Posterior cruciate ligament reconstruction in skeletally immature athletes.

Posterior cruciate ligament rupture is a rare knee ligamentous injury in skeletally immature patients with unfused growth plates. Despite being very uncommon, it still represents a significant challenge in terms of decision-making and treatment choice. The purpose of this case series was to report subject and objective outcomes (IKDC, TAS,LYSHOLM,KT2000) after PCL reconstruction in two teenage elite football players aged 15 and 16 respectively, who underwent surgical repair in July 2017 using for the femoral and tibial fixation of the PCL graft (hamstring tendons) respectively a curve cross-pin system and interferential screw. At fifteen months follow up, both athletes had returned to normal, pre-injury, competing levels with no leg discrepancy.

Modular dual mobility cups with multihole metal back in total hip arthroplasty revision: a systematic review.

Dislocation after hip revision is a frequent complication; amongst the strategies to prevent dislocation dual mobility (DM) implants are gaining popularity. We want to evaluate the reliability of non cemented DM cups with multihole metal back and chrome-cobalt liner called Modular Dual Mobility (MDM). We performed a systematic review and selected 5 studies with a total of 285 hips who underwent revision surgery with MDM implants. The mean survivorship rate of the 5 studies was 92.46% (range 90-96%). 267 prosthesis (93.6%) were still implanted at the last follow-up; the mean weighted follow up was 38.7% (range 24-48). We found 13 mechanical complications in 285 hips (4.5%). Five of them were treated conservatively; the other 8 were treated with re-revision. Nine of these complications were dislocation and recurrent instability; 2 of them were associated to metallosis and adverse local tissue reaction. There was 1 patient that had episodes of subluxation; 2 cases of impingement and 1 case of metallosis. Zero intraprosthetic dislocations (IPD) occurred in 285 hips. A 93.6% survivorship is a good result for MDM implants, considering that most of patients had important bone loss and went through multiple revisions. The rate of dislocation is very low compared to the mean rate of dislocation in revision hip surgery. In our review, fretting is a rare complication but it can lead to ALTR and metallosis. For this reason, MDM implants have to be used in selected cases at high risk of dislocation. In conclusion MDM is a great option for decreasing dislocation rate in hip revision, but a longer follow-up and a greater number of cases is needed to assess its reliability.

Technical note: double tibial tunnel using quadriceps tendon in anterior cruciate ligament reconstruction.

To avoid complications related to the use of patellar tendon and hamstring (semitendinosus and gracilis) tendon and to create a more anatomic reconstruction, we present a new technique based on the use of quadriceps tendon placed in a single half femoral tunnel and double tibial tunnels. The graft, harvested by a central longitudinal incision, possesses the following characteristics: (1) a bone plug 20 mm long and 10 mm in diameter; (2) a tendon component 7 to 8 cm long, 10 mm wide, and 8 mm thick; and (3) division of the tendon longitudinally into 2 bundles while maintaining the patellar insertion. Every bundle has a width and thickness of approximately 5 mm and 8 mm, respectively. The total length of the graft is 9 to 10 cm. A 10-mm half femoral tunnel is drilled through a low anteromedial portal with the knee flexed at 120 degrees. A suture loop is left in place in the half tunnel. A double tibial tunnel is drilled in a convergent manner (from outside to inside) obtaining an osseous bridge between the 2 tunnels. Two suture loops are passed trough the tibial tunnels and retrieved in a plastic cannula (10 mm) positioned in the anteromedial portal to allow the passage of the 2 bundles in the tibial tunnels. The suture loop left in the half tunnel permits the transportation of the bone plug in the femoral tunnel. Fixation is achieved by an interference screw at the femoral side and by 2 absorbable interference screws (1 for each tunnel). The advantages of this technique are a more cross-sectional area (80 mm(2)), greater bone-tendon interface, and a more anatomic reconstruction. Theoretically, easier bone incorporation, decreased windshield wiper and bungee effect, fewer donor site problems, and less tunnel enlargement can also be possible.

Neurocognitive rehabilitative approach effectiveness after anterior cruciate ligament reconstruction with patellar tendon. A randomized controlled trial.

