Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus.

PURPOSE: The importance of meniscus integrity in the prevention of early osteoarthritis is well known, and preservation is accepted as the primary goal. The purpose of the ESSKA (European Society for Sports Traumatology, Knee Surgery and Arthroscopy) European consensus on traumatic meniscus tears was to provide recommendations for the treatment of meniscus tears based on both scientific evidence and the clinical experience of knee experts. METHODS: Three groups of surgeons and scientists elaborated and ratified the so-called formal consensus process to define the recommendations for the management of traumatic meniscus tears. A traumatic meniscus tear was defined as a tear with an acute onset of symptoms caused by a sufficient trauma. The expert groups included a steering group of eight European surgeons and scientists, a rating group of another nineteen European surgeons, and a peer review group. The steering group prepared twenty-seven question and answer sets based on the scientific literature. The quality of the answers received grades of A (a high level of scientific support), B (scientific presumption), C (a low level of scientific support) or D (expert opinion). These question and answer sets were then submitted to and evaluated by the rating group. All answers were scored from 1 (= totally inappropriate) to 9 (= totally appropriate) points. Thereafter, the comments of the members of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the finalized question and answer sets were submitted for final review by the peer review group composed of representatives of the ESSKA-affiliated national societies. Eighteen representatives replied. RESULTS: The review of the literature revealed a rather low scientific quality of studies examining the treatment of traumatic meniscus tears. Of the 27 questions, only one question received a grade of A (a high level of scientific support), and another received a grade of B (scientific presumption). The remaining questions received grades of C and D. The mean rating of all questions by the rating group was 8.2 (95% confidence interval 8.1-8.4). A general agreement that MRI should be performed on a systematic basis was not achieved. However, MRI was recommended when arthroscopy would be considered to identify concomitant pathologies. In this case, the indication for MRI should be determined by a musculoskeletal specialist. Based on our data, stable left in situ lateral meniscus tears appear to show a better prognosis than medial tears. When repair is required, surgery should be performed as early as possible. Evidence that biological enhancement such as needling or the application of platelet-rich plasma would improve healing was not identified. Preservation of the meniscus should be considered as the first line of treatment because of an inferior clinical and radiological long-term outcome after partial meniscectomy compared to meniscus repair. DISCUSSION: The consensus was generated to present the best possible recommendations for the treatment of traumatic meniscus tears and provides some groundwork for a clinical decision-making process regarding the treatment of meniscus tears. Preservation of the meniscus should be the first line of treatment when possible, because the clinical and radiological long-term outcomes are worse after partial meniscectomy than after meniscus preservation. The consensus clearly states that numerous meniscus tears that were considered irreparable should be repaired, e.g., older tears, tears in obese patients, long tears, etc. LEVEL OF EVIDENCE: II.

Extra-Articular Plasty for Revision Anterior Cruciate Ligament Reconstruction.

Recent studies have renewed interest in the structures of the anterolateral aspect of the knee. Concomitant damage to these structures in the setting of anterior cruciate ligament rupture has led to various surgical techniques to address these combined injuries. This article is a description of the rationale and the indications for lateral extra-articular tenodesis as well as surgical technique.

Is There Any Benefit in Anterior Cruciate Ligament Reconstruction in Patients Older Than 60 Years?

