RESUMO
BACKGROUND: There is no consensus on managing severe patellar bone loss after total knee arthroplasty. We previously described an initial series involving a novel technique of patellar bone-grafting with a short follow-up. The purpose of this study was to determine long-term survivorship and the radiographic and clinical results of patellar bone-grafting during revision total knee arthroplasty in a larger series with an extended follow-up. METHODS: We identified 90 patients from a single institution who underwent 93 patellar bone-grafting procedures for severe patellar bone loss from 1997 to 2014. The mean age of the patients was 70 years, and 46% of patients were female. Forty-five knees (48%) underwent first-time revisions, and 19 knees (20%) had undergone a failed attempt at patellar resurfacings. Intraoperative patellar caliper thickness increased from a mean of 7 to 25 mm after patellar bone-grafting (p < 0.01). Radiographic review determined changes in patellar height, tracking, and remodeling. Knee Society scores (KSSs) were calculated. The mean follow-up was 8 years (range, 2 to 18 years). Kaplan-Meier methods determined survivorship free of any revision and any reoperation. Cox proportional hazards analysis determined predictive factors for failure. RESULTS: Survivorship free of patellar revision was 96% at 10 years. Survivorship free of any revision was 84% at 10 years. Survivorship free of any reoperation was 78% at 10 years. Increasing patient age was the only protective factor against further patellar revision (hazard ratio, 0.95; p < 0.01). When comparing initial radiographs with final radiographs, patellar height decreased from 22 to 19 mm (p < 0.01), 80% compared with 59% of patellae articulated centrally in the trochlea (p = 0.01), and 32% compared with 77% had remodeling over the lateral femoral condyle (p < 0.01). Anterior knee pain decreased from 51% to 27% postoperatively (p = 0.01). The mean knee flexion improved from 101° to 108° (p = 0.03). The mean KSS improved from 50 to 85 points (p < 0.01). CONCLUSIONS: Reliable long-term clinical results can be expected with patellar bone-grafting for severe patellar bone loss during revision total knee arthroplasty. Pain, range of motion, and other reported outcomes improve despite radiographic changes to patellar height, tracking, and remodeling. This technique is a durable and reliable option when standard patellar resurfacing is not possible. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Artroplastia do Joelho/métodos , Transplante Ósseo/métodos , Patela/cirurgia , Reoperação/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Articulação do Joelho/diagnóstico por imagem , Articulação do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Patela/transplante , Modelos de Riscos Proporcionais , Falha de Prótese , Radiografia , Amplitude de Movimento Articular , Sistema de RegistrosRESUMO
CASE: A 24-year-old female diagnosed with fibroblastic osteosarcoma of the patella underwent a total patellectomy and surgical reconstruction with a large bone-tendon allograft of the extensor mechanism and adjuvant chemotherapy. At 5 years' postoperative, the patient has adequate disease control and excellent joint function. CONCLUSIONS: Reconstruction with an extensor mechanism allograft is an appropriate alternative for patients with malignant patella tumors without tumor contamination of the joint, allowing for satisfactory knee function and disease control.
Assuntos
Neoplasias Ósseas/cirurgia , Osteossarcoma/cirurgia , Patela/transplante , Tendões/transplante , Neoplasias Ósseas/diagnóstico por imagem , Transplante Ósseo , Feminino , Humanos , Osteossarcoma/diagnóstico por imagem , Patela/diagnóstico por imagem , Adulto JovemRESUMO
BACKGROUND: The use of a quadriceps tendon-patellar bone (QTPB) autograft provides an alternative procedure in primary reconstruction of the anterior cruciate ligament (ACL). Using the press-fit technique for femoral fixation and knotting over a bone bridge as well as additional spongiosa filling for tibial fixation can completely eliminate the need for fixation implants. The objective of this study was to evaluate the long-term clinical, functional and radiological results of this operating method. METHODS: Sixty-nine patients (27 female-42 male) were included in this study. Fifty-seven patients (83%) received a comprehensive follow-up review after an average period of 7.5 years (range: 7-8.7). All other patients were surveyed by telephone. Six patients (9%) suffered a re-rupture of the ACL graft caused by a new related trauma and were therefore excluded from the statistical analysis. RESULTS: Of all patients, 98% were satisfied with the operation. Normal or almost normal results were recorded in the subjective IKDC scores form by 88% of the patients. The Lysholm score demonstrated very good and good results in 83% of the patients. Only 1 patient reported minor complaints in the donor area. Seven (12%) patients developed Cyclops syndrome with limited knee extension. This complication was treated arthroscopically within the first year postoperatively. Their results on follow-up were not worse than the results of the patients without Cyclops syndrome. Regarding the 57 patients who received a comprehensive evaluation, the stability test with the KT-1000 Arthrometer yielded a difference of less than 3 mm in the contralateral comparison for 89% of the operated knees. The pivot-shift test was normal in 79% and almost normal in 21%. In the Single-leg Triple Hop Test, patients achieved an average of 98% of the hopping distance attained with the contralateral leg. The radiological examination revealed a slight deterioration in the Kellgren-Lawrence Score in 2 patients. CONCLUSION: The ACL reconstruction using the QTPB autograft performed with the press-fit technique leads to good results in comparison with published results of established procedures for primary ACL surgery using other autografts. Further investigations should involve comparative studies with the objective of providing evidence-based, individually adapted therapy for ACL rupture.