Patient-Individualized Identification of Medial Patellofemoral Ligament Attachment Site to Femur Using "CLASS" MRI Sequences.

Background: Malposition of the femoral tunnel during medial patellofemoral ligament (MPFL) reconstruction may increase the risk of recurrence of patellar dislocation due to isometric changes during flexion and extension. Different methods have been described to identify the MPFL isometric point using fluoroscopy. However, femoral tunnel malposition was found to be the cause of 38.1% of revisions due to patellar redislocation. This high rate of malposition has raised the question of individual anatomical variability. Methods: Magnetic resonance imaging (MRI) was performed on 80 native knees using the CLASS (MRI-generated Compressed Lateral and anteroposterior Anatomical Systematic Sequence) algorithm to identify the femoral MPFL insertion. The insertions were identified on the MRI views by 2 senior orthopaedic surgeons in order to assess the reliability and reproducibility of the method. The distribution of the MPFL insertion locations was then described in a 2-plane coordinate system and compared with MPFL insertion locations identified with other methods in previously published studies. Results: The CLASS MPFL footprint was located 0.83 mm anterior to the posterior cortex (line 1) and 3.66 mm proximal to the Blumensaat line (line 2). Analysis demonstrated 0.90 and 0.89 reproducibility and 0.89 and 0.80 reliability of the CLASS method to identify the anatomical femoral MPFL insertion point. The distribution did not correlate with previously published data obtained with other methods. The definitions of the MPFL insertion point in the studies by Schöttle et al. and Fujino et al. most closely approximated the CLASS location in relation to the posterior femoral cortex, but there were significant differences between the CLASS method and all 4 previously published methods in relation to the proximal-distal location. When we averaged the distances from line 1 and line 2, the method that came closest to the CLASS method was that of Stephen et al., followed by the method of Schöttle et al. Conclusions: The CLASS algorithm is a reliable and reproducible method to identify the MPFL femoral insertion from MRI views. Measurement using the CLASS algorithm shows substantial individual anatomical variation that may not be adequately captured with existing measurement methods. While further research must target translation of this method to clinical use, we believe that this method has the potential to create a safe template for sagittal fluoroscopic identification of the femoral tunnel during MPFL surgical reconstruction. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Uncommon, foreign-body induced knee arthrofibrosis in a pediatric patient.

Arthrofibrosis is defined as an excessive fibrotic tissue response within a joint leading to a painful loss of motion. This pathological scar formation process with dysregulated, inordinate extracellular matrix formation, especially collagen, may occur in any joints, although is frequently localized in the knee. Different etiologies have been described and most of them are related to trauma, infection or recent surgical procedure. Although arthrofibrosis affects people of all ages, it is unusual in pediatric population. We present a case report of an uncommon, foreign body induced knee arthrofibrosis in a 14-year old boy. We also review the current literature regarding diagnostic procedures and treatment rationale for arthrofibrosis of the knee.

[Iron deficiency and anemia in junior women's competitive sport]. / Carence martiale et anémie dans le sport de compétition junior féminin.

An iron deficient athlete is likely to develop iron deficiency anemia, a pathology that may lead to a decrease in performance. If adult athletes, women and men, are aware of the need for regular monitoring, young people under 18 are not necessarily aware of the risks associated with competitive sports practice in the presence of anemia. Even if the guidelines are well known and described, a lack of regular monitoring is found for the aforementioned age group. In junior female athletes practicing basketball, a significant rate of iron deficiency or even iron deficiency anemia was found during annual analyses. The authors wish to emphasize the importance of regular medical and laboratory follow-up for younger athletes who often no longer have a pediatrician and no attending physician.

Un sportif carencé en fer risque de développer une anémie ferriprive qui peut être à l'origine d'une diminution des performances. Les sportifs adultes, femmes et hommes, ont conscience de la nécessité d'un suivi régulier mais cette connaissance des risques liés à l'anémie dans la pratique sportive n'est pas forcément présente chez les jeunes de moins de 18 ans. Même si les lignes de conduite sont décrites et connues, on observe un manque de suivi régulier dans la tranche d'âge précitée. Chez les basketteuses féminines juniors, un taux de carence martiale significatif, voire une anémie ferriprive, a été retrouvé lors des analyses annuelles. Les auteurs souhaitent mettre ce problème en évidence et souligner l'importance d'un suivi médical et biologique régulier pour les sportifs en devenir qui n'ont souvent plus de médecin pédiatre et pas encore de médecin traitant.

Compressed Lateral and anteroposterior Anatomical Systematic Sequences «CLASS¼: compressed MRI sequences with assessed anatomical femoral and tibial ACL's footprints, a feasibility study.