BACKGROUND: Results of anterior cruciate ligament (ACL) reconstruction are traditionally excellent in younger and nonarthritic patients. During the past few decades, people older than 60 years have become more active than ever, with more demanding physical lifestyles. An increase also has been noted in active patients with diagnosed ACL injuries. More patients are requesting treatment for ACL deficiency in hopes of returning to preinjury levels of activity. PURPOSE: The aims of this study were to evaluate the results of ACL reconstruction in patients older than 60 years in terms of functional recovery, return to sports, and postoperative incidence of osteoarthritis and to compare their results with published results of different age groups. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Consecutive patients older than 60 years with isolated ACL tear and no established osteoarthritic lesions (Ahlbäck grade 1 or no arthritis) who were treated from 2008 to 2013 were retrospectively included in this study. Primary ACL reconstruction was performed with the same technique in all patients by means of single-bundle autologous hamstring tendon graft. Meniscal injuries were treated with partial debridement when required. No further treatment on cartilage lesions was performed. Postoperative rehabilitation was the same in every case. The International Knee Documentation Committee (IKDC) objective grade, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS) were assessed before and after surgery, and the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) score was recorded during the final follow-up. Postoperative incidence of osteoarthritis was evaluated on weightbearing radiographs during final follow-up, and anteroposterior laxity was measured pre- and postoperatively with the use of stress radiographs. RESULTS: Twelve patients with mean age (±SD) of 61.0 ± 1.4 years at the time of surgery were included. They were followed-up for a mean period of 49.6 ± 24.0 months. Eight patients had associated meniscal tears, and 6 patients had International Cartilage Repair Society stage 1 or 2 chondral lesions. Preoperatively, the objective IKDC grades were B in 4 patients, C in 5, and D in 3. After surgery, the IKDC grades were A in 4 patients, B in 7, and grade C in 1. The mean subjective IKDC and Lysholm scores were a respective 43.4 ± 8.4 and 55.7 ± 12.4 preoperatively and 83.8 ± 9.4 and 93.2 ± 9.0 at the final follow-up ( P < .05). Ten patients (83%) reported recovery of sports activities, with 6 patients (50%) reaching the same level as before injury. The mean ACL-RSI score was 76.2%. Preoperatively, 50% (n = 6) of patients had Ahlbäck stage 1 medial compartment arthritis, versus 58% (n = 7) at the final follow-up ( P = nonsignificant). The side-to-side difference in anterior tibial translation on stress radiographs was 7.2 ± 6.4 mm preoperatively and 1.9 ± 4.3 mm postoperatively ( P < .05). No major complications were reported. CONCLUSION: ACL reconstruction in active patients older than 60 years without arthritis restored knee stability in all treated cases. In these patients, as in younger age groups, ACL reconstruction showed good results on functional recovery while not increasing the risk of midterm functional knee deterioration or evolution of knee arthritis. The majority of patients returned to activities at their preinjury level. These data show that older and active patients with nonarthritic ACL-deficient knees need not be excluded from surgical treatment.

Comparison of resorption and remodeling of bioabsorbable interference screws in anterior cruciate ligament reconstruction.

PURPOSE: The purpose of the study was to evaluate the influence of ß-tricalcium phosphate (ß-TCP) content on absorption rate and osteoconductive behavior of ß-TCP/poly-L-lactic acid (PLLA) interference screws for anterior cruciate ligament (ACL) reconstruction. The authors compared two biocomposite ß-TCP/PLLA screws containing 30 % (30TCP) and 60 % (60TCP) ß-TCP (Ligafix®, SBM), respectively, used in ACL reconstruction with patellar tendon (BPTB) and hamstrings (HS) autografts. METHODS: Twenty-eight knees with a 30TCP screw and 25 knees with a 60TCP screw were retrospectively included. Mean follow-up period was 37.5 months (range, 29-45 months). Post-operatively, all patients were examined clinically, had stress X-rays to measure anterior tibial translation and computed tomography (CT) to determine screw tract density, osteoconductivity and completed functional scores. RESULTS: Clinical evaluation and functional scores were similar for both groups. There was no case of tunnel widening, cyst formation, increased inflammatory process or osteolysis. Both types of screws evidenced a decrease of Hounsfield units (HU) density over time (p < 0.001). The 60TCP screw resorbed more rapidly than the 30TCP (-62 vs -52 % of initial HU density respectively, p < 0.01) at latest follow-up. At three years, 97 % of the 30TCP and 96 % of the 60TCP screws showed osteoconductivity according to the Barber-Dockery's architectural score. CONCLUSIONS: Both types of screws showed considerable osteoconductivity at the site of the screw tract. The majority of the 30 % ß-TCP screws were fully resorbed and osteointegrated during the fourth postoperative year. The clinical results are good-to-excellent for both groups. The addition of 30 % or 60 % ß-TCP in the biocomposite screw did not adversely affect clinical outcome and it minimized the inflammatory process. The material with the highest ß-TCP content was absorbed more rapidly, supporting the hypothesis that increased ß-TCP content in ß-TCP/PLLA biocomposite material resulted in enhanced absorption rate of interference screws used in ACL reconstruction without affecting fixation strength. LEVEL OF EVIDENCE: Level IV, Therapeutic case series.

