Radiological maturation and clinical results of double-bundle and single-bundle anterior cruciate ligament reconstruction. A 5-year prospective case-controlled trial.

INTRODUCTION: The aim of the study was to make a prospective comparison of the radiological and clinical outcomes of patients undergoing single-bundle and double-bundle anterior cruciate ligament (ACL) reconstruction. METHOD: This prospective, case-controlled study included 65 patients, separated into 2 groups as 33 patients undergoing single bundle (SB), and 32 patients undergoing double bundle (DB) ACL reconstruction. The patients were evaluated clinically using the International Knee Documentation Committee (IKDC) and the Lysholm knee scores. Stability was evaluated with the KT-1000 Arthrometer Measurement, the Lachman and pivot shift tests. Magnetic resonance images (MRI) at 1 and 5 years postoperatively were evaluated by a musculoskeletal radiologist. All the operations were performed by a single surgeon and the clinical evaluations were made by an independent researcher. RESULTS: Evaluation was made of a total of 53 patients (SB: 28, DB: 25). No statistically significant difference was determined between the groups regarding the postoperative IKDC and Lysholm scores. The pivot shift tests were negative in the DB group and positive in two patients of the SB group. The Lachman test was negative in all the patients. No significant difference was determined between the groups. No statistically significant difference was determined between the two groups in respect of the arthrometer measurements. In the SB group, revision surgery was performed in two patients due to graft failure. No graft failure findings were determined in the DB group, and no statistically significant difference was determined between the groups in respect of graft failure. On the MRIs taken at 1 year postoperatively, the ACL was seen to be hyperintense in 16 patients in the DB group and 6 patients in the SB group (p = 0.004). On the 5-year MRIs, ACL hypointensity could not be seen in three patients of the SB group and two of the DB group, with no difference determined between the groups (p > 0.05). CONCLUSION: In the 5-year follow-up period, no difference was determined between patients undergoing SB ACL reconstruction and those undergoing DB ACL reconstruction regarding clinical scores, knee stability, and MRI findings, but graft maturation occurs later the patients undergoing DB reconstruction.

Single-tunnel and double-tunnel medial patellofemoral ligament reconstructions have similar clinical, radiological and functional results.

PURPOSE: The aim of the present study was to evaluate the clinical, radiological and functional results of patients underwent single-tunnel (ST) and double-tunnel (DT) medial patellofemoral ligament(MPFL) reconstructions with hamstring autograft following recurrent patella dislocation prospectively in a single institution. METHODS: From 2013 to 2017, 80 patients with symptomatic recurrent patellar dislocation or instability were randomly divided into 2 groups for MPFL reconstruction with ST technique or DT technique and evaluated prospectively. In the ST group, there were 20 male and 20 female with a median follow-up of 46.5 months (range 24-74). The median age was 15 years (range 10-28). In the DT group, there were 18 male and 22 female with a median follow-up of 40 months (range 24-74). The median age was 19 years (range 14-29). Clinical scores (Kujala score, Lysholm score, Tegner score and IKDC score) and radiological measurements (congruence angle and patellar tilt angle) of the patients were evaluated preoperatively and at postoperative 24th month. Isokinetic dynamometric tests were performed at postoperative 24th month and the difference between the operated leg and the non-operated leg was found as a percentage deficit. RESULTS: There were no postoperative complications, redislocation or subluxation in any patient. Kujala, Lysholm, Tegner and IKDC scores were better and statistically significant postoperatively in both groups (p < 0.05). However, there was no statistically significant difference between the groups (n.s.). The congruence angle and patellar tilt angle were found to be returned to normal values postoperatively, but there was no statistically significant difference between the groups (n.s.). There was no statistically significant difference between the two groups in isokinetic dynamometric tests performed as 60° flexion, 60° extension, 180° flexion and 180° extension (n.s.). CONCLUSION: The present study is the first that compared the clinical, radiological and functional results of the ST and DT techniques to date. Regardless of the number of the tunnels, similar results were obtained in ST and DT reconstruction using transpatellar tunnel technique. LEVEL OF EVIDENCE: Level I.

