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PURPOSE: To characterize and compare the quality of regenerative cartilage tissue (ReCT) after conventional minced cartilage (CMC) and arthroscopic minced cartilage (AMC), in terms of cell viability, gene expression, and matrix synthesis and to investigate the influence of different shaver types. METHODS: Chondral tissue was harvested from the knees of 8 porcine donors. Porcine specimens were euthanized one day before harvest. AMC was created with 2 shaver blades in 2 operating modes (oscillating vs forward) and compared with a scalpel-fragmented CMC control. Before histologic analysis, 50% of the tissue was digested to prevent dedifferentiation of chondrocytes to fibroblasts. Cells were cultured and analyzed for cell viability, gene expression of cartilage-specific markers (aggrecan [ACAN], collagen type II, alpha1 [COL2A1], collagen type I, alpha1 [COL1A1], fibronectin-1 [FN1]), and matrix synthesis (Alcian-blue). RESULTS: AMC tissue contained fewer viable chondrocytes (41%-54% vs 91%; P = .001-.048) compared with CMC. After culture, CMC showed greater expressions of ACAN (27 virtual copy numbers [VCN]/housekeeping gene) and COL2A1 (30 VCN) compared with AMC (ACAN 2-9 VCN, COL2A1 2-7 VCN, P = .001-.039). AMC presented greater expressions of COL1A1 (9-21 VCN) and FN1 (12-17 VCN) than CMC (1 and 6 VCN, P = .001-.050). The signal intensity of the cartilage matrix formed by CMC (86/mm2) was greater than by AMC (7-10 mm2, P = .001-.032). CONCLUSIONS: CMC contained high numbers of viable chondrocytes, resulting in high-quality, hyaline-like ReCT. In contrast, AMC showed impaired chondrocyte quantity and viability, showing greater expressions of fibroblast markers and a decreased formation of mature cartilage matrix in porcine samples. The high chondrogenic potential of CMC to form hyaline-like ReCT was not confirmed for AMC. CLINICAL RELEVANCE: On the basis of our findings, arthroscopic harvest of minced cartilage leads to reduced chondrocyte viability and ReCT quality. Accordingly, CMC and AMC cannot be regarded as synonymous techniques, as arthroscopic techniques seem to be less efficacious.
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PURPOSE: This study compared mid-term outcomes of two anterior cruciate ligament (ACL) restoration techniques within an early total surgical care of acute knee dislocation: repair with additional internal bracing (ACLIB) and reconstruction with autograft (ACLR). Initial results at 12 months demonstrated that ACLR offered superior stability compared to ACLIB. METHODS: Retrospective clinical study of patients with acute type III or IV KD. ACLIB or ACLR procedures were performed accompanied by simultaneous suture and internal bracing of the posterior cruciate ligament (PCL) and repair with lateral augmentation of the medial and lateral complex injuries utilizing Arciero's reconstruction technique. Patient-reported outcome measurements (PROMs), instrumental stability assessment via the Rolimeter-Test, and stress radiographs were analyzed. RESULTS: The study involved 20 patients (5 IIIM, 5 IIIL, and 10 IV injuries) with an average follow-up of 35.2 ± 7.4 months. Notable differences in anterior tibial translation on stress radiography favouring ACLR persisted at 24-month follow-up in side-to-side difference (SSD) (ACLIB 2.8 ± 2.5 mm vs. ACLR 0.3 ± 2.6 mm; p = 0.0487), but Rolimeter test variance diminished (SSD ACLIB 2.5 ± 0.9 mm vs. ACLR 1.8 ± 1.7 mm). Both groups showed excellent PROMs (Lysholm Score: ACLIB 84.4 ± 15.8 vs. ACLR 89.9 ± 9.0; IKDC Score: ACLIB 77.1 ± 16.2 vs. ACLR 77.7 ± 8.6). CONCLUSION: Our results indicate improved anterior stability at 12 months, which persisted at 24 months after ACL reconstruction compared with ACL repair by stress radiography. Both groups showed favourable patient-reported outcomes throughout the follow-up period. Notable rates of postoperative knee stiffness were observed in both groups. These were successfully managed with early, one-time arthroscopic arthrolysis within the first seven months of treatment, resulting in no major range of motion limitations at the 24-month follow-up. LEVEL OF EVIDENCE: Retrospective cohort study, III.