BACKGROUND: A proper knee rehabilitation after a surgical reconstruction of the anterior cruciate ligament (ACL) should start immediately after the injury and it should be focused on recovery of symmetry, proprioception, swelling reduction, gait training, hyperextension exercises, and even mental preparation. AIM: Aim of this study was to test a neurocognitive rehabilitative approach based on proprioceptive exercises and proper motor strategy choices, compared with conventional rehabilitation, assessing baropodometric, gait and clinical changes. DESIGN: Randomized controlled trial. SETTING: Ambulatory University Centre. POPULATION: Fourteen subjects (27.9±5.2 years) underwent to a surgical reconstruction of ACL were divided into the two groups. METHODS: The subjects were randomly assigned into a group who received a specific neurocognitive and perceptive rehabilitation treatment (TG), and into a control group who received the common physical therapy (CG). The following outcome measures were assessed pre-intervention, one, three and six months later: static and dynamic baropodometry, Visual Analog Scale for pain, Short Form SF-36, Range of Motion, trophism of thigh region, edema, Manual Muscle Test, magneto-resonance imaging assessment. RESULTS: Lower impairment was observed in TG in respect of CG in terms of load asymmetry during static baropodometry (from 7% to 3% vs. from 10% to 7%, interaction time per treatment: P=0.037), less wide steps during gait (effect size=1.05 vs. 0.38 for CG), swelling (treatment effect: P=0.012). A significantly higher improvement (from 35% to 100%) in terms of SF-36 was recorded only in TG for physical activity (P=0.027). CG showed a quite higher walking speed (treatment effect: P=0.049). CONCLUSION: Even if further studies are needed on larger samples, the obtained results showed that a neurocognitive rehabilitative approach could be an effective treatment after ACL-reconstruction: in TG we observed a more rapid load symmetrization, the reduction of step width and a more rapid resolution of edema. CLINICAL REHABILITATION IMPACT: Posture, gait, clinical features and quality of life could benefit from a neurocognitive rehabilitation after ACL surgical reconstruction.

Discoid medial meniscus: report of a case treated by arthroscopy.

A complete discoid medial meniscus with a longitudinal tear was found in a 41-year-old man and treated by arthroscopy. The symptomatology was characterized by a sharp pain corresponding to the medial joint line, slight intrarticular effusion without locking or loss of motion. A review of the literature is described.

Osteonecrosis after arthroscopic medial meniscectomy.

Osteonecrosis of the medial femoral condyle is an uncommon complication of meniscal surgery. Whether this disease is associated with the original medial meniscus lesion or with the arthroscopic procedure is not yet known. We present two cases in which osteonecrosis has developed shortly after arthroscopy was performed for medial meniscus pathology. Magnetic resonance imaging has been the best tool to diagnose and follow up the changes in the involved area. Concerning the etiology, the authors raise the question of whether the medial compartment overloading observed in both of these cases had any significant meaning. Osteonecrosis following meniscal surgery in relatively young patients seems to have a good prognosis when correctly treated, with avoidance of weight bearing.

Healing of the patellar tendon after harvesting of its mid-third for anterior cruciate ligament reconstruction and evolution of the unclosed donor site defect.

The purpose of this study was (a) to evaluate by ultrasonography the healing of the patellar tendon after its mid-third was removed for anterior cruciate ligament (ACL) reconstruction in two randomized groups of patients in whom the tendon donor site was either left open or closed; (b) to compare clinical, radiographic, and isokinetic studies of these two groups to evaluate the incidence of patellofemoral disorders. We performed 61 ACL reconstructions (22 males, 39 females) using the arthroscopically assisted in-out technique. All operations were performed by the same surgeon, and the patients were all subjected to the same postoperative protocol. The tendon defect was left open in 25 subjects (group A) and was closed in 36 subjects (group B). Postoperative patellar tendon behavior was evaluated in these two groups by ultrasonography at 3, 6, 9, and 12 months. The vertical position of the patella was measured in the follow-up lateral view at 45 degrees of flexion and compared to that of the untreated knee. A clinical evaluation was performed throughout the follow-up period, and patellofemoral problems (pain, stiffness, patello-femoral crepitus) were evaluated and recorded using a modified Larsen and Lauridsen rating scale. Isokinetic evaluation was carried out at 6 months, and a quadriceps index of the two groups was recorded. Ultrasonography showed that healing of the patellar tendon initially progressed with a compensatory hypertrophy in width and thickness. The width was greater in group B (P < 0.01). In group A we observed in the cross-sections a characteristic image of two cords separated by a low signal bridge which we defined as a "binocular pattern." Areas of high ultrasound signal intensities persisted after 1 year in the open group; such areas were filled with scar tissue. In the closed group the ultrasound tendon signal returned to normal at 1 year. At 6 months the clinical, radiographic and isokinetic findings did not significantly differ between the open and closed groups. We conclude that defect closure after patellar tendon harvesting does not significantly influence the extensor apparatus.