Current concepts on trochleoplasty procedures for the surgical treatment of trochlear dysplasia.

UNLABELLED: Trochleoplasty is a surgical procedure, whose goal is to change the abnormal shape of the femoral trochlea in patients with recurrent patellar dislocation. Such surgeries that aim to reshape the articular surface of a bone without damaging it are quite unique in orthopaedic surgery. Although in the beginning, trochleoplasty was reserved for the refractory cases where previous surgery has failed, the last years it became more and more popular because of a better knowledge of anatomy and biomechanics and a greater availability of instruments. The roots of the deepening trochleoplasty could be found in the previous century when the first surgeons tried to directly remove the dysplastic bone with pioneer interventions but with devastating consequences. Since then, multiple procedures have been described and are analysed in this review; each one with its unique features, advantages and pitfalls. Regardless of the technique used, the very recent bibliography presents very encouraging results from the application of trochleoplasty with other procedures in a selected population with severe trochlear dysplasia and recurrent patellar dislocation, in whom the benign neglect of dysplasia would lead to unfavourable results. LEVEL OF EVIDENCE: IV.

Evidence of trochlear dysplasia in patellofemoral arthroplasty designs.

PURPOSE: The design of the trochlear compartment is crucial in patellofemoral arthroplasty (PFA), because 78% of patients with isolated patellofemoral arthritis present concomitant trochlear dysplasia with patellar maltracking and therefore remain predisposed to post-operative patellar subluxation and dislocation. The study investigated whether current PFA implants are designed with anatomic trochlear parameters such as the sulcus angle, lateral facet height and groove orientation. METHODS: Five trochlear components of commercially available PFA implants were scanned, and the generated three-dimensional surfaces were measured using engineering design software. The mediolateral trochlear profiles were plotted at various flexion angles (0°, 15°, 30° and 45°) to deduce the following variables: sulcus angle, height of lateral facet and trochlear groove orientation. RESULTS: Four specimens had sulcus angle>144° in the 45° of flexion, and all five specimens had sulcus angle>143° in 30° of flexion. Three specimens had a facet<5 mm high through the entire range of early flexion (0°-30°), and two specimens had a facet<5 mm high beyond early flexion (30°-45°). The trochlear groove was oriented laterally in all specimens (range 1.6°-13.5°). CONCLUSION: Current PFA trochlear components are not always designed with anatomic parameters, and some models exhibit characteristics of trochlear dysplasia. Surgeons are therefore advised to implant components with a deep sulcus, particularly in patients with history of patellofemoral disorders, and to adapt the surgical technique and extensor mechanism if the component implanted has a shallow sulcus, to ensure normal patellar tracking. LEVEL OF EVIDENCE: III.

The incidence of trochlear dysplasia in anterior cruciate ligament tears.