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PURPOSE: To provide normal values for physiological patellofemoral tracking in a representative group of healthy individuals, as well as sex differences, using real-time 3T-magnetic resonance imaging (MRI) and to test for the reliability of the presented technique. METHODS: One hundred knees of healthy individuals with no history of patellofemoral symptoms were scanned with dynamic MRI sequences, during repetitive cycles of flexion (40°) and full extension. Within a 30-seconds time-frame, three simultaneous, transverse slices were acquired. Dynamic mediolateral patellar translation (dMPT) and dynamic patellar tilt (dPT) were measured on two occasions by two independent examiners. Common radiological parameters were measured using static MRI, and correlations were calculated. RESULTS: 100 knees (53 right, 47 left; age: 26.7 ± 4.4 years; BMI: 22.5 ± 3.1) of 57 individuals (27 females, 30 males) were included. Mean height was 170.1 ± 7.7 cm in women and 181.8 ± 6.4 cm in men. Average patella diameter was 37.9 ± 2.7 (95% CI 37.1-38.7) mm in women and 42.4 ± 3.2 (95% CI 41.5-43.3) mm in men. In females, the patellar diameters and intercondylar distances were significantly smaller than in males (P < .001). Radiological parameters for patellar maltracking were within the normal range. During the range of motion, mean dMPT was 1.7 ± 2.4 (95% CI .9-2.5) mm in females and 1.8 ± 2.7 (95% CI 1.1-2.6) mm in males (P = .766). Mean dPT was 1.3 ± 2.9° (95% CI .4-2.1°) in females and -0.2 ± 3.8° (95% CI -1.2-.9°) in males (P = .036). Neither dMPT nor dPT was correlated with height, BMI, or patellar diameter. Intercondylar distance correlated weakly with dPT (r = -.241; P = .041). Intra- and interrater reliability were excellent for dMPT and dPT. CONCLUSION: Dynamic mediolateral patellar translation is a size- and sex-independent parameter for proximal patellar tracking. In healthy individuals without patellofemoral abnormalities normal dMPT proximal to the trochlea groove was 1.7 ± 2.5 (1.2-2.2) mm, independent of size or sex. Normal dPT showed a dependency on sex and was 1.3 ± 2.9 (.4-2.1)° in women and -0.2 ± 3.8 (-1.2-0.9)° in men. LEVEL OF EVIDENCE: Level II, diagnostic study.
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Rótula , Articulación Patelofemoral , Adulto , Fenómenos Biomecánicos , Estudios de Casos y Controles , Femenino , Humanos , Imagen por Resonancia Magnética/métodos , Masculino , Rótula/diagnóstico por imagen , Rótula/patología , Articulación Patelofemoral/diagnóstico por imagen , Articulación Patelofemoral/patología , Reproducibilidad de los Resultados , Adulto JovenRESUMEN
PURPOSE: Trochlear dysplasia is a significant risk factor for patellofemoral instability. The severity of trochlear dysplasia is commonly evaluated based on the Dejour classification in axial MRI slices. However, this often leads to heterogeneous assessments. A software to generate MRI-based 3D models of the knee was developed to ensure more standardized visualization of knee structures. The purpose of this study was to assess the intra- and interobserver agreements of 2D axial MRI slices and an MRI-based 3D software generated model in classification of trochlear dysplasia as described by Dejour. METHODS: Four investigators independently assessed 38 axial MRI scans for trochlear dysplasia. Analysis was made according to Dejour's 4 grade classification as well as differentiating between 2 grades: low-grade (types A + B) and high-grade trochlear dysplasia (types C + D). Assessments were repeated following a one-week interval. The inter- and intraobserver agreement was determined using Cohen's kappa (κ) and Fleiss kappa statistic (κ). In addition, the proportion of observed agreement (po) was calculated for assessment of intraobserver agreement. RESULTS: The assessment of the intraobserver reliability with regard to the Dejour-classification showed moderate agreement values both in the 2D (κ = 0.59 ± 0.08 SD) and in the 3D analysis (κ = 0.57 ± 0.08 SD). Considering the 2-grade classification, the 2D (κ = 0.62 ± 0.12 SD) and 3D analysis (κ = 0.61 ± 0.19 SD) each showed good intraobserver matches. The analysis of the interobserver reliability also showed moderate agreement values with differences in the subgroups (2D vs. 3D). The 2D evaluation showed correspondences of κ = 0.48 (Dejour) and κ = 0.46 (high / low). In the assessment based on the 3D models, correspondence values of κ = 0.53 (Dejour) and κ = 0.59 (high / low) were documented. CONCLUSION: Overall, moderate-to-good agreement values were found in all groups. The analysis of the intraobserver reliability showed no relevant differences between 2 and 3D representation, but better agreement values were found in the 2-degree classification. In the analysis of interobserver reliability, better agreement values were found in the 3D compared to the 2D representation. The clinical relevance of this study lies in the superiority of the 3D representation in the assessment of trochlear dysplasia, which is relevant for future analytical procedures as well as surgical planning. LEVEL OF EVIDENCE: Level II.
