Posterior tibial slope changes after opening- and closing-wedge high tibial osteotomy: a comparative prospective multicenter study.

INTRODUCTION: Valgus high tibial osteotomy is considered to be an effective treatment for unicompartmental medial osteoarthritis. It is generally admitted that tibial slope increases after open-wedge high tibial osteotomy and decreases after closing-wedge high tibial osteotomy. However, the effects on posterior tibial slope of closing- or opening-wedge osteotomies remain controversial. HYPOTHESIS: We analyzed the modifications of tibial slope after opening- and closing-wedge high tibial osteotomies and compared the results of these two procedures. We hypothesized that there was no difference in postoperative tibial slope between opening and closing-wedge osteotomies. PATIENTS AND METHODS: This prospective consecutive nonrandomized multicenter study was conducted between January 2008 and March 2009 and included 321 patients: 205 men and 116 women. A total of 224 patients underwent an opening-wedge high tibial osteotomy and 97 a closing-wedge osteotomy. The mean age was 52 years ± 9 and the mean body mass index was 28kg/m(2) ± 5. The main etiology was primary arthritis. Posterior tibial slope was measured preoperatively and at the last follow-up on a lateral radiograph in relation to the posterior tibial cortex. RESULTS: In the opening-wedge group, a definite 0.6° increase in tibial slope (P=0.016) was observed. In the closing-wedge group, a definite 0.7° decrease in tibial slope (P=0.02) was found. Fourteen percent of the opening-wedge osteotomies increased tibial slope by 5° or more versus only 2% of the closed-wedge osteotomies (P<0.001). Twelve percent of the closing-wedge high tibial osteotomies led to a decrease of 5° or more of the tibial slope versus 7% of the opening-wedge osteotomies (P<0.02). DISCUSSION AND CONCLUSION: These results confirm what is generally reported in the literature, i.e., an increase in tibial slope in opening-wedge high tibial osteotomy and a decrease in the slope in closing-wedge osteotomies. These tibial slope changes appear to be very limited in this series, less than 1° on average. However, there was a bias since the open-wedge technique was preferred in cases with substantial varus deformity. We emphasize the importance of surgical technique to avoid alteration of the tibial slope, particularly in opening-wedge high tibial osteotomy for which we recommend a release of posterior soft tissue and a complete osteotomy of the posterior cortex of the tibia. LEVEL OF EVIDENCE: III. Prospective consecutive nonrandomized multicenter study.

High lateral portal for sparing the infrapatellar fat-pad during ACL reconstruction.

During arthroscopic ACL reconstruction, intra-articular visualization can be compromised by the interposition of the infrapatellar fat pad (IPFP) between the scope and the notch. In this technical note, we describe our technique of using lateral higher arthroscopic portal, starting arthroscopy with the resection of the ligamentum mucosum and performing the tibial tunnel in 40° of knee flexion to optimise the intra-articular view without IPFP debridement. This technique was performed in 112 consecutive arthroscopic ACL reconstructions and compared to that in the previous 112 cases in which a conventional method was used. The use of this technique was associated with a shorter operative time and no increase in the difficulty in performing associated meniscal procedures.

Meniscal ossicle in a professional soccer player.

Meniscal ossicles are an unusual finding and a rare cause for knee pain. They are often initially diagnosed as a loose body, chondrocalcinosis or meniscal calcification within the knee joint. Few cases have been reported in the literature. We present a case of a meniscal ossicle with an associated femoral cartilage lesion in a healthy 26-year-old male professional soccer player who presented with swelling and pain. The purpose of this article is to discuss the origins, radiological features, clinical symptoms and prognosis of meniscal ossicles.

Biologically enhanced ACL reconstruction.

Biological integration of the tendon graft is a crucial prerequisite for successful ACL reconstruction. Histological studies showed that the human ACL remnants contain a cellular capacity for healing potential. The goal of this technical note is to describe an ACL reconstruction technique, using ACL remnants as a biological sleeve for the graft. In case of complete ACL rupture with a large remnant, the tibial tunnel was performed inside and through the ACL tibial stump by careful sequential drilling. Femoral tunnel placement was performed by an outside-in technique. The hamstring graft was kept attached to the tibia and routed through the ACL remnant to the femur. The aim of this technique is the preservation of the biological and mechanical properties of the ACL remnant. In order to preserve large remnants resulting in greater graft coverage, the best period to perform this reconstruction is during the first weeks after the injury.

Isolated posterior cruciate ligament reconstruction: is non-aggressive rehabilitation the right protocol?

INTRODUCTION: Reconstruction Surgery of the posterior cruciate ligament (PCL) has not yet been fully standardized, and associated rehabilitation protocols have not been clearly defined. The aim of this study is to report the results of a consecutive series of patients who underwent the same surgical technique for isolated PCL reconstruction and were submitted to the same specific rehabilitation protocol. A non-aggressive rehabilitation protocol which protects the graft from excess mechanical stress produces satisfying and reproducible clinical and laxity results in the knee. MATERIALS AND METHODS: Our series included 17 patients who underwent single bundle arthroscopic reconstruction of the PCL with an autologous quadriceps tendon graft and who followed the same non-aggressive rehabilitation protocol. All patients were followed up for an average of 30 months (range 12-60 months). The preoperative evaluation and the last follow-up included objective and subjective IKDC scores as well as the Tegner & Lysholm knee scales. The side to side laxity was measured radiologically with the Telos stress testing device. A statistical analysis was performed to compare preoperative and postoperative results. RESULTS: Preoperatively, no patients were classified as A or B on the IKDC objective score. At last follow-up visit, 88.2% of patients were classified as A or B. Average side to side anteroposterior laxity was 11.9 mm (range 8-18) in the preoperative evaluation and 3.8mm (range 1-7) in the final follow-up (p=0.01) The average subjective IKDC score was 37.7 before surgery and 74.7 at last follow-up (p< 0.01). The Tegner & Lysholm scores were significantly improved by surgery. DISCUSSION: Although the results are still less successful than ACL reconstruction, successful PCL reconstruction results were obtained with a standardized single bundle reconstruction technique and an adapted specific postoperative rehabilitation protocol. A non-aggressive rehabilitation protocol can limit postoperative mechanical stress on the graft. TYPE OF STUDY: Retrospective Level IV.