Arthroscopic-assisted posterior cruciate ligament reconstruction using patellar tendon autograft: a technique for graft passage.

During arthroscopic posterior cruciate ligament (PCL) reconstruction, passage of the graft into the knee joint may be difficult, especially when using the patellar tendon. Because of the angle of passage, the bone block ends may become entangled or caught on the superior edge of the posterior tibial tunnel when passing the graft from the tibia to the femur. The use of a blunt trocar through the posteromedial portal avoids impingement of the bone block against the edge of the tibial tunnel. This method uses the pulley principle and permits the graft to pass freely into the knee. This method has been used successfully by the authors in more than 40 PCL arthroscopic reconstructions.

Arthroscopic treatment of bilateral Freiberg's infraction.

Freiberg's disease is a relatively rare disorder with a multifactorial cause. The condition has a definite predilection for the second metatarsal head, and it is rare to find a bilateral involvement, especially of the first metatarsal head described in the literature. The results of different methods of surgical treatment have been reported, but no single procedure has produced uniformly good results. We describe a case of a 28-year-old man, a lawyer with a 4-year history of bilateral intermittent forefoot pain on weightbearing without any recollection of specific trauma to his feet. Radiographic and magnetic resonance imaging investigations were performed and the patient underwent a bilateral arthroscopic treatment with joint debridement and drilling of the metaphyseal portion of both distal metatarsal head. Three months after surgery, the patient returned to unrestricted activity without pain. At last evaluation, 2 years postoperatively, he is symptom free and new magnetic resonance examination has shown satisfactory restructuring of the lesions.

Magnetic resonance imaging of tunnel placement in posterior cruciate ligament reconstruction.

The aim of this study was to define a reproducible method for evaluating posterior cruciate ligament (PCL) reconstructions using magnetic resonance imaging (MRI). A 2-fold investigation was performed. In part I, the "footprints" of an intact PCL were located on MRI and their coordinates were defined. Measurements were made on the images of 50 subjects using axial, coronal, and sagittal planes. Interobserver variability was calculated by averaging the measurements of the 2 reviewers and using the Kappa coefficient. Three points of reference were located: tibial attachment on the tibial axial plane, and two femoral attachments on the sagittal and coronal oblique planes. In part II, stability of 20 PCL reconstructions with a bone-patellar tendon-bone (BPTB) autograft were evaluated and scored using the IKDC evaluation form after a 2-year follow-up. Stability was evaluated clinically and instrumentally using a KT-2000 arthrometer at 89 N with the knee flexed at a neutral quadriceps knee angle of approximately 70 degrees . Seven cases were graded A (0 to 2 mm), 11 graded B (3 to 5 mm), and 2 graded C (6 to 10 mm). All patients had an MRI after an average of 16 months (range, 12 to 24 months, 2 SD). The previous measurements from part I of the study were used to make a correlation between achieved stability and tunnel location. A 1-factor analysis of variance (ANOVA), nonparametric ANOVA, and the Fisher Exact test were used to determine if clinical outcome of the 3 groups was influenced by graft placement. At MRI evaluation, excessive deep placement was observed in 4 cases and a correlation between improper femoral tunnel location and stability was statistically significant (P < .05). A correct placement of tibial tunnel was observed in all patients. In our analysis, proper location of the femoral tunnel seems to be more critical and difficult to achieve than tibial tunnel placement, probably because of the lack of specific anatomic landmarks during surgery.

[Arthroscopic reconstruction of the posterior cruciate ligament. Magnetic resonance study for bone tunnel positioning and comparison with clinical results]. / La ricostruzione artroscopica del legamento crociato posteriore. Studio con Risonanza Magnetica per il posizionamento dei tunnel ossei e confronto con i risultati clinici.