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Instabilidade Articular/epidemiologia , Patela/transplante , Ligamento Patelar/transplante , Adolescente , Adulto , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Autoenxertos , Feminino , Seguimentos , Humanos , Instabilidade Articular/etiologia , Instabilidade Articular/fisiopatologia , Articulação do Joelho/fisiopatologia , Articulação do Joelho/cirurgia , Masculino , Amplitude de Movimento Articular , Estudos Retrospectivos , Transplante Autólogo/efeitos adversos , Transplante Autólogo/métodos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Quadriceps tendon-patellar bone (QTPB) autograft is an excellent graft option with good clinical outcome. Use of QTPB autografts have increased because they minimize donor-site morbidity including anterior knee pain, while providing adequate mechanical strength. Although, there were many clinical results about allografts that used in anterior cruciate ligament (ACL) reconstruction, it have never been reported about the clinical outcome of ACL reconstruction with QTPB allograft. The purpose of this study is to evaluate the clinical outcome of ACL reconstruction with QTPB allograft and to compare with QTPB autograft. We hypothesized that ACL reconstruction with QTPB allograft had good functional outcomes and stability and no significant difference compared to the ACL reconstruction with QTPB autograft. METHODS: From February 2009 to January 2014, 213 cases who received ACL reconstruction with QTPB grafts were included. Forty-five patients who received ACL reconstruction with QTPB allograft were individually matched in age, sex, direction of the injured knee and body mass index (BMI) to a control group of 45 patients who received QTPB autograft. Clinical results were evaluated using International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner scale, Knee injury and Osteoarthritis Outcome Score (KOOS) and ligament laxity. An average follow-up time was 31.2 months. RESULTS: The functional scores and ligament laxity improved from initial to the last visit in those with ACL reconstruction with QTPB allograft (p < 0.05). No significant statistical difference was found in clinical outcomes and complications including re-rupture between the QTPB allograft and autograft groups (p > 0.05). Laxity using anterior drawer test, Lachman test and KT-2000 showed no significant difference. No significant difference was found between the two groups in quadriceps peak extension torque, except at 60° per second at 6 months. CONCLUSION: QTPB allograft achieved good clinical outcome with no difference compared with QTPB autograft. QTPB allograft for ACL reconstruction is promising alternative to selected and compliant patients. Long-term follow-up needs to further evaluate the clinical outcomes and complications including re-rupture rate.
Assuntos
Aloenxertos/transplante , Reconstrução do Ligamento Cruzado Anterior/métodos , Patela/transplante , Músculo Quadríceps/transplante , Adulto , Estudos de Casos e Controles , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Double-bundle anterior cruciate ligament (ACL) reconstruction has demonstrated improved biomechanical properties and moderately better objective outcomes compared with single-bundle reconstructions. This could make an impact on the rerupture rate and reduce the risk of revisions in patients undergoing double-bundle ACL reconstruction compared with patients reconstructed with a traditional single-bundle technique. The National Knee Ligament Registers in Scandinavia provide information that can be used to evaluate the revision outcome after ACL reconstructions. QUESTIONS/PURPOSES: The purposes of the study were (1) to compare the risk of revision between double-bundle and single-bundle reconstructions, reconstructed with autologous hamstring tendon grafts; (2) to compare the risk of revision between double-bundle hamstring tendon and single-bundle bone-patellar tendon-bone autografts; and (3) to compare the hazard ratios for the same two research questions after Cox regression analysis was performed. METHODS: Data collection of primary ACL reconstructions from the National Knee Ligament Registers in Denmark, Norway, and Sweden from July 1, 2005, to December 31, 2014, was retrospectively analyzed. A total of 60,775 patients were included in the study; 994 patients were reconstructed with double-bundle hamstring tendon grafts, 51,991 with single-bundle hamstring tendon grafts, and 7790 with single-bundle bone-patellar tendon-bone grafts. The double-bundle ACL-reconstructed patients were compared with the two other groups. The risk of revision for each research question was detected by the risk ratio, hazard ratio, and the corresponding 95% confidence intervals. Kaplan-Meier analysis was used to estimate survival at 1, 2, and 5 years for the three different groups. Furthermore, a Cox proportional hazard regression model was applied and the hazard ratios were adjusted for country, age, sex, meniscal or