PURPOSE: The purpose of the present epidemiologic study is to record the radiographic presence of trochlear dysplasia and patella alta in patients who undergo anterior cruciate ligament (ACL) reconstruction as a potential underlying factor for post-operative anterior knee pain (AKP). METHODS: All consecutive cases of skeletally-mature ACL-deficient knees that would undergo ACL reconstruction in three different hospitals were prospectively included during a six-month period. Inclusion criteria were acute and sub-acute ACL injury with no previous ipsilateral knee operation. Patients with chronic ACL tears, prior-to-ACL-injury history of patellar instability or other PF disorders were excluded from the study. RESULTS: A total of 299 knees were included (mean age 32 ± ten years). Forty-four (14.7 %) knees had a positive 'crossing sign' in the lateral X-rays and 255 (85.3 %) had no sign of trochlear dysplasia (p < 0.01). Among the cases with trochlear dysplasia, 41 (93 %) had type A trochlear dysplasia with the presence only of the 'crossing sign' and three (7 %) had type C trochlear dysplasia. Patellar height results included a mean Caton-Deschamps index of 1.0 ± 0.14 (0.5-1.4). Twenty (6.6 %) knees had an index of less than 0.8, and two (0.6 %) knees had an index less than 0.6. In contrast, 15 (5.0 %) knees had an abnormal value of more than 1.2, indicating patella alta. CONCLUSIONS: The most important finding of the study is the increased prevalence of trochlear dysplasia and patella alta in patients with ACL injury, when compared to the incidence of trochlear dysplasia and patella alta in the general population in the literature. This finding could sound as an alert of a possible additional risk factor for post-operative anterior knee pain after ACL reconstruction.

Evidence of trochlear dysplasia in femoral component designs.

PURPOSE: The study aimed to compare trochlear profiles of various total knee arthroplasty (TKA) models to anatomic profiles observed in healthy and pathologic knees and to evaluate trochlear designs against radiologic indicators for PF disorders and trochlear dysplasia. METHODS: The trochlear profiles of 14 different TKA models were digitized using a coordinate measurement machine at various flexion angles (0°, 15°, 30° and 45°) to deduce the following variables: sulcus angle, trochlear groove orientation, height of lateral facet, and mediolateral groove position. The effect of externally rotating the femoral component on those variables was simulated. RESULTS: The sulcus angle was greater than the indicators for trochlear dysplasia of 144° in 11 implants at 45° flexion, and in 13 implants at 30° flexion. The lateral facet height was less than average anatomic values of 5 mm in eight specimens through the entire range of early flexion (0°-30°). The trochlear groove was oriented laterally in 13 specimens (3.3°-11.7°) and was vertical in one specimen (0.3°). Applying an external rotation up to 6° resulted in noticeable lateral translation of the trochlear groove and facets, but negligible posterior translation. CONCLUSIONS: The study presented a detailed description of previously overlooked TKA design parameters and revealed that some femoral components exhibit characteristics of trochlear dysplasia. The clinical relevance of this descriptive study is that surgeons should be aware of such design limitations to improve choice of implant for patients with history of PF disorders and to adapt surgical techniques as necessary to optimize PF tracking. LEVEL OF EVIDENCE: Case-control study, Level III.

Are the tubular grafts in the femoral tunnel in an anatomical or isometric position in the reconstruction of medial patellofemoral ligament?

PURPOSE: The purpose of this study was to evaluate the biomechanical results from the in vitro reconstruction of medial patellofemoral ligament (MPFL) using a navigation-assisted technique on a cadaveric model and its effects on patellar stability and kinematics. The authors investigated the hypothesis that patellar kinematics after reconstruction with a tubular graft are not optimal when compared with the original fan-shaped MPFL. METHODS: In six fresh-frozen cadaveric knees, lateral loads (25 N) were applied on the patella at 0°, 30°, 60° and 90° of knee flexion in three different MPFL states: intact, cut and reconstructed. The arrangement allowed positional measurements of patellar motion to be tracked in six degrees of freedom. Medial to lateral patellar translation and patellar tilt were recorded. The kinematics after a technique of MPFL reconstruction, performed with a gracilis tendon in a blind femoral tunnel guided by navigation, were compared against kinematics recorded in the MPFL intact state. A temporary fixation of adequate tension to engage the lateral patellar facet in extension was applied to the MPFL and, after graft cycling, the final fixation was done at 70° knee flexion with an interference screw. RESULTS: There was a comparable medial to lateral patellar translation and tilting of the patella in the MPFL-intact and the MPFL-reconstructed state. Static patellar translation in the MPFL-reconstructed state, with and without the application of load, was comparable to patellar translation in the MPFL-intact state. The dynamic patellofemoral shift kinematics recorded an under-constraint in early flexion and over-constraint in late flexion, while an opposite effect was recorded in patellar tilt. However, these differences were not statistically significant. CONCLUSION: The study confirmed the major role of the MPFL in case of medial loading between 0° and 60°, by focusing on the importance of kinematically identifying the proper femoral point for fixation. While the study demonstrates the importance of kinematic determination of the proper femoral point of fixation, as the anatomical insertion remains difficult to identify. Even in dissected cadavers, the authors recorded a slightly anterior placement than native MPFL. After reconstruction, patellar stability in terms of lateral translation and tilt was similar to the intact MPFL, but patellar kinematics were not optimal with the use of a smaller and tubular graft than the native wider and fan-shaped MPFL.