INTRODUCTION: The success of arthroscopic cruciate ligament reconstruction depends on several factors, such as patient selection, correct surgical execution, and postoperative rehabilitation. Technical considerations include graft choice, positioning, fixation, intercondylar notch enlargement, and new ligament tensioning. Graft acceptance is effected by all these factors. Tunnel position is of great importance both for biomechanical reasons and optimal function of the new ligament, and to avoid stress, friction, abnormal strain, and/or damage to the reconstructed ligament. Many orthopedic and radiographic literature studies discuss the exact site of anterior cruciate ligament insertion for the best possible anatomical reconstruction. In contrast, the debate over insertional area and anatomical landmarks is open for the posterior cruciate ligament (PCL), because of the difficult execution of this type of reconstruction and the smaller number of candidates. MATERIAL AND METHODS: Fifty patients with a healthy PCL underwent MRI of the knee for other diagnostic reasons and we measured the position of PCL insertion at the tibial and femoral condyles. We also examined with MRI 20 surgical patients with a reconstructed PCL. Graft position was assessed with the same method and the results compared with physical findings of joint stability and the IKDC form score. RESULTS: Three main landmarks were found on standard axial, coronal and sagittal MR images: T1 on the tibia, and F1 and F2 on the femur. These points refer to the fibrous ligament center and designate the medial, middle and lateral portion of the tibial plateau, as well as the anterior/posterior and high/low positions on the roof of the intercondylar notch and anteromedial side of the medial condyle, respectively. According to these data, the midline position, whether slightly medial or lateral, of tibial insertion, was clinically less important. On the contrary, correct femoral tunnel positioning was found to effect subsequent joint stability and prompt rehabilitation. CONCLUSIONS: This method for MR measurement is easy and repeatable, and can be used for surgical planning and patient follow-up. We found it extremely useful for the correct positioning of bone tunnels, particularly the femoral condyle, in all cases.

Accelerated rehabilitation after arthroscopic meniscal repair: a clinical and magnetic resonance imaging evaluation.

Twenty-two patients who underwent meniscal repair using the outside-in technique combined with anterior cruciate ligament (ACL) reconstruction were submitted to an accelerated rehabilitation protocol that included immediate full range of motion and weightbearing. The patients were reviewed postoperatively by means of clinical assessment and magnetic resonance imaging (MRI) after an average of 28 months. Clinical evaluation was performed according to the International Knee Documentation Committee form, and sagittal knee laxity was measured with a KT-2000 arthrometer (MedMetric Corp, San Diego, CA). The MRI scans were obtained using a 0.2-T high-resolution MRI unit dedicated to the study of limbs, and the meniscal signal was graded according to a modified Crues classification. Overall, 77.3% of patients reported clinically good results. Loss of extension of < 5 degrees was detected in only 2 patients (9.1%). Three out of 22 patients showed clinical signs of meniscal retear. One of these patients had a second operation for a bucket-handle tear. The presence of a full-thickness rim at MRI evaluation, present in 10 patients (45.5%), did not correlate with the presence of clinical symptoms of retear. Instead, the 3 symptomatic patients presented a complete rim with a gap > 1 mm between the meniscal wall and the fragment of the posterior horn. This finding is believed to be a more reliable indicator for retear following meniscal repair. The low failure rate in this series suggests that an aggressive rehabilitation regimen may be prescribed without deleterious effects in subjects undergoing ACL reconstruction and concomitant meniscus repair.

Arthroscopic posterior cruciate ligament reconstruction with bone-tendon-bone patellar graft.

We present a retrospective study of 24 patients with chronic injury of the posterior cruciate ligament (PCL) treated by arthroscopically assisted reconstruction with bone-tendon-bone patellar autograft. At a mean follow-up of 26.5 months (range 24-53 months) the International Knee Documentation Committee (IKDC) evaluation form, Lysholm and Tegner rating systems were used to evaluate symptoms, functional limitations during sports and daily activities, and changes in activity level. At the final IKDC evaluation we found 6 patients (25%) with grade A (normal), 13 patients (54.2%) with grade B (nearly normal), 3 patients (12.5%) with grade C (abnormal) and 2 patients (8.3%) with grade D (severely abnormal). The average side-to-side difference, as measured by the KT-2000 arthrometer, was 8.38 (+/-1.95) preoperatively and 4.08 (+/-2.09) mm postoperatively at 89 N with the knee flexed at a neutral quadriceps knee angle of approximately 70 degrees. The worst results significantly correlated with the time elapsed from injury to surgery (P < 0.001). The preoperative Lysholm score was 56+/-12 (range 41-79) and at follow-up 94+/-8 (range 76-100). The Tegner activity score improved for all patients after surgical treatment. Average preinjury score was 7.4 (range 4-9), decreasing to 3.40 (range 2-7) preoperatively and increasing to 5.4 (range 4-9) postoperatively. At follow-up, 12 patients (50%) regained to their preinjury scores after surgery. Our study suggests that this arthroscopic technique, which allows a more precise placement of tunnels, can improve the results of the PCL reconstruction with a bone-tendon-bone autograft.

