Outcomes of Medial Closing-Wedge Distal Femoral Osteotomy for Femoral- and Tibial-Based Valgus Deformity.

BACKGROUND: In carefully selected patients with an arthritic valgus knee, distal femoral osteotomy (DFO) can improve symptoms at medium- to long-term follow-up, reducing osteoarthritis progression. To date, there is no clear evidence in the current literature regarding the role of postoperative joint line obliquity (JLO) in valgus deformity correction. PURPOSE: To assess the clinical and radiological outcomes of medial closing-wedge DFO (MCW-DFO) for the treatment of valgus knees, considering both tibial- and femoral-based deformities, as well as to verify the efficacy and safety of MCW-DFO according to JLO boundaries (≤4°). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective analysis was conducted on a cohort of patients with valgus knees. Patients were divided into 2 groups: femoral-based valgus (FB-V) and tibial-based valgus (TB-V). Knee radiographs were collected before surgery and at the last follow-up. The clinical outcome was evaluated through several validated scores (International Knee Documentation Committee, Knee Society Score, Knee injury and Osteoarthritis Outcome Score, Tegner, Numeric Rating Scale, Crosby-Insall). RESULTS: A total of 30 patients (34 knees) with a mean age of 49.3 ± 9.1 years were included in the study. The overall mean follow-up was 9.4 ± 5.9 years. The mean preoperative hip-knee-ankle angle was 187.6°± 3.3° (range, 181.5°-191°) and the postoperative angle was 180°± 3.1° (range, 176°-185°). Most postoperative JLOs were within the safe zone of ≤4° in both groups (the postoperative JLO was >4° in 4 patients in the TB-V group and 1 patient in the FB-V group), although FB-V knees exhibited significant superior JLO correction (postoperative JLO in the TB-V group: mean, 4.0°± 2.5° [P = .1]; postoperative JLO in the FB-V group: mean, 2.4°± 1.4° [P = .5]). Significant improvements in all clinical scores were observed in both groups (P < .01). Additionally, the severity of the osteoarthritis did not worsen at the last follow-up. CONCLUSION: MCW-DFO is an effective procedure for treating pathological valgus knees, regardless of the site of the deformity. Both FB-V and TB-V groups showed comparable improvements in the clinical scores, development of osteoarthritis, and the restoration of a neutral mechanical axis. Notably, FB-V knees achieved more JLO correction compared with the TB-V ones.

Cell-free osteochondral scaffolds provide a substantial clinical benefit in the treatment of osteochondral defects at a minimum follow-up of 5 years.

PURPOSE: The treatment of osteochondral lesions is challenging and no consensus has been established about the best option for restoring both cartilage and subchondral bone. Multilayer collagen-hydroxyapatite scaffolds have shown promising clinical results, but the outcome at a follow-up longer than 5 years still has to be proved. The aim was to evaluate the clinical outcome of patients with a knee isolated osteochondral lesion treated with a biomimetic three-layered scaffold at a minimum 5 years of follow-up. METHODS: Twenty-nine patients (23 males and 6 females, mean age 31.5 ± 11.4 years) were evaluated retrospectively before surgery, at 1 and 2 years and at last follow-up (FU). Visual Analog Scale (VAS) for pain, International Knee Documentation Committee (IKDC) Subjective Score, Tegner-Lysholm Knee Scoring Scale and Tegner Activity Level Scale were collected. Mean FU was 7.8 ± 2.0 years (min 5.1 - max 11.3). The etiology of the defect was Osteochondritis Dissecans or osteonecrosis (17 vs 12 cases). RESULTS: At 12 months FU the IKDC score improved from 51.1 ± 21.7 to 80.1 ± 17.9 (p < 0.01), Tegner Lysholm Score from 59.9 ± 17.3 to 92.5 ± 9.0 (p < 0.01), VAS from 6.1 ± 2.1 to 1.7 ± 2.3 (p < 0.01) and Tegner Activity Level Scale from 1.6 ± 0.5 to 4.9 ± 1.7 (p < 0.01). The results remained stable at 24 months, while at last FU a statistically significant decrease in IKDC, Tegner Lysholm and Tegner Activity Scale was recorded, though not clinically relevant. Patients under 35 achieved statistically better outcomes. CONCLUSIONS: The use of a cell-free collagen-hydroxyapatite osteochondral scaffold provides substantial clinical benefits in the treatment of knee osteochondral lesions at a minimum follow-up of 5 years, especially in patients younger than 35 years. LEVEL OF EVIDENCE: Level IV.

