstruction, but the huge amount of data may generate much confusion.The aim of this review is to resume the data collected from literature on the risk of graft failure after ACL reconstruction in athletes, focusing on the following three key points: individuate the predisposing factors to ACL reconstruction failure, analyze surgical aspects which may have significant impact on outcomes, highlight the current criteria regarding safe return to sport after ACL reconstruction.

Innervation patterns of the inferior glenohumeral ligament: Anatomical and biomechanical relevance

Although the Inferior Glenohumeral Ligament (IGHL) has a well known mechanical and proprioceptive relevance in shoulder stability, the interrelation of the ligament's anatomical disposition/innervation has not actually been described previously. The purpose of the study was to determine the IGHL innervation patterns and relate them to dislocation. Forty-five embalmed and 16 fresh-frozen human cadaveric shoulders were studied. Masson's Trichrome staining detailed the intraligamentous nerve fiber arrangements. The effect on the articular nerves of an anteroinferior dislocation of the shoulder joint and the position of 60 degrees abduction and 45 degrees external rotation was studied dynamically. The axillary nerve provided IGHL innervation in 95.08% of the cases. We saw two distinct innervation patterns originating from the axillary nerve. In Type 1, one or two collaterals diverged later from the main trunk to enter the ligament. Type 2 showed innervation to the ligament provided by the posterior branch for three to four neural branches. In both cases, these branches enter the ligament near the glenoid rim and at the 7 o'clock position (right shoulder). The radial nerve (Type 3 innervation pattern) provided IGHL innervation in 3.28% of the cases. Microscopic analysis revealed wavy intraligamentous neural branches. The articular branches relaxed and separated from the capsule at the apprehension position and stayed intact after dislocation. These results showed a special predisposition to avoid possible denervation and suggested that the neural arch probably remains unaffected after most dislocations. Knowledge of the neural anatomy of the shoulder will clearly help in avoiding its injury in surgical procedures.

Effectiveness of a footprint guide to establish an anatomic femoral tunnel in anterior cruciate ligament reconstruction: computed tomography evaluation in a cadaveric model

PURPOSE

To compare drilling the femoral tunnel with an offset aimer and BullsEye guide (ConMed Linvatec, Largo, FL) to perform an anatomic single-bundle reconstruction of the anterior cruciate ligament (ACL) through the anteromedial portal.

METHODS

Seven matched pairs of cadaveric knees were studied. The intent was to drill the femoral tunnel anatomically in all cases. In group A the femoral tunnel was drilled arthroscopically with an offset aimer. In group B the femoral tunnel was drilled arthroscopically with the BullsEye guide. Two tunnels were drilled through the same entry point in each knee. One was done at 110° of knee flexion and the other at 130°. They were scanned by computed tomography and reconstructed 3-dimensionally. Volume-rendering software was used to document relations of the drilled tunnel to the bony anatomy and tunnel length.

RESULTS

In group B the femoral tunnel was placed at the center of the femoral insertion site. The center of the tunnel was 9.4 mm from the high cartilage margin and 8.6 mm from the low cartilage margin. In group A the tunnels were placed deeper (5.4 mm and 12.6 mm, respectively) (P = .018). There were no differences in tunnel length for either knee flexion degree. Three of the tunnels drilled at 110° in group A compromised the posterior tunnel wall and measured less than 25 mm in length.

CONCLUSIONS

Accurate placement in the center of the femoral footprint of the ACL is better accomplished with the BullsEye guide rather than 5-mm offset aimers. Five-millimeter offset aimers might cause posterior tunnel blowout and present the risk of obtaining short tunnels when performing oblique femoral tunnel placement through the anteromedial portal at 110° of knee flexion.

CLINICAL RELEVANCE

The BullsEye guide might be better than standard offset aimers in the performance of anatomic single-bundle ACL reconstruction.