The Effect of Traction Force and Hip Abduction Angle on Pudendal Nerve Compression in Hip Arthroscopy: A Cadaveric Model.

PURPOSE: To investigate the site of pudendal nerve compression and the relation between traction force and abduction angle regarding pressure levels at setup for hip arthroscopy. METHODS: A total of 17 hips from 9 fresh-frozen cadavers (6 male and 3 female cadavers) were used. The pudendal nerves were dissected, and 3 FlexiForce force sensors (Tekscan, Boston, MA) were implanted on the pudendal nerve where the inferior rectal nerve, perineal nerve, and dorsal nerve of the clitoris/penis emerge. A custom-made traction table in a supine position was used with a padded perineal post of 9 cm. Recordings were made at 0, 10, 20, 30, and 40 kg of traction at varying hip abduction angles of 0°, 15°, 30°, and 45°. RESULTS: The tuber ischiadicum (perineal nerve) and genital region (dorsal nerve of penis/clitoris) had statistically higher pressure values when compared with the pudendal canal (inferior rectal nerve) (P < .05). There was a significant increase in forces acting on the pudendal nerve with increasing application of 0 to 40 kg of traction in steps of 10 kg, with the exception of the pudendal canal sensor and reading of the perineal nerve sensor at 45° of hip abduction (P < .004 with Bonferroni correction for significant values). On the contrary, hip abduction angle had no statistically significant effect on pudendal nerve compression. (All specific P values with Bonferroni correction were greater than .003.) CONCLUSIONS: To avoid nerve palsy completely, the etiopathogenesis of compressive neuropathy should be identified. The location for compression and relation between different traction positions and forces are clarified in this study. This information can be used for further research and prevention. CLINICAL RELEVANCE: This study adds objective data on the etiopathogenesis of pudendal nerve compression, which potentially contributes to prevention of pudendal nerve palsy as a common complication of hip arthroscopy.

Tibiotalocalcaneal ankle arthrodesis with posterior approach arthroscopic-assisted hindfoot nailing.

PURPOSE: End-stage ankle arthrosis causes severe pain and limited movement. Tibiotalocalcaneal arthrodesis with arthroscopy-assisted hindfoot nailing can be used to achieve a high union rate and low complication rate. We aimed to examine the early- and mid-term results of patients treated with this technique from various perspectives and to evaluate them by comparing them with the current literature. METHODS: Data were collected from 25 patients who met the established criteria and underwent TTCA with arthroscopic-assisted hindfoot nailing. In addition to the demographic data of the patients, their clinical and pain scores were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS). Additionally, the union time and complication data during the follow-up period were examined. RESULTS: When the AOFAS and VAS scores of the 25 patients were examined, a significant improvement was observed in the preoperative period and early postoperative period comparisons (p < .001). No significant change was observed between the comparison of the postoperative 12th month and last postoperative control clinical scores. While the union rate of the patients was observed to be 92%, the average union time was 13.1 ± 3.5 weeks. During follow-up, peri-implant fracture, deep infection, and non-union were observed in one patient each (12%). CONCLUSION: The early- and mid-term postoperative results of patients treated with TTCA surgery with posterior approach arthroscopic-assisted hindfoot nailing show that this technique may be an option with low complication and high union rates for the appropriate group of patients planned for ankle arthrodesis.

Comparison of subtransverse process wiring and sublaminar wiring in the treatment of idiopathic thoracic scoliosis.