chondral injury, and utilized fixation devices on the femoral and tibial sides. RESULTS: There were no differences in the crude risk of revision between the patients undergoing the double-bundle technique and the two other groups. A total of 3.7% patients were revised in the double-bundle group (37 of 994 patients) versus 3.8% in the single-bundle hamstring tendon group (1952 of 51,991; risk ratio, 1.01; 95% confidence interval (CI), 0.73-1.39; p = 0.96), and 2.8% of the patients were revised in the bone-patellar tendon-bone group (219 of the 7790 bone-patellar tendon-bone patients; risk ratio, 0.76; 95% CI, 0.54-1.06; p = 0.11). Cox regression analysis with adjustment for country, age, sex, menisci or cartilage injury, and utilized fixation device on the femoral and tibial sides, did not reveal any further difference in the risk of revision between the single-bundle hamstring tendon and double-bundle hamstring tendon groups (hazard ratio, 1.18; 95% CI, 0.85-1.62; p = 0.33), but the adjusted hazard ratio showed a lower risk of revision in the single-bundle bone-patellar tendon-bone group compared with the double-bundle group (hazard ratio, 0.62; 95% CI, 0.43-0.90; p = 0.01). Comparisons of the graft revision rates reported separately for each country revealed that double-bundle hamstring tendon reconstructions in Sweden had a lower hazard ratio compared with the single-bundle hamstring tendon reconstructions (hazard ratio, 1.00 versus 1.89; 95% CI, 1.09-3.29; p = 0.02). Survival at 5 years after index surgery was 96.0% for the double-bundle group, 95.4% for the single-bundle hamstring tendon group, and 97.0% for the single-bundle bone-patellar tendon-bone group. CONCLUSIONS: Based on the data from all three national registers, the risk of revision was not influenced by the reconstruction technique in terms of using single- or double-bundle hamstring tendons, although national differences in survival existed. Using bone-patellar tendon-bone grafts lowered the risk of revision compared with double-bundle hamstring tendon grafts. These findings should be considered when deciding what reconstruction technique to use in ACL-deficient knees. Future studies identifying the reasons for graft rerupture in single- and double-bundle reconstructions would be of interest to understand the findings of the present study. LEVEL OF EVIDENCE: Level III, therapeutic study.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Ligamento Cruzado Anterior/cirurgia , Transplante Ósseo/métodos , Tendões dos Músculos Isquiotibiais/transplante , Patela/transplante , Ligamento Patelar/cirurgia , Complicações Pós-Operatórias/cirurgia , Adolescente , Adulto , Ligamento Cruzado Anterior/fisiopatologia , Lesões do Ligamento Cruzado Anterior/diagnóstico , Lesões do Ligamento Cruzado Anterior/fisiopatologia , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Fenômenos Biomecânicos , Transplante Ósseo/efeitos adversos , Distribuição de Qui-Quadrado , Feminino , Tendões dos Músculos Isquiotibiais/fisiopatologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Patela/fisiopatologia , Ligamento Patelar/fisiopatologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Modelos de Riscos Proporcionais , Sistema de Registros , Reoperação , Medição de Risco , Fatores de Risco , Países Escandinavos e Nórdicos , Fatores de Tempo , Transplante Autólogo , Resultado do Tratamento , Adulto JovemRESUMO
An important consideration for the successful use of fresh osteochondral allografts for the patellofemoral joint is selection of appropriately sized donor allografts. This is particularly challenging for matching grafts to the patella because of the substantial variability in articular contour that exists. At present, selection of donor patellae is based only on the width of the proximal tibia, with no established means of quantifying basic patellar size, facet configuration, or articular contour. We hypothesized that using a combination of standard radiographic measurements to generate an accurate profile of the recipients native patella would result in a more accurate donor graft. We radiographically measured seven dimensions of 30 fresh frozen cadaveric patellar specimens, and then, following dissection, accurate ex vivo measurements of patellar morphology were taken. Measurements obtained on the merchant view included total width, width of the medial and lateral facets, central ridge height (CRH) and location, as well as the patellar angle. The lateral view was obtained to measure the articular length. Ex vivo measurements were subsequently taken using a standard ruler, caliper, and goniometer following removal of all soft tissue attachments. To simulate a larger population of knees, we then used bootstrapping methods with simple random selection and replacement to generate a sample of measurements from 4,500 knees. In the bootstrapping process, measurements from one random specimen are added to the "population" at each iteration until the target sample size is reached. Data from this bootstrapped population were subsequently used to calculate statistically significant radiographic predictors of each ex vivo measurement, using a multivariate regression model with backward elimination. These predictors were then used to compare the calculated values to the actual ex vivo measurements for each dimension in our original 30 specimens' sample. Overall, these formulas were very successful in predicting ex vivo measurements. While further validation is warranted, we propose that these formulas can be utilized to select a more accurate donor.