[New femoral fixation system for tendon transplantation in ACL reconstruction. Preliminary experience with MR imaging]. / Nuovo sistema di fissazione femorale dei trapianti tendinei pro-LCA. Esperienza preliminare con RM.

INTRODUCTION: The Authors describe the MR aspects of a new femoral fixation technique which has been recently introduced in anterior cruciate ligament recontructive surgery. This fixation device is composed of bioabsorbable material and of a thin thread which measures about 2,8 mm in diameter and 3,5 cm in length. This thread is positioned via the lateral transcondylar approach using the same arthroscopic technique as is used to position the transcondylar interference screw. By means of this technique it is possible to fix all the types of autologous grafts which are presently employed: patellar tendon, flexor tendons and quadriceps tendon. In MR, the absence of paramagnetic artifacts allows to detect also the graft portion inside the femoral bone tunnel and to acquire very accurate images. MATERIAL AND METHODS: By means of MR examination, we have studied 16 patients of either sex (11 M/ 5 F) with an age ranging from 18 to 37 years (mean age: 28,9 years). All of them underwent an anterior cruciate pro-ligament reconstruction by employing autologous tendons: the patellar tendom (=9), the quadriceps tendon (=4) and the flexor tendons (=3). By means of dedicated MR equipment at low-field intensity and with permanent magnet (Artoscan 0,2 T, Esaote, Genoa, Italy), every patient underwent follow-up controls during a period of time ranging from 1 to 9 months after the operation. We employed T1-weighted and T2-weighted spin-echo, gradient-echo and STIR sequences with fat tissue suppression. Besides the standard axial, sagittal and coronal planes, we employed a coronal plane with doubt obliquity which runs both along the axial plane and along the sagittal one with the aim of visualizing the whole graft on a single scanning plane including completely either the intra-articular portion or the bone tunnel portion. RESULTS: In none of these cases we did detect para-magnetic artifacts which could prevent us from performing a complete assessment either of the fixation device or of the content of the femoral tunnel. The tendinous graft was studied along the hole intra-articular length and inside the portions of the femoral and tibial bone tunnel. For this purpose the images acquired on oblique plane along the roof of the intercondylar notch were very useful. No patient reported significant complications, apart from two cases of maniscus everlasting pain as regards medial fibrocartilaginous sutures and one case of residual pain which concerns the anterior region of the patellar tendinous donor site. The evaluation form of the International knee Document Committee shows that in clinical terms all the patients achieved good results (=7) or excellent results (=9). Overall, we detected no new grant rupture or any functional limitation of the flexor-extension. DISCUSSION AND CONCLUSIONS: The advent of small-size bioabsorbable synthetic materials that are compatible with the MR equipment at out disposal, make it easier to obtain a good visualization of all the portions of the anterior cruciate tendinous ligament graft. By employing suitable sequences as well as scanning planes, MR is the only technique which is able to meet any operated patient's requirements and in particular those one which concern the development state of his/her recovery progress as well as the grant-taking. Follow-up studies will be necessary, however, to determine the real evolution as well as the complete integration of these reconstructions.

MR evaluation of anterior cruciate ligament reconstruction with quadriceps tendon. Preliminary experience.