Midterm results of comprehensive surgical reconstruction including sulcus-deepening trochleoplasty in recurrent patellar dislocations with high-grade trochlear dysplasia.

BACKGROUND: Trochlear dysplasia is one of the most consistent anatomic factors that can lead to recurrent patellar dislocations. Various trochleoplasty procedures have been described to treat patellar dislocations in high-grade dysplasia by creating a new congruent trochlea. PURPOSE: To present the midterm efficacy and outcome of the sulcus-deepening trochleoplasty procedure in patients with recurrent patellar dislocations due to high-grade trochlear dysplasia. The clinical evaluation results, the amount of radiological correction, and the prevalence of arthritis were recorded. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 27 skeletally mature patients (31 knees) with recurrent patellar dislocations due to high-grade trochlear dysplasia without any previous surgery were retrospectively included from September 1993 to September 2006. All patients underwent sulcus-deepening trochleoplasty combined with a bony and/or soft tissue procedure according to concomitant etiological factors to patellar dislocations: medial patellofemoral ligament reconstruction (16.1%), vastus medialis obliquus plasty (83.8%), tibial tuberosity distalization (51.6%), tibial tuberosity medialization (67.7%), and lateral retinaculum release (67.6%). Mean follow-up was 7 years (range, 2-9 years). RESULTS: The mean sulcus angle decreased significantly (P < .01) from 152° ± 16° preoperatively to 141° ± 9° postoperatively, tibial tuberosity-trochlear groove distance decreased significantly (P < .001) from 19 ± 4 mm to 12 ± 5 mm, and patellar tilt decreased significantly (P < .001) from 37° ± 7° to 15° ± 8°. No recurrence was observed, and there was no case of stiffness. Apprehension signs remained positive in 19.3% of the cases, patellar tracking was normal in all cases, and the lateral patellar glide test finding was negative in 96.8%. The mean preoperative International Knee Documentation Committee (IKDC) score was 51 (range, 25-80), and the mean postoperative IKDC score was 82 (range, 40-100) (P < .001), while the mean Kujala score improved from a preoperative 59 (range, 28-81) to 87 (range, 49-100) postoperatively (P < .001). There was no radiographic evidence of patellofemoral arthritis at the latest follow-up. CONCLUSION: Sulcus-deepening trochleoplasty is a valid option for the primary surgical treatment of carefully selected patients with recurrent patellar dislocations with high-grade trochlear dysplasia type B and D. Concomitant etiological factors must be cautiously corrected in an associated procedure. Midterm follow-up showed satisfactory restoration of patellar stability and improvement of knee scores with no complication of subsequent arthritis.

The diagnostic value of clinical tests, magnetic resonance imaging, and instrumented laxity in the differentiation of complete versus partial anterior cruciate ligament tears.