STUDY DESIGN: A retrospective study. OBJECTIVE: The objectives of this study were to show the advantages of an alternative segmental spinal instrumentation technique, termed subtransverse process wiring, and compare it with a sublaminar wiring technique in the treatment of idiopathic thoracic scoliosis. SUMMARY OF BACKGROUND DATA: High rates of neurological complications and the need for high experience limit the use of the sublaminar wiring technique, although it is an effective segmental spinal instrumentation technique in the treatment of scoliosis. This is the first study to correlate sublaminar wiring and subtransverse process wiring techniques clinically. METHODS: In a retrospective study, 64 patients with idiopathic thoracic scoliosis were chosen randomly. Nineteen patients were treated with subtransverse process wires (group A), and 45 patients were treated with sublaminar wires (group B). RESULTS: The mean follow-up period was 50.9 months (25 to 90 mo) in group A and 57.9 months (26 to 108 mo) in group B. The average deformity correction was 26.5 degrees (52.9%) in group A and 28.9 degrees (54.1%) in group B. The average correction loss was 2.9 degrees (17.2%) in group A and 6.4 degrees (27%) in group B. None of the patients developed neurological complications in group A. In group B, 5 (11.1%) intraoperative dural tears, 4 (8.9%) neurological deficits, and 8 (14.4%) transient dysesthesia syndromes were seen. The average operation time was 3.6 hours (3 to 4 h) in group A and 4.9 hours (3.75 to 8 h) in group B. The average replacement of blood (erythrocyte suspension) was 2.9 U (2 to 5 U) in group A and 3.1 U (2 to 6 U) in group B. CONCLUSIONS: Sublaminar wiring is a time-consuming technique with high risks of neurological complications, whereas subtransverse process wiring is an easy and neurologically safe method, which maintains effective deformity correction and stability of the correction.

Cam impingement of the posterior femoral condyle in unicompartmental knee arthroplasty.

PURPOSE: There has been much emphasis on the importance of cam impingement, which is a cause of pain and knee hyperflexion restriction in unicompartmental knee arthroplasty (UKA). This study aimed to correlate cam impingement in the posterior femoral condyle with an α-angle showing the severity of the impingement. METHODS: The study groups consisted of 87 knees of 74 patients operated on with phase 3 medial Oxford UKA. Postoperatively, Group A (68 knees, 78.2 %) had no remnant of cam lesion; Group B (19 knees, 21.8 %) had cam lesion remnants. In Group C (18 knees, 20.7 %), which is a subgroup of Group A, cam lesions seen preoperatively were cleaned and not seen postoperatively. RESULTS: The mean increase in active flexion was 20.4° (± 7.3°) in Group A, 9.7° (± 6.1°) in Group B and 20.8° (± 7.3°) in Group C. The difference between Group A and Group B and between Group B and Group C was statistically significant (p < 0.001, p < 0.001). The mean decrease of α-angle was 11.2° (± 4.1°) in Group B, and 31.1° (± 3.4°) in Group C. The difference was statistically significant (p < 0.001). Mean Oxford Knee Scores were 24 preoperatively, 41 postoperatively in Group A; 22 preoperatively, 38 postoperatively in Group B; and 24 preoperatively, 40 postoperatively in Group C. The differences were not significant. CONCLUSIONS: Posterior condylar cam lesion is an impingement which limits hyperflexion and may be an early clinical finding prior to bearing dislocation and wear. The α-angle is a marker showing the severity of this cam lesion. This problem can be overcome using intraoperative fluoroscan views during cam excison and replacing the femoral component in 105° knee flexion.

Use of contact pressure-sensitive surfaces as an indicator of graft tension in medial patellofemoral ligament reconstruction.

BACKGROUND: No previous description has been made about an objective method to test the graft resistance in MPFL reconstruction intraoperatively. In our study, we aimed to obtain intraoperative objective data about the graft resistance using contact pressure-sensitive surfaces and measuring pressure formed under the graft. MATERIALS AND METHODS: In 2012, double-layered contact pressure-sensitive Fuji Prescale Film bands were placed under MPFL in 15 fresh-frozen high above-knee amputates (Group 1) and under graft in 10 patients who underwent MPFL reconstruction (Group 2). Measured values at different flexion angles were compared between and in groups. RESULTS: Statistical analysis was performed by Student's t test. It has been found that the pressure under the graft was higher in patients having reconstruction as compared to the pressure under natural MPFL. Decreasing pressure values were observed with increasing flexion angles in both groups. CONCLUSION: Contact pressure-sensitive surfaces provided objective data when placed under the graft in natural MPFL and during surgery. Therefore, they may be used as an objective marker providing information about graft resistance.

Muscle strength and function of shoulders with Bankart lesion after successful arthroscopic treatment: interlimb comparison 24 months after surgery.