Assuntos
Cartilagem/anatomia & histologia , Cartilagem/transplante , Seleção do Doador , Patela/anatomia & histologia , Patela/transplante , Articulação Patelofemoral/cirurgia , Aloenxertos , Cadáver , Humanos , Modelos Estatísticos , Articulação Patelofemoral/diagnóstico por imagemRESUMO
PURPOSE: Tendon harvesting for anterior cruciate ligament (ACL) reconstruction often injure sensory branches of the saphenous nerve (SN). Our purpose was to estimate the prevalence and postoperative course of sensory nerve injuries in bone patellar tendon bone (BPTB) autograft harvesting for ACL reconstruction. METHODS: Between 2012 and 2014, patients who had primary ACL with BPTB autograft were included ( n = 60) and interviewed specifically for sensory loss and its recovery. The surface area of sensory loss was documented. Evaluation also included demographic details, level of activity, and description of postoperative sensation disturbances. RESULTS: The mean postoperative follow-up time was 24 ± 14 months. At the last follow-up, 46 (77%) patients reported on postoperative reduced sensation; however, only 35 (58%) remained with sensation loss. The most involved region of reduced sensation was of the infrapatellar branch of the SN. Three patients claimed they regret to have had the surgery specifically because of sensation loss and kneeling difficulties, while all others did not. CONCLUSION: Primary ACL reconstruction using the midline incision for harvesting the middle third of the patellar tendon autograft has a high prevalence of sensory nerve injury with a minor possibility for complete recovery within the first year. However, sensory loss secondary to this injury does not impair normal daily activities in these patients.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Transplante Ósseo/métodos , Patela/transplante , Ligamento Patelar/transplante , Tendões/transplante , Adulto , Feminino , Humanos , Masculino , Prevalência , Transplante AutólogoRESUMO
Many techniques for reconstruction of pediatric and adolescent anterior cruciate ligament (ACL) ruptures have been described, yet the best technique to reproduce normal kinematics of the knee while causing minimal growth disturbance is not definitively determined. We describe a technique which adapts the Allen Anderson technique for all-inside, all-epiphyseal, anatomic ACL reconstruction. However, this technique uses a novel quadriceps tendon-patellar bone-autograft to provide the best-possible patient outcomes. ACL reconstruction advancement in pediatrics is important as an increasing number of adolescent athletes experience ACL rupture and desire to return to sport.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Autoenxertos/transplante , Patela/transplante , Tendões/transplante , Adolescente , Criança , Humanos , Músculo QuadrícepsRESUMO
PURPOSE: To evaluate the clinical results of a randomized controlled trial of single-layer versus double-layer bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction. METHODS: Fifty-eight subjects who underwent primary ACL reconstruction with a BPTB allograft were prospectively randomized into two groups: single-layer reconstruction (n = 31) and double-layer reconstruction (n = 27). The following evaluation methods were used: clinical examination, KT-1000 arthrometer measurement, muscle strength, Tegner activity score, Lysholm score, subjective rating scale regarding patient satisfaction and sports performance level, graft retear, contralateral ACL tear, and additional meniscus surgery. RESULTS: Forty-eight subjects (24 in single-layer group and 24 in double-layer group) who were followed up for 3 years were evaluated. Preoperatively, there were no differences between the groups. At 3-year follow-up, the Lachman and pivot-shift test results were better in the double-layer group (P = 0.019 and P < 0.0001, respectively). KT measurements were better in the double-layer group (mean 2.9 versus 1.5 mm; P = 0.0025). The Tegner score was also better in the double-layer group (P = 0.024). There were no significant differences in range of motion, muscle strength, Lysholm score, subjective rating scale, graft retear, and secondary meniscal tear. CONCLUSIONS: In ACL reconstruction, double-layer BPTB reconstruction was significantly better than single-layer reconstruction regarding anterior and rotational stability at 3-year follow-up. The results of KT measurements and the Lachman and pivot-shift tests were significantly better in the double-layer group, whereas there was no difference in the anterior drawer test results. The Tegner score was also better in the double-layer group; however, there were no differences in the other subjective findings.
Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Ligamento Cruzado Anterior/cirurgia , Transplante Ósseo/métodos , Traumatismos do Joelho/cirurgia , Patela/transplante , Tendões/transplante , Adulto , Lesões do Ligamento Cruzado Anterior/diagnóstico , Lesões do Ligamento Cruzado Anterior/fisiopatologia , Feminino , Seguimentos , Humanos , Traumatismos do Joelho/diagnóstico , Traumatismos do Joelho/fisiopatologia , Escore de Lysholm para Joelho , Masculino , Força Muscular/fisiologia , Ligamento Patelar/cirurgia , Satisfação do Paciente , Estudos Prospectivos , Amplitude de Movimento Articular/fisiologia , Transplante HomólogoRESUMO
PURPOSE: Recent anatomic studies have suggested that the dominant arterial supply of the patella enters through the inferior pole. Based upon these findings, we hypothesized that bone-patellar tendon-bone graft harvest can significantly diminish patellar vascularity. METHODS: Nine matched pair cadaveric knee specimens (mean age 47.4 years) were dissected and cannulated. A single knee was selected to undergo routine graft harvest, and the contralateral knee was left intact to serve as a control. Gadolinium was injected, and magnetic resonance imaging (MRI) signal enhancement was quantified to determine differences in uptake. Each matched pair was subsequently injected with a urethane polymer compound and dissected to correlate vessel disruption with MRI findings. RESULTS: We identified two predominating patterns of vessel entry. In one pattern, the vessel entered the inferomedial aspect (five o'clock/right, seven o'clock/left) of the patella and was disrupted by graft harvest in 2/9 (22.2 %) pairs. In the second pattern, the vessel entered further medial (four o'clock/right, eight o'clock/left) and was not disrupted (7/9, 78.8 %). The mean decrease in gadolinium uptake following disruption of the predominant vessel measured 56.2 % (range 42.6-69.5 %) compared to an average decrease of 18.3 % (range 7.1-29.1 %) when the dominant arterial supply to the inferior pole remained intact (p < 0.04). CONCLUSION: Medial entry of the predominant vessel precluded vessel disruption. Disruption of the dominant arterial supply can result in a significant decrease in patellar vascularity. Modification of graft harvest techniques and areas of surgical dissection should be explored to minimize vascular insult. Further correlation with clinical studies/outcomes is necessary to determine a potential association between vascular insult and anterior knee pain.
Assuntos
Enxerto Osso-Tendão Patelar-Osso/métodos , Enxertos Osso-Tendão Patelar-Osso/transplante , Patela/irrigação sanguínea , Coleta de Tecidos e Órgãos/métodos , Adulto , Enxertos Osso-Tendão Patelar-Osso/diagnóstico por imagem , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Patela/diagnóstico por imagem , Patela/transplante , Transplante Autólogo/métodosRESUMO
CASE: A 19-year-old soldier presented with sudden onset of left knee pain and giving-way while running. Evaluation showed a pathologic fracture through a radiolucent lesion of the tibial metaphysis. Excision of a giant cell tumor of bone entailed removal of much of the lateral tibial articular surface. The joint surface was replaced by transposition of the patella, which was transfixed in position with an ASIF (Association for the Study of Internal Fixation) condylar blade plate. This technique resulted in satisfactory knee function that has persisted for 43 years. CONCLUSION: When excision of a tumor of the tibia results in removal of a substantial portion of the articular surface, the defect can be replaced by transposition of the patella to provide long-lasting satisfactory knee function.
Assuntos
Neoplasias Ósseas/cirurgia , Transplante Ósseo , Tumor de Células Gigantes do Osso/cirurgia , Articulação do Joelho/cirurgia , Patela/transplante , Humanos , Ílio/transplante , Masculino , Adulto JovemRESUMO
BACKGROUND: To compare the mechanical performance of a rotator cuff repaired with a novel tendon-fibrocartilage-bone composite bridging patch vs the traditional Mason-Allen repair in an in vitro canine model. METHODS: Twenty shoulders and 10 bridging patches from patellar tendon were harvested. The patches were trimmed and sliced into 2 layers. An infraspinatus tendon tear was created in each shoulder. Modified Mason-Allen sutures were used to repair the infraspinatus tendon to the greater tuberosity, with or without the bridging patch (bridging patch group and controls, respectively). Shoulders were loaded to failure under displacement control at a rate of 0.5mm/s. FINDINGS: The ultimate tensile load was significantly higher in the bridging patch group than control (mean [SD], 365.46 [36.45] vs 272.79 [48.88] N; P<.001). Stiffness at the greater tuberosity repair site and the patch-infraspinatus tendon repair site was significantly higher than the control repair site (93.96 [27.72] vs 42.62 [17.48] N/mm P<.001; 65.94 [24.51] vs 42.62 [17.48] N/mm P=.02, respectively). INTERPRETATION: The tendon-fibrocartilage-bone composite bridging patch achieved higher ultimate tensile load and stiffness at the patch-greater tuberosity repair site compared with traditional repair in a canine model. This composite tissue transforms the traditional tendon-to-bone healing interface (with dissimilar tissues) into a pair of bone-to-bone and tendon-to-tendon interfaces, which may improve healing quality and reduce retear rate.