PURPOSE: To evaluate the question of whether different arthroscopically confirmed anterior cruciate ligament (ACL) injury patterns have distinctive preoperative findings on clinical examination, instrumented laxity, and magnetic resonance imaging (MRI). METHODS: Three hundred consecutive ACL-deficient patients with isolated ACL tears were evaluated with the Lachman test (LT), the pivot-shift test (PST), stress radiographs using the Telos Stress Device (Metax, Hungen, Germany), and MRI. After arthroscopic confirmation of the ACL injury, we grouped patients into 4 different ACL tear types (complete, partial anteromedial [AM] bundle intact, posterolateral [PL] bundle intact, and posterior cruciate ligament [PCL] healing), and partial tears were further evaluated for mechanical integrity and functionality of the remaining fibers. RESULTS: PST grades of +2 and +3 were consistent with complete ACL tears (86%; P < .00001), whereas PST grades of 0 or +1 were strongly related to partial tears (76%; P < .00001). Instrumented laxity results showed a significant difference in side-to-side difference (SSD) of anterior tibial translation in complete tears (9.1 ± 3.4 mm) versus partial tears (5.2 ± 2.9 mm; P < .0001). Most PL-intact cases were "functional" (67%), with lower instrumented laxity values (SSD, 4.3 ± 2.3 mm) than the "nonfunctional" cases (SSD, 6.7 ± 2.9 mm; P < .001). The contrary was not observed for AM-intact cases (17% functional). Partial ACL tears with functional remaining fibers had PST grades of 0 or +1 and less than a 4 mm SSD in stress radiographs (sensitivity, 0.76; specificity, 0.90). Partial ACL tears with nonfunctional fibers had positive PST results and an SSD of anterior tibial displacement from 4 to 9 mm (sensitivity, 0.56; specificity, 0.92). Positive PST results and an SSD greater than 9 mm was recorded in complete ACL tears (sensitivity, 0.88; specificity, 0.96). MRI analysis revealed overlapping results between complete and partial tears. CONCLUSIONS: Preoperative evaluation of different ACL tear types showed differences between complete and partial ACL tears with functional fibers in clinical examination and instrumented laxity tests. The combination of clinical tests and stress radiographs produced threshold values that distinguished complete from partial ACL tears, which may help the surgeon in the early identification of the presence of remaining functional fibers. LEVEL OF EVIDENCE: Level III, case-control study.

The Lyon's sulcus-deepening trochleoplasty in previous unsuccessful patellofemoral surgery.

PURPOSE: Trochleoplasty is a relatively rare operation with few published results and it remains a technically demanding procedure which requires careful patient selection. The ideal candidate for surgery remains to be elucidated, and some authors consider it as a good revision option in cases of previous unsuccessful operations for persisting patellar dislocation with underlying trochlear dysplasia. The purpose of this study is to record the results from the application of sulcus-deepening trochleoplasty in patients with trochlear dysplasia and previous unsuccessful surgery for patellar dislocation. METHODS: Twenty-two patients (24 knees) were operated upon during the period 9/1993-9/2006; they had undergone surgery for patellofemoral instability and had persistent patellar dislocation, and were followed-up for a mean of 66 months (24-191). Trochleoplasty was performed in all patients using the same technique and rehabilitation protocol. Additional soft-tissue and bony operations were performed in every case. RESULTS: Of all cases, 29.1% had type B and 70.9% had type D trochlear dysplasia. After trochleoplasty, no patient had a patellar re-dislocation up to the last follow-up. Pain decreased in 72% and the apprehension sign was negative in 75% of the cases (p < 0.01). Sulcus angle decreased from 153° ± 14° to 141° ± 10° (p < 0.01), TT-TG distance decreased from 16 ± 6 mm to 12 ± 2 mm (p < 0.001), and patellar tilt decreased from 31° ± 14° to 11° ± 8° (p < 0.0001). Mean pre-operative Kujala score was 44 (25-73) and at the latest follow-up it increased to 81 (53-100), (p < 0.001). At the time of final follow-up, there was no case of patellofemoral arthritis. CONCLUSIONS: Trochlear dysplasia is a key factor in the treatment of recurrent patellar dislocation and its correction could be included in the surgical options. Sulcus-deepening trochleoplasty is an acceptable revision option for the surgical treatment of patients with persisting patellar dislocation and high-grade trochlear dysplasia.

A new technique in double-bundle anterior cruciate ligament reconstruction using implant-free femoral fixation.