PURPOSE: Anterior cruciate ligament reconstructions are becoming increasingly frequent, and MRI has been shown to be the best imaging modality for the non-invasive assessment of surgical outcome. Use of the quadriceps tendon as a biological replacement for injured cruciate ligament is a recent innovation. This study evaluated by MRI the results of anterior cruciate reconstruction in 27 consecutive patients who underwent arthroscopic reconstruction with homologous quadriceps tendon. MATERIAL AND METHODS: MRI was carried out on 27 patients who had undergone anterior cruciate ligament reconstruction with the middle third of the homolateral quadriceps tendon. The examinations were performed on two MRI units: a permanent 0.2-Tesla dedicated magnet (Artoscan, Esaote Italy) and whole-body 1.5-Tesla superconducting magnet (Signa, GE Medical Systems Milwaukee, Winsconsin USA). Axial, sagittal and coronal images were acquired with SE, GE and STIR fat suppression sequences. The examinations were performed 1, 3, and 6 months post-operatively in 16 patients, and 1 and 3 post-operatively in 11 patients. The same arthroscopic surgical technique was employed in all patients, with 20 cases of tibial mono-tunnel femoral semi-tunnel, and 7 cases with tibial bi-tunnel technique. All patients were assessed by arthrometric and clinical tests after surgery. Bioabsorbable interference screws were used for tibial fixation in all patients and metallic interference screws were used for femoral graft fixation in 8 patients. RESULTS: In all cases MRI correctly visualised the tunnel positions, the articular portion and the bone-portion of the graft inside the tibial and femoral tunnels. The absence of paramagnetic artefacts in the tibia allowed complete visualisation on the axial, sagittal and coronal MRI images with optimal spatial and contrast resolutions. In 6 cases, the presence of metal residues from the surgical cutter prevented correct evaluation of femoral tunnel content. No new graft or articular lesions were found. In 18/27 cases peri-focal marrow edema around the tibial tunnel had disappeared 3 months after surgery. The process of synovial incorporation was judged to be correct in all cases. DISCUSSION: The use of anterior cruciate ligament reconstruction with the quadriceps tendon is a important innovation given the size of the harvested material and the possibility of completely filling the osseous tunnels, without interposition of synovial proliferation or fluid collection between tendon and bone, as confirmed by MRI. Furthermore, the use of non-metallic screws allows MRI evaluation of tunnel content and oedema in the spongy bone around the tunnel. The study of the double tibial tunnel requires specific obliqueness in the coronal plane scans. CONCLUSIONS: This arthroscopic technique for anterior cruciate ligament reconstruction allows thorough MRI evaluation of all portions of the transplant, and in particular those coursing within the tibia and femur. The absence of bone oedema around the tunnels and synovial proliferation within the tunnels may be predictive of faster healing and complete bone incorporation of the grafts.

Histological and structural study of the adhesive tissue in knee fibroarthrosis: a clinical-pathological correlation.

In fibroarthrosis of the knee, it is still unknown if joint range of motion is affected by anatomopathological differences in adhesive tissue, such as tissue maturity, location, and quantity. A retrospective study of 78 patients who underwent arthoscopic arthrolysis was performed to determine a correlation between location of adhesions and preoperative range of motion (ROM). In another 17 patients, a histological and structural evaluation of adhesive tissue was performed. Based on vascularization, number and shape of cells, and collagen fiber orientation, the adhesive tissue was classified into three groups: low, medium, and high maturity. Preoperative joint ROM and the time of onset of joint stiffness was correlated with the degree of adhesion tissue maturity. A strong and statistically significant correlation between the location of adhesions and joint restriction was found. However, histological and structural evaluation showed no correlation between the degree of tissue maturity, the time of onset of joint stiffness, and the amount of joint ROM.

A prospective evaluation of a test for lateral meniscus tears.

A test for diagnosing lesions to the lateral meniscus is described. Due to our inability to find its description in the literature we called it 'dynamic test'. The accuracy of this test was assessed in 421 knees. The test was compared against arthroscopic findings in all cases. Inter-rater reliability was also estimated among three observers, who were shown to have a K coefficient ranging from 0.61 to 0.85. In a series of healthy subjects, the test was positive in eight normal knees (9.4%), but none of these false-positives was unanimously identified by more than one rater. This manipulative test was very accurate: sensitivity 85%, specificity 90.3%, positive predictive value 73.2%, negative predictive value 95% prevalence 23.7% and accuracy 89%. Thus, the test seems to be a tool that can improve the diagnostic accuracy of meniscal lesions. An important feature of this test is that it can be performed in patients with acute injuries.

[Assessment with magnetic resonance of reconstruction of the posterior cruciate ligament. Preliminary experience]. / Valutazione con Risonanza Magnetica della plastica ricostruttiva del legamento crociato posteriore. Esperienza preliminare.