PURPOSE: This study's main objective is to assess the feasibility of processing the MRI information with identified ACL-footprints into 2D-images similar to a conventional anteroposterior and lateral X-Ray image of the knee. The secondary aim is to conduct specific measurements to assess the reliability and reproducibility. This study is a proof of concept of this technique. METHODS: Five anonymised MRIs of a right knee were analysed. A orthopaedic knee surgeon performed the footprints identification. An ad-hoc software allowed a volumetric 3D image projection on a 2D anteroposterior and lateral view. The previously defined anatomical femoral and tibial footprints were precisely identified on these views. Several parameters were measured (e.g. coronal and sagittal ratio of tibial footprint, sagittal ratio of femoral footprint, femoral intercondylar notch roof angle, proximal tibial slope and others). The intraclass correlation coefficient (ICCs), including 95% confidence intervals (CIs), has been calculated to assess intraobserver reproducibility and interobserver reliability. RESULTS: Five MRI scans of a right knee have been assessed (three females, two males, mean age of 30.8 years old). Five 2D-"CLASS" have been created. The measured parameters showed a "substantial" to "almost perfect" reproducibility and an "almost perfect" reliability. CONCLUSION: This study confirmed the possibility of generating "CLASS" with the localised centroid of the femoral and tibial ACL footprints from a 3D volumetric model. "CLASS" also showed that these footprints were easily identified on standard anteroposterior and lateral X-Ray views of the same patient, thus allowing an individual identification of the anatomical femoral and tibial ACL's footprints. LEVEL OF EVIDENCE: Level IV diagnostic study.

Occurrence of inadequate ACL healing after Dynamic Intraligamentary Stabilization and functional outcome-a multicentre case series.

INTRODUCTION: Dynamic Intraligamentary Stabilization (DIS) is a technique for preservation, anatomical repair and stabilization of a freshly injured anterior cruciate ligament (ACL). The main purpose of this study was to evaluate the short-term re-operation rate when compared to traditional autograft reconstruction. METHODS: Four, from the developer independent, centres enrolled patients that underwent ACL repair by DIS, according to the specific indications given by MRI imaging at a minimum follow-up of 12 months. The re-operation rate was recorded as primary outcome. Secondary outcome measures were the postoperative antero-posterior knee laxity (using a portable Rolimeter®), as well as the Tegner, Lysholm and IKDC Scores. RESULTS: A total of 105 patients were investigated with a median follow-up of 21 months. Thirteen patients were lost to follow-up. Of the remaining 92 patients 15 (16.3%) had insufficient functional stability and required subsequent ACL reconstruction. These patients were excluded from further analysis, leaving 77 consecutive patients for a 12 months follow-up. The median age at time of surgery was 30 years for that group. At time of follow-up a median antero-posterior translation difference of 2 mm was measured. None of these patients reported subjective insufficiency (giving way), but in 14 patients (18.2%), the difference of antero-posterior translation was more than 3 mm. We found a median Tegner Score of 5.5, a median Lysholm Score of 95.0 and a median IKDC Score of 89.4. CONCLUSION: The main finding of this multicentre study is a relevant re-operation rate of 16.3%. Another 18.2% showed objective antero-posterior laxity (≥ 3 mm) during testing raising the suspicion of postoperative non-healing. The failure rate of DIS in this study is higher than for reconstruction with an autologous tendon graft. However, our successfully treated patients had a good clinical and functional outcome based on antero-posterior knee laxity and clinical scores, comparable to patients treated by autograft reconstruction.

Osteoarticular vascular corrosion casting using industrial polyurethane for the 3D representation of the vascular tree on human knee.

Vascular casting is a widely used method for the representation of body vascularization. Many different injection materials have been described throughout the time to enhance the arterial vascular supply within a specifically defined anatomical location. The use of industrial polyurethane has been recently evaluated and applied to animal and human anatomy. The aim of this study was to confirm the safe and reliable use of industrial polyurethane in knee specimen in order to obtain a three-dimensional vascular tree of the distal femur. 10 fresh-frozen knees (mid-thigh to mid tibia) were used to assess the vascularity around the femoral condyles. Industrial polyurethane foam (Soudal™ foam) was diluted with acetone in order to obtain a runny fluid, easy to inject. After injection, the knees were bathed in a 10% NaOH solution, heated at 30°. The corrosion process took from 20 to 24h and allowed all the soft tissue surrounding the knee to be subsided, leaving only the bone with polyurethane vascular architecture. After soft tissue corrosion, the vascular network around the knees was easily identified underlying the relation of the vessels to the bone. Even small arterioles (diameter<1mm) were distinguished with a good resistance to breakage. Corrosion casting remains an easy and reliable alternative to dissection for the understanding of tissue perfusion as the handling of the polyurethane is easy and has low costs. The described author's method can be used osteo-articular specimen as well as in other organs. The protocol of injection and corrosion needs however to be adapted to the different specimen and anatomical location. Polyurethane associated to acetone can safely be used as injection material in order to demonstrate the vascularity of a specimen and remains easy to use.