PURPOSE: The study is a prospective case-series analysis to demonstrate a new double bundle technique for anterior cruciate ligament (ACL) reconstruction with the use of hamstring tendons through a single tibial tunnel, a double femoral socket with implant-free femoral fixation and interference screw for tibial fixation. MATERIALS AND METHODS: Twenty-one patients were treated with the same technique. Hamstring tendons were not removed from the tibial side, and using a single tibial and a double femoral tunnel of 8 and 6 mm, respectively, anatomic ACL reconstruction was performed. Graft passage was performed from the tibial side to the posterolateral femoral tunnel and was looped back to the anteromedial femoral tunnel to be fixed on the tibial tunnel with an interference screw and additional extracortical fixation. Follow-up of the study group was performed for a two-year period, documenting standard clinical and radiographic parameters. RESULTS: Post-operative follow-up (mean 24 months) revealed radiological widening of tibial tunnel (mean 133.6%) in all patients and minor femoral tunnels widening (119.4% and 117.5%). Clinical evaluation showed no signs of instability, and knee evaluation using the IKDC score was performed. CONCLUSION: The manuscript describes a novel technique in ACL reconstruction, and reports the radiographic results of tunnel widening and clinical scores. Implant-free femoral fixation led to minor tunnel widening similar to previously published data. Further studies need to be performed to compare the long-term results with different published techniques of cost-effective implant-free ACL reconstruction.

Concomitant ipsilateral subcapital and intertrochanteric fractures of the femur: a case report.

INTRODUCTION: We report the case of an unusual combination of concomitant subcapital and intertrochanteric fractures of the hip in a patient after a motorcycle accident. To the best of our knowledge, there is no previous report in the literature of these conditions as a result of high energy trauma or of the treatment used. CASE PRESENTATION: A 36-year-old Caucasian man was admitted with this rare fracture combination, and was managed with closed fracture reduction and fixation with a dynamic hip screw combined with an anti-rotational cannulated screw. We found four similar cases on reviewing the literature from 1989 to 2009, but these were reports of older patients after low energy injury. CONCLUSION: We found that segmental fracture of the femoral neck region is an extremely rare and uncategorized hip injury that can occur not only in older people but also in young non-osteoporotic patients, and should be considered for inclusion in femoral fracture classification systems.

Computer-assisted three-dimensional correlation between the femoral neck-shaft angle and the optimal entry point for antegrade nailing.

Optimal entry point for antegrade femoral intramedullary nailing (IMN) remains controversial in the current medical literature. The definition of an ideal entry point for femoral IMN would implicate a tenseless introduction of the implant into the canal with anatomical alignment of the bone fragments. This study was undertaken in order to investigate possible existing relationships between the true 3D geometric parameters of the femur and the location of the optimum entry point. A sample population of 22 cadaveric femurs was used (mean age=51.09+/-14.82 years). Computed-tomography sections every 0.5mm for the entire length of femurs were produced. These sections were subsequently reconstructed to generate solid computer models of the external anatomy and medullary canal of each femur. Solid models of all femurs were subjected to a series of geometrical manipulations and computations using standard computer-aided-design tools. In the sagittal plane, the optimum entry point always lied a few millimeters behind the femoral neck axis (mean=3.5+/-1.5mm). In the coronal plane the optimum entry point lied at a location dependent on the femoral neck-shaft angle. Linear regression on the data showed that the optimal entry point is clearly correlated to the true 3D femoral neck-shaft angle (R(2)=0.7310) and the projected femoral neck-shaft angle (R(2)=0.6289). Anatomical parameters of the proximal femur, such as the varus-valgus angulation, are key factors in the determination of optimal entry point for nailing. The clinical relevance of the results is that in varus hips (neck-shaft angle

Can low doses of simvastatin enhance fracture healing? An experimental study in rabbits.