Primary lipoma arborescens of the knee may involve the development of early osteoarthritis if prompt synovectomy is not performed

BACKGROUND

Primary lipoma arborescens (LA) is a rare, benign intra-articular hyperplastic tumor that has been associated with osteoarthritis (OA). The aim of this study was to determine whether prompt synovectomy could avoid progressive joint degeneration in cases of primary LA of the knee.

MATERIALS AND METHODS

A review of currently available literature about the disease was carried out. The clinical, histological and radiological records of a series of nine knees with primary LA diagnosed and treated between 2002 and 2012 were retrospectively reviewed. Eight of the knees had histological confirmation of LA and none had evidence of condropathy on the initial magnetic resonance image or degenerative changes at the initial radiographic examination.

RESULTS

At the final follow-up no evidence of OA was found in the three knees that underwent synovectomy when symptoms did not last more than 1 year. The five knees in which synovectomy was delayed developed progressive joint degeneration.

CONCLUSION

In this series, primary LA of the knee involved the development of early osteoarthritis when prompt synovectomy was not performed. Timely synovectomy is strongly recommended, if not mandatory.

LEVEL OF EVIDENCE

IV.

Combined fracture of the talus: Arthroscopic treatment

The purpose of this article is to report the treatment and short-term results of a combined fracture of the talus treated arthroscopically. A 29-year-old man sustained an anterolateral osteochondral grade III fracture of the talus dome associated with a coronal fracture of the body of the talus. This injury was reduced and fixed arthroscopically using cannulated screws. The patient returned to his daily style of living after 3 months time. One year later, the patient remains asymptomatic. Radiography showed neither signs of osteonecrosis nor osteoarthritis of the talus at the 1-year follow-up. Therefore, arthroscopic surgery could be an alternative treatment for this kind of talus fracture.

The vancomycin soaking technique: no differences in autograft re-rupture rate. A comparative study

PURPOSE

The main aim of this study was to evaluate the re-rupture risk after an anterior cruciate ligament reconstruction (ACL-R) using the vancomycin soaking technique and to compare it with the re-rupture risk in patients on whom this technique was not utilized. The secondary purpose was to compare the functional outcomes of those two subsets of patients operated on for ACL-R. The hypotheses are that the vancomycin soaking technique does not affect the re-rupture risk or the functional outcomes.

MATERIAL AND METHODS

A retrospective historical cohort study was conducted. Two groups were compared in terms of the re-rupture rate (traumatic or atraumatic) and functional outcomes (International Knee Documentation Committee (IKDC), Tegner, and Lysholm). Group 1 consisted of patients that received pre-operative IV antibiotics. In group 2, the patients received pre-operative IV antibiotics along with a graft that had been presoaked in a vancomycin solution. A minimum follow-up of five years was required.

RESULTS

There were 17 patients that suffered a re-rupture in group 1 (4.7%) and 15 in group 2 (3.9%) (n.s.). IKDC was 82.0 in group 1 and 83.9 in group 2 (p = 0.049); Tegner scored 4 in both groups (n.s.) and Lysholm was 90.3 in group 1 and 92.0 in group 2 (p = 0.015).

CONCLUSION

The vancomycin soaking technique for ACL autografts is a safe procedure for the daily clinical practice, in terms of re-ruptures. Moreover, it does not impair functional outcomes after an ACL-R.

Reliability of preoperative measurement with standardized templating in Total Knee Arthroplasty

AIM: To investigate the correlation between preoperative measurement in total knee arthroplasty and the prosthetic size implanted.

METHODS: A prospective double-blind study of 50 arthroplasties was performed. Firstly, the reliability and correspondence between the size of said measurement and the actual implant utilized was determined. Secondly, the existing correlation between the intra- and interobserver determinations with the intraclass correlation coefficient was analyzed.

RESULTS: An overall correspondence of 54%, improving up to 92% when the measured size admitted a difference of one size, was found. Good intra- and interobserver reliability with an intraclass correlation coefficient greater than 0.90 (P < 0.001) was also discovered.

CONCLUSION: Agreement between the preoperative measurement with standardized acetate templates and the prosthetic size implanted can be considered satisfactory. We thus conclude it is a reproducible technique.