Posterior cruciate ligament (PCL) tears are definitely less common than anterior cruciate ligament (ACL) tears: their incidence in literature ranges 3-20% of all capsuloligamentous injuries versus 45-90% for ACL tears. Recent papers reported that if these injuries are not operated on, they evolve first into medial femorotibial and femoropatellar arthrosis and then into tricompartmental arthrosis. There are several MR studies dealing with ACL reconstruction, while MR studies on PCL reconstruction are lacking, both because the frequency of the latter injuries is lower and because they are difficult to demonstrate. We report our preliminary experience with PCL reconstruction studied with MRI in 12 patients submitted to arthroscopy. We used the ipsilateral patellar tendon (11 cases) or the contralateral one (1 case). The patients were submitted to MRI 4-16 months after surgery. Axial, coronal and sagittal images were acquired, together with oblique sagittal and coronal slices to show the graft completely. We also used SE, GE and fat suppression STIR MR sequences, trying to identify which of them are the most useful in patients with healing or exudative reaction in the intercondylar notch. MR exams were performed with a dedicated permanent magnet (0.2 T) and a permanent total body unit (0.3 T). The graft was clearly depicted on all images in 11 patients, while graft retear was shown in 1 patient. MRI did depict the whole graft in all patients, which finding is useful to study the signal intensity changes which indicate graft trophism. MRI also depicted correctly the femoral and tibial tunnel position and alignment, the presence of possible impingement with bone, the presence and extent of the healing reaction or of serum-hematic material in the intercondylar notch. The latter factor prevents the graft depiction, in which case the MR techniques providing the highest possible contrast in the different structures under examination are mandatory. Finally, MRI permitted to study possible associated capsuloligamentous or meniscal injuries and the state of femorotibial and femoropatellar chondral covering, the presence of articular synovia changes and the amount of possible joint effusion. We believe that MRI exhibited a high standard of sensitivity, versatility and diagnostic accuracy in the examination of surgical patients submitted to arthroscopic PCL reconstruction. Further studies and long-term follow-up will help define the use of MRI in these patients.

A cadaveric study of endoscopic decompression of the cubital tunnel.

A cadaveric study of endoscopic decompression of the cubital tunnel was performed. Four fresh-frozen upper limbs were used for dissection, with a focus on the relationship between the ulnar nerve and Osborne's band. The endoscopic procedure was performed with the Ectra II system (Smith & Nephew, Andover, MA). After the surgical procedure, further dissection was done to evaluate the effectiveness and safety of the endoscopic cut of Osborne's band. Our conclusion is that endoscopic release is not a technically difficult procedure, and may be limited to certain clinical situations.

Comparison of surgical treatments for knee dislocation.

This retrospective study compared three surgical procedures for acute knee dislocation. Eleven patients (group 1) underwent direct repair of the cruciate ligaments, 6 patients (group 2) underwent anterior cruciate ligament (ACL) reconstruction with hamstring tendons and posterior cruciate ligament (PCL) reattachment, and 6 patients (group 3) underwent PCL reconstruction with ipsilateral bone-patellar tendon-bone and ACL reconstruction with doubled semitendinosus and gracilis tendons. Average follow-up was 6.9 years (range: 24 months to 19 years). Surgical results were evaluated using the IKDC evaluation form, KT-2000 arthrometer, and Lysholm and Tegner scores. Statistical analysis was performed using Fisher's exact test and the Cochran-Mantel-Haenszel test to compare different surgical procedures. In terms of stability and range of motion, results were less favorable after direct repair and cruciate ligament reattachment. Better results were reported after combined ACL and PCL reconstruction. Average side-to-side total anteroposterior translation as measured by the KT-2000 arthrometer at 20 degrees +/- 5 degrees of knee flexion was 6.67 mm, 3.6 mm, and 3.2 mm in groups 1, 2, and 3, respectively. At final International Knee Documentation Committee (IKDC) evaluation, only 2 group 3 patients achieved a group qualification A, while a group qualification B was achieved by 5 patients (2 patients in group 1, 2 patients in group 2, and 1 patient in group 3). Nine patients in group 1, 4 patients in group 2, and 3 patients in group 3 achieved group qualifications C and D (fair or poor results). Based on these results, we do not recommend reattachment of the cruciate ligaments after knee dislocation for obtaining a stable knee with full range of motion.