Several observational and experimental studies have investigated the potential anabolic effects of statins on undisturbed bone but only a few recent studies have examined the effect of statins on skeletal repair. The goal of the study is to investigate any potential early anabolic effect of the systemic administration of simvastatin in low doses (based on earlier safety and efficacy studies on undisturbed bone) on fracture healing. Fifty-four skeletally mature male New Zealand White rabbits were used for the study. The rabbits were assigned to one of three experimental groups: a control group, and two groups that were orally administrated a diet with 10 and 30 mg/kg/day of simvastatin, respectively. A complete biochemical blood count was performed to exclude drug-induced complications. Half of the animals of each group were sacrificed at 15 days and the other half at 30 days after surgery at which time intervals healing quality was assessed. The bones were subjected to biomechanical testing, histomorphometric analysis and peripheral quantitative computed tomography. In animals received simvastatin of 30 mg/kg/day a significant reduction of BMD, stiffness, and energy absorbed to failure were observed. At 15 days, the amount of cartilaginous callus formation was reduced, and the void space was significantly increased, in the animals of both groups that received simvastatin when compared to the control group (p<.05). Our results suggest that simvastatin doses of 30 mg/kg/day may have a negative anabolic effect on callus formation in rabbits, whereas doses of 10 mg/kg/day seem not to produce a significant positive or a negative effect, especially at the early stages of fracture remodeling.

The "fish-vertebra" sign.

The "fish-vertebra" sign appears as biconcave lumbar vertebrae with bone softening in lateral and posterior-anterior radiographs of the spine as an exaggeration of the normal concavity of the superior and inferior surfaces of one or more vertebral bodies. This is due to ischaemia of the central growth plate of the spine, and is typically seen in sickle cell disease.

Evaluation of the Stryker S2 IM Nail Distal Targeting Device for reduction of radiation exposure: a case series study.

Distal locking is one challenging step during intramedullary nailing of femoral shaft fractures that can lead to an increase of radiation exposure. In the present study, the authors describe a technique for the distal locking of femoral nails, implementing a new targeting device in an attempt to reduce radiation exposure and operational time. Over a 2-year period, 127 consecutive cases of femoral shaft fractures were included in the study. All cases were treated with nailing of femoral shaft fractures with an unslotted reamed antegrade femoral nail and distal locking was performed with the use of a proximally mounted aiming device. Mean duration of the procedure was 63.5 18.1 min while the duration for distal locking was 6.6 +/- 2.6 min. In all successful cases, exposure from intraoperative fluoroscopy was 17.2 +/- 7.4 s for the whole operative procedure, and for distal locking was 2 shots, 1.35 s (range, 0.9-2.2 s) and 1.9 mGy (range, 1.1-2.9 mGy). Five cases (3.9%) were unsuccessful, but overall no intraoperative complications were encountered from the application of this technique. The ability of the device to correspond to the level of nail deformation and to properly identify the distal holes, reduced exposure to radiation compared to other published reports, and should be considered as a valuable tool for distal locking of femoral fractures.

Distal locking of tibial nails : a new device to reduce radiation exposure.

UNLABELLED: The indications for intramedullary nailing have expanded to include most tibial shaft fractures. Nail design has improved since their first introduction, but distal locking remains a difficult part of the procedure, resulting in radiation exposure to the patient and the surgeon and increased operation time. To address these issues, we describe an alternative surgical technique using a newly designed distal targeting device that consists of a proximally mounted aiming arm, and we report the preliminary data from its use in all tibial shaft fractures amenable to surgery for a 2-year period. Sixty-three tibial shaft fractures were treated with this method. The mean duration of the distal locking was 6.5 minutes, and in all successful cases, radiation exposure for distal locking was two shots (one shot before targeting and another for the confirmation of proper screw insertion). Radiation exposure was on average 0.85 seconds (range, 0.4-1.2 seconds) and 1.4 mGy (range, 0.8-1.9 mGy). There were no major intraoperative complications related to the technique. The method has certain advantages and can reduce radiation exposure and operation time. Nonetheless, familiarity with the instrumentation is a prerequisite for accurate distal locking. LEVEL OF EVIDENCE: Level IV Therapeutic study.