BACKGROUND: The purpose of this study was to examine outcomes following arthroscopic Bankart repair with the focus on strength after the repair. METHODS: 56 shoulders with Bankart lesion were operated on arthroscopically. Gender, mechanism of the first dislocation, number of dislocations, dominant side, operated side and the number of anchors used for surgery were recorded. DASH and Oxford instability scoring systems were applied preoperatively and compared to scores at the 24-month follow-up. The scoring systems were also applied to contralateral shoulders at the 24th month of follow-up. Range of motion was measured with a goniometer. Muscle strength was analyzed with a dynamometer simultaneously with the muscle activity of four perishoulder muscles. The data were recorded with surface EMG. Range of motion, muscle strength and activity were evaluated according to the contralateral shoulder at the 24th month of follow-up. RESULTS: Male/female ratio was 42/14 with a mean age of 32 years. The mean number of dislocations was 3 ± 1 and all were traumatic dislocations. The number of mean anchors used was 3.1 and the mean follow-up period was 24 months. In clinical evaluation, the preoperative and postoperative results of the DASH and Oxford instability scores of the unstable shoulders were significantly different. In the comparison between the operated and contralateral shoulders, there was no significant difference in DASH and Oxford instability scores at the 24th month of follow-up. There was no significant loss of range of motion. Only internal rotation strength was significantly reduced and there was no significant change in the EMG patterns. CONCLUSIONS: Although good clinical results can be achieved, internal rotation strength is reduced after arthroscopic surgery, but daily activities are not affected. There is no guarantee for patients of excellent recovery. LEVEL OF EVIDENCE: Level III cohort study.

Combined arthroscopic synovectomy and radiosynoviorthesis in the treatment of chronic non-specific synovitis of the knee.

INTRODUCTION: Chronic non-specific synovitis has a higher recurrence rate with arthroscopic synovectomy due to the insufficient removal of all pathological tissues. Neither has radiosynoviorthesis been sufficiently effective in treatment in contrast to cases of chronic specific synovitis such as rheumatoid arthritis. This study aimed to investigate the efficiency of combined arthroscopic and radionuclide synovectomy in chronic non-specific synovitis of the knee with the evaluation of clinical and radiological results. MATERIALS AND METHODS: 14 knees of 14 patients (11 female, 3 male) diagnosed as chronic non-specific synovitis were treated with arthroscopic subtotal synovectomy combined with radiosynoviorthesis. The efficiency was evaluated retrospectively by comparing preoperative and postoperative modified cincinnati knee score, Visual Analogue Scale, joint USG and MRI. The mean age was 29.2 ± 10.3 years and the mean follow-up period was 30.3 ± 3.7 months. RESULTS: Clinical parameters such as pain, limitation of motion and effusion were regressed. Daily activities at the final follow-up were significantly better than in the preoperative period. The mean modified cincinnati knee score of the patients increased from 25.8 ± 8.7 preoperatively to 67.8 ± 13.4 postoperatively (p = 0.002). The mean VAS score was 7.2 ± 1.1 preoperatively and 1.3 ± 0.8 postoperatively (p = 0.003). Clinically and radiologically on MRI there was no recurrence. Mean synovial membrane thickness was 4.5 ± 2.4 mm in the preoperative period. At the final follow-up, noticeable regression of synovial membrane thickness (2.1 ± 0.5 mm) was recorded in the knee joint USG (p = 0.015). No complications were observed. CONCLUSION: The combination of arthroscopic subtotal synovectomy and radiosynoviorthesis can be an effective treatment modality for chronic non-specific synovitis of the knee.

Short-Term Outcomes After Treatment of Isolated Hidden Meniscal Ramp Lesions.