Stable clinical long term results after AMIC in the aligned knee.

INTRODUCTION: The aim of this study was to report a long-term follow-up of patients treated with autologous matrix-induced chondrogenesis (AMIC) for full-thickness chondral and osteochondral defects of the femoral condyle or patella combined with the correction of lower limb malalignment or patellar tracking if indicated. METHODS: Thirty-three patients (thirty-four knees) were treated surgically for chondral and osteochondral cartilage defects of the knee joint. Regarding the origin of the lesion, patients were divided into three groups. Chondral lesions were observed in the patella (cP group) in fifteen patients, whereas eight patients demonstrated a femoral condylar location (cF group). Eleven patients presented with osteochondritis dissecans of the femur (ocF group). Associated procedures involving realignment of the patella, osteotomy around the knee, or cancellous bone grafting were performed when necessary. The mean size of the lesions was 2.8 ± 1.6 cm2, and the mean patient age was 37.1 ± 11.9 years. To evaluate the clinical outcomes, the Lysholm score and the VAS pain score were imposed, as well as the reoperation rate. RESULTS: After an average of 9.3 ± 1 years, follow-up was completed in 79% of the patients. Two patients from the cohort received a total knee prosthesis. The primary outcome measures (Lysolm and VAS pain) at 9-year follow-up were 85 ± 13 for the Lysholm score and 1.9 ± 1.6 for the VAS score in the entire analyzed population. Compared to the preoperative values (Lysholm 56 ± 19, VAS 5.8 ± 2.4) and the 2-year results (Lysholm 85 ± 16, VAS 2.0 ± 2.1), there was significant improvement in the first 2 years after intervention and a stable course in the long-term observation. The same was observed in the cP and ocF subgroups, whereas patients of the cF group showed even further improvement. CONCLUSIONS: AMIC showed durable results in aligned knees. The favorable outcome was maintained after an average of 9 years when malalignment of the lower limb and patellar maltracking were corrected. Such data are particularly encouraging for young adult patients who may benefit from a procedure that circumvents early arthroplasty.

Osteonecrosis of the femoral head: pathophysiology and current concepts of treatment.

Osteonecrosis of the femoral head is a disabling pathology affecting a young population (average age at treatment, 33 to 38 years) and is the most important cause of total hip arthroplasty in this population. It reflects the endpoint of various disease processes that result in a decrease of the femoral head blood flow.The physiopathology reflects an alteration of the vascularization of the fine blood vessels irrigating the anterior and superior part of the femoral head. This zone of necrosis is the source of the loss of joint congruence that leads to premature wear of the hip.Several different types of medication have been developed to reverse the process of ischemia and/or restore the vascularization of the femoral head. There is no consensus yet on a particular treatment.The surgical treatments aim to preserve the joint as far as the diagnosis could be made before the appearance of a zone of necrosis and the loss of joint congruence. They consist of bone marrow decompressions, osteotomies around the hip, vascular or non-vascular grafts.Future therapies include the use of biologically active molecules as well as implants impregnated with biologically active tissue. Cite this article: EFORT Open Rev 2019;4:85-97. DOI: 10.1302/2058-5241.4.180036.

Review and Long-Term Outcomes of Cruciate Ligament Reconstruction versus Conservative Treatment in Siblings with Congenital Anterior Cruciate Ligament Aplasia.

There is no consensus on the best treatment for anterior cruciate ligament hypoplasia or aplasia. To our knowledge, no comparative study between operative and conservative treatment of this condition has ever been performed. Conservative treatment is a viable alternative to surgery for ACL aplasia. Two siblings were examined at our outpatient clinic. The male patient underwent bilateral ACL reconstruction, while his sister was treated conservatively. Our results show a worse long-term outcome for the operative patient. At her last follow-up, the female patient treated conservatively showed subjective improvement in stability and gait. A review of the literature shows inconsistent outcomes after reconstruction in contrast to reports with cruciate ligament agenesis that did not undergo reconstruction with acceptable to good outcomes. Cruciate reconstruction should be reserved for cases of impaired articular instability, objectively manifest in the frequency of giving-way episodes. Treatment depends on the patient's condition and expectations. Surgery should therefore only be suggested after proper patient counseling.