Assuntos
Fibrocartilagem/transplante , Procedimentos Ortopédicos/métodos , Patela/transplante , Ligamento Patelar/transplante , Lesões do Manguito Rotador , Manguito Rotador/cirurgia , Aloenxertos , Animais , Fenômenos Biomecânicos , Cães , Técnicas In Vitro , Modelos Animais , Suturas , Resistência à TraçãoRESUMO
PURPOSE: Quadriceps tendon grafts have renewed interest for ACL reconstruction; however, biomechanical studies comparing anatomic single-bundle (SB) and double-bundle (DB) reconstruction techniques are rare. The purpose of this study was to compare the knee biomechanics in four different types of anatomic ACL reconstruction techniques, using the quadriceps tendon in a human cadaver. METHODS: Four different tibial (T) and femoral (F) tunnel configurations, (a) DB-2F-2T, (b) DB-2F-1T, (c) SB-1F-1T and (d) DB-1F-2T, were used for ACL reconstruction using the split quadriceps tendon with patella bone. Ten cadaver knees were subjected to an 89 N anterior tibial load and combined 7 N m valgus and 5 N m internal torques. The anterior tibial translation (ATT) and in situ force were measured using a robotic system for the ACL-intact, ACL-deficient and ACL-reconstructed knees. RESULTS: DB reconstructions mostly restored ATT to the intact ACL. The in situ forces under the anterior load in the DB reconstructions were similar to the intact ACL, but that of the SB reconstruction was different at 30°, 60° and 90° of flexion (P < 0.05). Under combined torques, the in situ force of the SB graft was less than that of intact ACL at 0°, 15° and 30° of knee flexion (P < 0.05), while that of the ACL DB reconstruction was similar to the intact ACL. CONCLUSION: DB ACL reconstruction using quadriceps tendon can restore biomechanics of the knee to that of the intact ACL regardless of whether three or four tunnels are used, but SB reconstruction does not.
Assuntos
Reconstrução do Ligamento Cruzado Anterior/métodos , Ligamento Cruzado Anterior/cirurgia , Articulação do Joelho/fisiologia , Tendões/transplante , Idoso , Fenômenos Biomecânicos , Transplante Ósseo , Fêmur/fisiologia , Fêmur/cirurgia , Humanos , Articulação do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Patela/transplante , Amplitude de Movimento Articular , Robótica , Tendões/fisiologia , Tíbia/fisiologia , Tíbia/cirurgia , Torque , Suporte de CargaRESUMO
BACKGROUND: Calcaneal lengthening with allograft is frequently used for the treatment of patients with symptomatic planovalgus deformity; however, the behavior of allograft bone after calcaneal lengthening and the risk factors for graft failure are not well documented. QUESTIONS/PURPOSES: (1) What proportion of the patients treated with allograft bone had radiographic evidence of graft failure and what further procedures were performed? (2) What are the risk factors for radiographic graft failure after calcaneal lengthening? (3) What patient factors are associated with the magnitude of correction achieved after calcaneal lengthening? METHODS: Between May 2003 and January 2014, we performed 341 calcaneal lengthenings on 202 patients for planovalgus deformity, the etiology of which included idiopathic, cerebral palsy, and other neuromuscular disease. Of these, 176 patients (87%) had adequate followup for graft evaluation, defined as lateral radiographs taken before and at least 6 months after the index procedure (mean, 18 months; range, 6-100 months) and 117 patients (58%) had adequate followup for the assessment of the extent of correction, defined as weightbearing anteroposterior and lateral radiographs taken before and at least 1 year after the index procedure (mean, 24 months; range, 12-96 months). These patients' results were evaluated retrospectively. The Goldberg scoring system was chosen for demonstration of allograft behavior. A score lower than 6 at 6 months after surgery was defined as radiographic graft failure; the highest possible score was 7 points, and this represented graft incorporation with excellent reorganization of the graft and no loss of height. The patient age, sex, diagnosis, graft material, ambulatory status, and use of antiseizure medication were evaluated as possible risk factors, and we controlled for the interaction of potentially confounding variables using multivariate analysis. Additionally, six radiographic indices were analyzed for their effects on the extent of correction. RESULTS: The mean estimated Goldberg score was 6 (SD, 1.14) at 6 months after calcaneal lengthening with 11 feet (4%) classified as radiographic graft failure (Goldberg score < 6). Of these, four feet (1%) underwent reoperation using an iliac autograft bone resulting from pain and loss of correction. Multivariate analysis showed that the tricortical iliac crest allograft was superior to the patellar allograft (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.1-9.8; p = 0.038) and the possibility of radiographic graft failure was found to increase along with age (OR, 1.2; 95% CI, 1.0-1.3; p = 0.006). Radiographically, the extent of correction was found to decrease with patient age, as observed at the anteroposterior talus-first metatarsal angle (p < 0.001), lateral talocalcaneal angle (p < 0.001), lateral talus-first metatarsal angle (p < 0.001), and relative calcaneal length (p = 0.041). CONCLUSIONS: Graft failure can occur after calcaneal lengthening using allograft. Our study showed that the tricortical iliac allograft was superior to the patellar allograft, and further studies are warranted to further elucidate the effects of age on radiographic graft failure. LEVEL OF EVIDENCE: Level III, therapeutic study.