Background: Ramp lesions are encountered in 16% to 24% of all anterior cruciate ligament (ACL) ruptures. However, isolated ramp lesions without a ruptured ACL have also been reported. Purpose: To evaluate outcomes after type 3 hidden ramp lesions without ACL rupture were treated with all-inside sutures passed through the standard anterior portal. Study Design: Case series, Level of evidence, 4. Methods: Included were 41 patients (26 female; 63.4%) with isolated type 3 ramp lesions who underwent surgery between January 2017 and January 2019. Patients with concomitant lateral meniscal injuries and revision meniscal surgeries were excluded. We retrospectively recorded patient age, sex, and body mass index (BMI), as well as follow-up periods, comorbidities, and postoperative and early midterm complications. The Lysholm, visual analog scale (VAS) for pain, and International Knee Documentation Committee (IKDC) scores were compared preoperatively to final follow-up. In addition, patients were classified as having either a sedentary or active lifestyle according to Sedentary Behavior Research Network (SBRN) criteria. The Shapiro-Wilk test was used to evaluate the normality of the data, and the Wilcoxon and Mann-Whitney U tests were used to compare preoperative and postoperative outcome scores. The Spearman test was employed to evaluate the correlation between patient variables. Results: The mean follow-up period was at 37.6 (range, 25-49) months. A total of 17 patients (41.46%) had a sedentary lifestyle based on SBRN criteria. All scores improved significantly from preoperatively to final follow-up (VAS, from 8.43 ± 1.53 to 2.34 ± 2.9; Lysholm, from 47.73 ± 17.02 to 85.37 ± 14.01; and IKDC, from 27.12 ± 14.81 to 85.32 ± 8.78; P < .001 for all). Although no significant relationship was established between patient activity level and postoperative Lysholm and IKDC scores, an inverse correlation was observed between BMI and Lysholm (r =-0.9906) and BMI and IKDC (r =-0.9402). Conclusion: Satisfactory postoperative clinical results were obtained in patients with type 3 ramp lesions not accompanied by ACL rupture who were treated with all-inside suturing through standard anterior portals.

Comparison of All Arthroscopic Implantation of Chitosan-Based Liquid Scaffold and Hyaluronan-Based Soft Scaffold in the Treatment of Condylar Osteochondral Lesions in the Knee.

Cell-free scaffolds used in cartilage regeneration are produced from different materials. The aim of this study is to compare the clinical and radiological results of two different scaffolds with hyaluronan- or chitosan-based structure used in the treatment of symptomatic condylar osteochondral lesions. The study comprises 69 patients who were operated for osteochondral lesion repair with hyaluronan- (n = 37) or chitosan-based (n = 32) scaffold. The International Knee Documentation Committee (IKDC), Lysholm Knee Scoring Scale and Visual Analog Scale (VAS) scores were collected for both groups at the preoperative and postoperative 3rd, 12th, and 24th months. Magnetic resonance imaging was performed between the 12th and 15th months postoperatively and this with magnetic resonance observation of cartilage repair tissue (MOCART) scoring were compared. Within group assessments demonstrate significant improvement in IKDC, Lysholm, and VAS scores at postoperative 3rd and 12th months. However, in both groups, IKDC, Lysholm and, VAS scores at the postoperative 24th month indicate no significant further improvement, compared with the 12th month results. There was no significant difference between the groups in terms of IKDC, Lysholm, VAS, and MOCART scores at any time period. This study shows that both scaffolds are useful in cartilage regeneration but have no clinical or radiological superiority to each other. Surgeons should select the method with which they feel comfortable. This is a level III, retrospective comparative study.

Effect of Soft Tissue Interposition and Postoperative Suspensory Cortical Button Migration on Functional Outcomes and Ligamentization After Single-Bundle ACL Reconstruction.

Background: Soft tissue interposition between a suspensory cortical button and the lateral femoral condyle is the most common cause of postoperative suspensory cortical button migration in patients undergoing anterior cruciate ligament reconstruction (ACLR). Purpose: To investigate the effects of soft tissue interposition and suspensory cortical button migration after ACLR on functional outcomes and graft ligamentization. Study Design: Cohort study; Level of evidence, 3. Methods: Included were 249 patients who underwent single-bundle ACLR with hamstring tendon autografts. To measure soft tissue imposition, the patients were divided into 2 groups: those in whom the suspensory cortical button was in contact with (group 1) or at least 1 mm away from (group 2) the lateral femoral condyle on 1-day postoperative radiographs. To measure suspensory cortical button migration, the patients in group 2 were further divided into 2 subgroups: those with button migration (group M) and those without migration (group non-M) as observed on 12-month postoperative radiographs. Ligamentization was evaluated according to Howell classification (grades 1-4) on 12-month follow-up magnetic resonance imaging scans. Also recorded were preoperative and 24-month postoperative Lysholm and Tegner scores and 24-month postoperative arthrometer measurements for anterior knee laxity. Results: There was no significant difference between groups 1 and 2 or between groups M and non-M in terms of demographic characteristics or additional intra-articular pathologies detected intraoperatively. Normal anterior laxity (<3 mm) was detected in 83.7% of the patients postoperatively, and all patients showed statistically significant pre- to postoperative improvement on the Tegner (from 4.1 to 4.3) and Lysholm (from 44.0 to 89.2) scores (P < .05 for both). No significant difference in postoperative functional results or graft ligamentization was found between either the soft tissue interposition groups (groups 1 and 2) or the suspensory cortical button migration groups (groups M and non-M). Conclusion: Differences between patients in soft tissue interposition and suspensory cortical button migration did not significantly affect postoperative clinical or functional outcomes or graft ligamentization after single-bundle ACLR.