Suture Anchors Fixation in MPFL Reconstruction using a Bioactive Synthetic Ligament.

Medial patellofemoral ligament (MPFL) reconstruction has a key role in patellofemoral instability surgery. Many surgical techniques have been described so far using different types of grafts (autologous, heterologous, or synthetic) and fixation techniques. The hereby described technique for MPFL reconstruction relies on the use of a biosynthetic graft (LARS Arc Sur Tille, France). Fixation is obtained by means of suture anchors on the patellar side and a resorbable interference screw on the femoral side locating the insertion point according to Schottle et al. An early passive range of motion (ROM) recovery is fundamental to reduce the risk of postoperative stiffness; a partial weight bearing with crutches is allowed until 6 weeks after the surgery. In our experience, the use of a biosynthetic graft and suture anchors provides stable fixation, minimizing donor site morbidity and reducing the risk of patellar fracture associated with transosseous tunnels. This technique represents a reliable and reproducible alternative for MPFL reconstruction, thereby minimizing the risk of possible complications.

Revision Surgery in Permanent Patellar Dislocation in DiGeorge Syndrome.

A 29-year-old patient, suffering from DiGeorge syndrome, came to our attention with a history of persistent pain and patellar instability in the left knee after failure of arthroscopic lateral release and Elmslie-Trillat procedure. The patient was unable to walk without crutches and severely limited in daily living activities. Because of arthritic changes of the patellofemoral joint and the failure of previous surgeries it was decided to perform only an open lateral release and medial patellofemoral ligament (MPFL) reconstruction using a biosynthetic ligament in order to obtain patellofemoral stability. At one year post-op range of motion (ROM) was 0-120 with a firm end point at medial patellar mobilization; patella was stable throughout the entire ROM. All the scores improved and she could be able to perform daily activity without sensation of instability. Bilateral patellar subluxation and systemic hyperlaxity are characteristics of syndromic patients and according to literature can be also present in DiGeorge syndrome. MPFL reconstruction with lateral release was demonstrated to be the correct solution in the treatment of patellar instability in this complex case. The choice of an artificial ligament to reconstruct the MPFL was useful in this specific patient with important tissue laxity due to her congenital syndrome.

Medial patellofemoral ligament reconstruction with bioactive synthetic ligament is an option. A 3-year follow-up study.

PURPOSE: The purpose of this study was to evaluate mid-term follow-up results of medial patellofemoral ligament (MPFL) reconstruction using a bioactive synthetic ligament in the treatment of objective patellofemoral (PF) instability. METHODS: Sixteen patients (18 knees) presenting with objective PF instability underwent a MPFL reconstruction, isolated or associated with other surgical procedures for PF stabilization. All patients were clinically evaluated at a minimum follow-up of 3 years. Kujala, subjective IKDC and KOOS scores were used to assess clinical outcome. Pre-operative and post-operative pain was quantified with VAS scale and the overall satisfaction graded according to Insall and Crosby. Although none of the patients in this series were involved in high-level sports activity because of patellofemoral instability, activity level pre-operatively and at follow-up were evaluated according to Tegner scale. RESULTS: No recurrence of dislocation was observed in this series. The overall satisfaction rate was 88.8%. Kujala score improved significantly from 57±8.4 to 84.3±10.2 points (p<.01). Both subjective IKDC (42.4±7.13 to 70.1±3.9) and KOOS (62.7±4.34 to 82.8±8.8) significantly improved from pre-operative evaluation (p<.01). VAS decreased from a mean pre-operative value of 2.5±1.6 to 1.4±1.5 at 3 years follow-up. Only one patient required revision debridement surgery for persistent medial epicondylar pain. CONCLUSIONS: Isolated or associated MPFL reconstruction with bioactive synthetic ligament is a valid option in surgical treatment of objective PF instability, with results at mid-term follow-up comparable to autologous graft, thus minimizing donor-site morbidity and associated complications. LEVEL OF EVIDENCE: IV.

Congenital absence of the cruciate ligaments.

Congenital absence of the cruciate ligaments is a rare condition with a prevalence of 0.017 per 1,000 live births. The most important finding of this study was the presence of a posterior menisco-femoral ligament of Wrisberg with cruciate ligaments agenesia and the hypothesis advanced about the development of the ligamentous structures of the knee. Reviewing the literature, we assume that the congenital anomaly that causes the anatomical defect expresses itself around the 7th to 8th post-ovulatory week. Literature teaches us that the need for a knee replacement seems to be inevitable before or after and during the life of a patient without cruciate ligaments.