Assuntos
Alongamento Ósseo/efeitos adversos , Transplante Ósseo/efeitos adversos , Calcâneo/cirurgia , Deformidades Adquiridas do Pé/cirurgia , Ílio/transplante , Patela/transplante , Adolescente , Fatores Etários , Aloenxertos , Alongamento Ósseo/métodos , Calcâneo/diagnóstico por imagem , Calcâneo/fisiopatologia , Criança , Feminino , Deformidades Adquiridas do Pé/diagnóstico , Deformidades Adquiridas do Pé/fisiopatologia , Sobrevivência de Enxerto , Humanos , Ílio/diagnóstico por imagem , Ílio/fisiopatologia , Incidência , Modelos Lineares , Masculino , Análise Multivariada , Razão de Chances , Osseointegração , Patela/diagnóstico por imagem , Patela/fisiopatologia , Radiografia , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Falha de Tratamento , Adulto JovemRESUMO
BACKGROUND: Irradiated autografts have been used to aid the recovery of bone defects, and the results are well documented. Recently, bone allografts with tendinous attachments have been used to restore the function of joints. Similar reconstructions can be performed with irradiated autografts. However, little information is available on the biology of extracorporeal irradiated tendon autografts. QUESTIONS/PURPOSES: An experimental rabbit model was used to investigate the quality of healing and remodeling of the irradiated autogenous patellar tendon graft after 3 and 12 weeks using immunohistochemical and morphometric analyses. METHODS: New Zealand rabbits (n = 40) were randomly divided into autograft and allograft groups. The right knees of all animals served as the control (sham). The patellar tendon graft of the control right knee was reimplanted into its original location without any processing, while the patellar tendon of the left knee in the autograft group was reimplanted into the original location after 50 Gy irradiation. In the allograft group, the patellar tendon was sutured to the knee of another rabbit following 50 Gy irradiation. Five rabbits from each group were sacrificed and examined histologically. RESULTS: There were significant differences in the number of fibroblasts after 12 weeks between allograft and sham groups (P = 0.002). On the other hand, there were no differences between the allograft and autograft groups at the 12th week (P = 0.139). The difference in fibroblast numbers between autograft and allograft groups was statistically significant after the 3rd week (P < 0.05). Collagen fibril thickness was different between both the allograft and sham groups (P = 0.002) and the allograft and autograft groups at the 12th week (P = 0.000). Collagen fibrils were thicker in the sham and autograft groups compared with the allograft group at the 3rd week of evaluation (P < 0.05). The Ki67 index was significantly different between the allograft and sham groups at the 12th week (P < 0.032), while there was no difference between the allograft and autograft groups (P > 0.05). At the 3rd week, Ki67 reactivity was higher in the allograft group compared with the other two groups (P < 0.05).
Assuntos
Remodelação Óssea , Enxerto Osso-Tendão Patelar-Osso/métodos , Aloenxertos , Animais , Autoenxertos , Remodelação Óssea/efeitos da radiação , Fibroblastos , Patela/efeitos da radiação , Patela/transplante , Ligamento Patelar/efeitos da radiação , Ligamento Patelar/cirurgia , Coelhos , Tendões/cirurgiaRESUMO
Medial patellofemoral ligament (MPFL) reconstruction is used to treat patellar instability and recurrent patellar dislocation. Anatomical studies have found the MPFL to be a double-bundle structure. We carried out a meta-analysis of studies reporting outcomes of patellofemoral reconstruction using hamstring tendon autograft in a double-bundle configuration and patellar fixation via mediolateral patellar tunnels. A literature search was undertaken with no language restriction in various databases from their year of inception to July 2012. The primary outcome examined was the post-operative Kujala score. We identified 320 MPFL reconstructions in nine relevant articles. The combined mean post-operative Kujala score was 92.02 (standard error (se) 1.4, p = 0.001) using a fixed effects model and 89.45 (se 37.9, p = 0.02) using random effect modelling. The reported rate of complications with MPFL reconstruction was 12.5% (40 of 320) with stiffness of the knee being the most common. High-quality evidence in assessing double-bundle MPFL reconstruction is lacking. The current literature consists of a mixture of prospective and retrospective case series. High-quality randomised trials evaluating this procedure are still awaited.