Single-Incision, Single Patellar Tunnel For Double-Bundle Medial Patellofemoral Ligament Reconstruction: A Technical Note.

The medial patellofemoral ligament (MPFL) is the main medial stabilizer of the patella, while reconstruction of the ligament is a common surgery performed by orthopedic surgeons. Although several surgical methods have been described regarding MPFL reconstruction, the common goals of these surgeries are to imitate the anatomic features of the native MPFL. In the single-incision and single patellar tunnel and double-bundle MPFL reconstruction technique, we will present the anatomical footprint of the MPFL located in the medial aspect of the patella, which is filled with the graft. In this technique, graft fixation is performed in the femoral tunnel using only one bioabsorbable screw without the need for fixation in the patella.

The Application of All-arthroscopic Technique to Deep Osteochondral Lesions in the Talus With Scaffold and Autograft Bone Taken From the Tibial Plafond.

Osteochondral lesions in the talus are frequently seen disorders that can cause chronic ankle pain. Surgical treatment is determined by the size and location of the lesion. The microfracture procedure and additional application of scaffold technique have gained popularity for the treatment of small osteochondral defects. However, these techniques may be insufficient and have poor outcomes in deep lesions. Therefore, several different invasive surgical techniques that require the malleolar osteotomy have been described. Problems associated with the invasive surgical intervention may be seen such as reduction loss in the osteotomy site, delayed union or nonunion, permanent pain, and/or swelling. We describe a new all-arthroscopic technique for the treatment of deep talus osteochondral lesions using an autologous bone graft taken from the tibial plafond region together with a chitosan-based noncellular scaffold.

The effectiveness of peripheral compartment first access and periportal capsulotomy technique for arthroscopic management of femoroacetabular impingement: A prospective case series.

OBJECTIVE: The aim of this study was to evaluate the functional results of hip arthroscopy for femoroacetabular impingement (FAI) performed via the periportal capsulotomy technique combined with capsular thinning and peripheral compartment first access. METHODS: This prospective study included 34 patients (20 female, 14 male; mean age = 32.3 ± 12.5 years) treated for combined type FAI and labral tears between January 2016 and January 2018. In radiographic evaluation, center-edge angle (CEA) and alpha angle were measured preoperatively and postoperatively. Patients' functional status was assessed at 3, 6, 12, and 24 months using the modified Harris Hip Score (mHHS), Hip Disability and Osteoarthritis Outcome Score - Activities of Daily Living (HOOS-ADL), and Hip Disability and Osteoarthritis Outcome Score - Sports-Specific Subscale (HOOS-SSS), and visual analog scale (VAS). RESULTS: The mean alpha angle decreased from 55.5°±2.9° preoperatively to 48.3° ± 2.6° postoperatively. The mean CEA decreased from 39.2° ± 3.0° preoperatively to 32.9° ± 2.6° postoperatively. The mean duration of surgery was 96.7 ± 21.1 minutes; the mean traction time was 45.5 ± 14.6 minutes. The mean mHHS at the 3rd , 6th, 12th, and 24th months showed a statistically significant increase compared to the preoperative value (P < 0.05). The mean HOOS-ADL and HOOS-SSS at the postoperative 3rd, 6th, and 12th months demonstrated a statistically significant increase compared to the preoperative values (P < 0.05). The same scores measured at the 24th month, however, did not demonstrate a significant increase. The mean VAS scores at the 3rd and 6th months postoperative illustrated a significant decrease compared to the preoperative values (P < 0.05) whereas this significant decrease was not observed at the 12th and 24th months. CONCLUSION: The combined technique of periportal capsulotomy and capsular thinning used in this study seems to be a reliable surgical method with favorable functional results, a low complication rate, and a low risk of hip instability. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

A New Clinical Sign for Diagnosing Medial Meniscus Posterior Root Tear.