Assuntos
Articulação do Joelho/cirurgia , Patela/cirurgia , Ligamento Patelar/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias/epidemiologia , Tendões/cirurgia , Transplante Autólogo/métodos , Humanos , Patela/transplante , Ligamento Patelar/transplante , Procedimentos de Cirurgia Plástica/efeitos adversos , Tendões/transplante , Transplante Autólogo/efeitos adversos , Resultado do TratamentoRESUMO
PURPOSE: The purpose of this review was to determine if there is an ideal operation for large symptomatic articular cartilage lesions on the undersurface of the patella in young patients. METHODS: A systematic search of PubMed was conducted to determine the outcome of operations performed for large patellar lesions in young patients. Inclusionary criteria were English language, original clinical trials published from 1992 to 2012, patellar lesions 4 cm(2) or larger, mean patient age 50 years or younger, and all evidence levels. RESULTS: Of 991 articles identified, 18 met the inclusionary criteria, encompassing 840 knees in 828 patients. These included 613 knees that underwent autologous chondrocyte implantation (ACI) (11 studies), 193 knees that had patellofemoral arthroplasty (PFA) (5 studies), and 34 knees that underwent osteochondral allografting (OA) (2 studies). The mean patient age was 37.2 years and the mean follow-up was 6.2 years. Long-term follow-up (>10 years) was available in only 4 studies (2 PFA, 1 ACI, 1 OA). All studies except one were Level IV and none were randomized or had a control group. Twenty-one outcome instruments were used to determine knee function. When taking into account knees that either failed or had fair/poor function, the percentage of patients who failed to achieve a benefit averaged 22% after PFA and 53% after OA and ranged from 8% to 60% after ACI. In addition, all 3 procedures had unacceptable complication and reoperation rates. CONCLUSIONS: The combination of failure rates and fair/poor results indicated that all 3 procedures had unpredictable results. We concluded that a long-term beneficial effect might not occur in one of 3 ACI and PFA procedures and in 2 of 3 OA procedures. We were unable to determine an ideal surgical procedure to treat large symptomatic patellar lesions in patients 50 years or younger. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.
Assuntos
Doenças das Cartilagens/cirurgia , Cartilagem Articular/cirurgia , Articulação Patelofemoral/cirurgia , Adulto , Artroplastia , Condrócitos/transplante , Humanos , Pessoa de Meia-Idade , Procedimentos Ortopédicos/métodos , Patela/cirurgia , Patela/transplante , Reoperação , Transplante AutólogoRESUMO
Extensor mechanism reconstruction with an extensor mechanism allograft (EMA) remains one of the most reliable methods for treating the extensor mechanism deficient total knee arthroplasty. We report 3 patients who were treated with an EMA who sustained a proximal tibial shaft fracture. In all 3 cases, a short tibial component was present that ended close to the level of the distal extent of the bone block. When performing an EMA, it is important to recognize that the tibial bone block creates a stress riser and revision to a long-stemmed tibial component should be strongly considered to bypass this point to minimize the risk of fracture.
Assuntos
Artroplastia do Joelho/efeitos adversos , Articulação do Joelho/cirurgia , Patela/transplante , Tendões/transplante , Tíbia/cirurgia , Fraturas da Tíbia/cirurgia , Idoso , Idoso de 80 Anos ou mais , Transplante Ósseo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Patela/lesões , Amplitude de Movimento Articular , Procedimentos de Cirurgia Plástica , Reoperação , Tíbia/lesões , Tíbia/transplante , Fraturas da Tíbia/etiologia , Transplante HomólogoRESUMO
BACKGROUND: This article describes an arthroscopic anterior cruciate ligament (ACL) reconstruction technique with a quadriceps tendon autograft using an anteromedial portal technique. METHODS: A 5 cm quadriceps tendon graft is harvested with an adjacent 2 cm bone block. The femoral tunnel is created through a low anteromedial portal in its anatomical position. The tibial tunnel is created with a hollow burr, thus acquiring a free cylindrical bone block. The graft is then passed through the tibial tunnel and the bone block, customized at its tip, is tapped into the femoral tunnel through the anteromedial portal to provide press-fit fixation. The graft is tensioned distally and sutures are tied over a bone bridge at the distal end of the tibial tunnel. From the cylindrical bone block harvested from the tibia the proximal end is customized and gently tapped next to the graft tissue into the tibial tunnel to assure press fitting of the graft in the tibial tunnel. The distal part of the tibial tunnel is filled up with the remaining bone.All patients were observed in a prospective fashion with subjective and objective evaluation after 6 weeks, 6 and 12 months. RESULTS: Thirty patients have been evaluated at a 12 months follow-up. The technique achieved in 96.7% normal or nearly normal results for the objective IKDC. The mean subjective IKDC score was 86.1 ± 15.8. In 96.7% the Tegner score was the same as before injury or decreased one category. A negative or 1+ Lachman test was achieved in all cases. Pivot-shift test was negative or (+) glide in 86.7%. The mean side-to-side difference elevated by instrumental laxity measurement was 1.6 ± 1.1 mm. Full ROM has been achieved in 92.3%. The mean single one-leg-hop index was 91.9 ± 8.0 at the follow-up. CONCLUSIONS: Potential advantages include minimum bone loss specifically on the femoral side and graft fixation without implants.