BACKGROUND: In the presence of medial meniscus posterior root tear (MMPRT), there is a possibility of reduced compression of meniscal tissue in hyperflexion as the intra-articular mobility of the meniscus increases. This phenomenon can be mimicked during clinical examination. PURPOSE: To describe, evaluate, and validate the diagnostic performance of a new clinical indicator, the Akmese sign, for the diagnosis of an MMPRT. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: In this study, we prospectively enrolled patients aged 18 to 55 years who were scheduled for arthroscopic surgery after a diagnosis of medial meniscal lesion at a single institution between January 2016 and January 2018. All of the patients underwent preoperative examination for the Akmese sign. All surgeries were performed by a single surgeon with more than 5 years of experience in sports injury surgery, who was blinded to the Akmese sign results. RESULTS: A total of 273 patients with a mean age of 42.4 ± 5.3 years met the study criteria. The Akmese sign was identified as positive in 33 patients, and MMPRT was confirmed during arthroscopy in 36 cases. The performance parameters of the Akmese sign were a sensitivity of 86.1%, specificity of 99.1%, Youden index of 0.85, and kappa index of 0.88. CONCLUSION: This study showed that the Akmese sign is a useful new physical examination test that can help clinicians distinguish MMPRTs from other meniscal medial meniscal pathology.

A Surgical Algorithm According to Pivot-Shift Grade in Patients With ACL Injury: A Prospective Clinical and Radiological Evaluation.

BACKGROUND: Some patients have a positive pivot-shift finding and rotational instability after anterior cruciate ligament (ACL) reconstruction (ACLR). Three major pathologies known to affect the pivot-shift examination include ACL tear, anterolateral ligament injury, and loss of posterior lateral meniscus root function. PURPOSE: To describe a surgical algorithm determining indications for lateral extra-articular tenodesis (LET) based on intraoperative pivot-shift examination to prevent postoperative pivot shift and rotational instability and to evaluate the 2-year clinical and functional outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The study included 47 consecutive patients (39 men and 8 women) who underwent operative treatment for ACL injury between 2016 and 2017. Pivot-shift examination was performed under anesthesia, and the pivot shift was graded as grade 1 (glide), grade 2 (clunk), or grade 3 (gross). According to the surgical algorithm, single-bundle ACLR was performed in patients with grade 1 pivot shift. In patients with grade 2 with loss of posterior lateral meniscus root function, concurrent lateral meniscal repair was performed, and in patients with grade 2 with an intact lateral meniscus posterior root, concurrent extra-articular iliotibial band tenodesis was performed. Patients with grade 3 underwent ACLR, lateral meniscal repair, and LET. Clinical and radiographic evaluations were performed. RESULTS: The mean age was 27.2 years (range, 16-56 years). In total, 26 (55.3%) patients were evaluated as having pivot-shift grade 1; 16 (34%) patients, grade 2; and 5 (10.6%) patients, grade 3. A total of 7 (14.9%) patients underwent LET in addition to ACLR. Two of these patients had pivot-shift grade 2, and LET was performed since the lateral meniscus posterior root was intact. In 14 of 16 patients with grade 2, lateral meniscus root disruption was detected, and lateral meniscal repair was performed. One patient was excluded from the further follow-up because of graft failure. At a mean postoperative follow-up of 29 months in 46 patients, the pivot-shift examination was negative in all patients. The mean Lysholm and International Knee Documentation Committee subjective scores were 95.35 ± 4.40 and 82.87 ± 9.36, respectively. Radiographic evidence of osteoarthritis was not detected. CONCLUSION: Only 14.9% of patients needed LET. With proper ACL, lateral meniscal, and anterolateral ligament surgery, it was possible to prevent positive pivot-shift findings postoperatively.

Comparison of Chitosan-Based Liquid Scaffold and Hyaluronic Acid-Based Soft Scaffold for Treatment of Talus Osteochondral Lesions.

BACKGROUND: The aim of this study was to evaluate the clinical and radiologic results of 2 different scaffolds with hyaluronan or chitosan-based structure used in the treatment of talus osteochondral lesions. METHODS: Eighty-one patients who underwent chondral lesion repair with hyaluronan (n = 42) or chitosan-based (n = 39) scaffold were included. American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) scores were evaluated within and between groups preoperatively and at the 3rd, 12th, and 24th month postoperatively. In all patients, magnetic resonance imaging was performed between the 12 and 18th month postoperatively and compared with magnetic resonance observation of cartilage repair tissue (MOCART) scoring. RESULTS: Within-group evaluations revealed significant improvements in AOFAS and VAS scores at postoperative 3 and 12 months. The postoperative 24th-month results of AOFAS scores in any group did not differ significantly from the 12th-month results. There was no significant difference between the groups in comparison of AOFAS, VAS, and MOCART scores at any time period. CONCLUSION: Both scaffolds were found to be effective in cartilage healing but had no clinical or radiologic superiority to each other. This is the first study to compare the use of different cell-free scaffold types in osteochondral defects of the talus. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Comparison of muscle activation levels and knee valgus between individuals with medial patellofemoral ligament reconstruction and healthy individuals during fatiguing step down task.

BACKGROUND: Medial patellofemoral ligament reconstruction becomes first-choice surgical procedure for patients with a history of lateral patellar dislocations but there is limited knowledge about neuromuscular activation patterns of individuals with a history of patellar dislocation who underwent medial patellofemoral ligament reconstruction. OBJECTIVE: The aim of this study was to compare muscle activation levels and knee valgus during step down performance test between individuals with a history of medial patellofemoral ligament reconstruction and healthy individuals. METHODS: Fifteen individuals with medial patellofemoral ligament reconstruction and 15 healthy individuals were included. Vastus medialis obliquus, vastus lateralis and gluteus medius muscle activation levels and knee valgus were measured during 60-s- step down performance test. Two-way repeated-measures of analysis of covariance was used for statistical analysis. FINDINGS: Compared to the healthy individuals, individuals with medial patellofemoral ligament reconstruction showed lower vastus medialis obliquus (p = .04) and gluteus medius (p = .005) activation levels, and higher knee valgus (p = .002) in last period of the step down performance test. INTERPRETATION: Since the significant results were only observed in the fatiguing section of the test, endurance tests may provide more information about neuromuscular control of the individuals with history of medial patellofemoral ligament reconstruction. Future studies should investigate whether endurance exercises that target to improve vastus medialis obliquus and gluteus medius activity result in better clinical outcomes than conventional programs for individuals with medial patellofemoral ligament reconstruction.

[Lipoma arborescens occurring in both knees at different times: a case report]. / Iki dizde farkli zamanlarda ortaya çikan lipoma arboresan: olgu sunumu.

Lipoma arborescens is a rare intraarticular lesion, mainly affecting the knee. A fourteen-year-old girl presented with a slow-growing painless mass in the right knee, of a six-year history. There were no limitations in the movements of the knee. Magnetic resonance imaging (MRI) revealed multiple lesions showing villous lipomatous proliferation of the synovium in the supra- and retropatellar regions and effusion in the knee joint. The mass was excised with arthrotomy and synovectomy and a histopathologic diagnosis of lipoma arborescens was made. Two years postoperatively, and when the right knee was completely asymptomatic, she developed a similar mass in the suprapatellar region of the left knee. An MRI scan showed a mass lesion in the supra- and retropatellar regions, effusion in the knee joint, and a synovial cyst in the popliteal fossa. Again, arthrotomy and synovectomy were performed and the histopathologic diagnosis was lipoma arborescens. This case differs from simultaneously involved knees in that lipoma arborescens in the contralateral knee developed two years after the initial operation.