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Inestabilidad de la Articulación , Humanos , Inestabilidad de la Articulación/cirugía , Articulación de la Rodilla , Imagen por Resonancia Magnética , Reproducibilidad de los Resultados , Programas InformáticosRESUMEN
PURPOSE: The purpose of this study was to evaluate the clinical outcomes of patients who were treated with an arthroscopic popliteus bypass (PB) technique, in cases of a posterolateral rotational instability (PLRI) and a concomitant posterior cruciate ligament (PCL) injury of the knee. METHODS: This was a retrospective case series in which 23 patients were clinically evaluated after a minimum of 2 years following arthroscopic PB and combined PCL reconstruction. Lysholm, Tegner and Knee Injury and Osteoarthritis Outcome scores as well as visual analog scales (VAS) for joint function and pain were evaluated. Posterior laxity was objectified with stress radiography and a Rolimeter examination. Rotational instability was graded with the dial test. RESULTS: 23 patients were available for follow-up, 46.0 ± 13.6 months after surgery. The median time interval from the initial injury to the surgery was 6.0 (3.5;10.5) months. The postoperative Lysholm Score was 95.0 (49-100); the Tegner Score changed from 6.0 (3-10) before the injury to 5.0 (0-10) at the follow-up examination (p = 0.013). The side-to-side difference on stress radiography (SSD) of posterior translation changed from 10.4 (6.6-14.8) mm before the injury to 4.0 (0.2-5.7) mm postoperatively (p < 0.01). Rotational instability was reduced to grade A (82.6%) or B (17.4%) (IKDC). The Rolimeter SSD was 2.0 (0-3) mm at the follow-up examination. VAS Function 0 (0-5), VAS pain 0 (0-6). CONCLUSIONS: The arthroscopic PB graft technique provided good-to-excellent clinical results in the mid-term follow-up in patients with type A PLRI and concomitant PCL injury. However, an exact differentiation of lateral, rotational and dorsal instabilities of posterolateral corner (PLC) injuries is crucial, for the correct choice of therapy, as cases with lateral instabilities require more complex reconstruction techniques. Arthroscopic posterolateral corner reconstruction is a safe procedure with a high success rate in the mid-term follow-up. LEVEL OF EVIDENCE: IV.
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Inestabilidad de la Articulación , Reconstrucción del Ligamento Cruzado Posterior , Ligamento Cruzado Posterior , Artroscopía/métodos , Estudios de Seguimiento , Humanos , Inestabilidad de la Articulación/diagnóstico , Inestabilidad de la Articulación/cirugía , Articulación de la Rodilla/cirugía , Dolor/cirugía , Ligamento Cruzado Posterior/lesiones , Ligamento Cruzado Posterior/cirugía , Reconstrucción del Ligamento Cruzado Posterior/métodos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Despite the growing number of studies reporting on the best surgical treatment in the management of periprosthetic joint infection, there are no robust data regarding the type of infected prosthesis before any kind of exchange arthroplasty. To overcome these shortcomings, we asked the following questions: (1) What is the survivorship of nonhinged and hinged knee implants after one-stage exchange arthroplasty and (2) what is the functional outcome after one-stage exchange procedure focusing on knee prostheses and the type of prior infected knee implant. In a secondary radiographic analysis, we also investigated if (3) the type of femoral bone morphology measured by the inner femoral diameter influences the rate of aseptic failures also in patients with periprosthetic joint infection. METHODS: Between January 2011 and December 2017, we performed a retrospective designed study including 211 patients with infected knee prostheses. After all, seventy-six percent (161 of 211 patients) were available for final data analysis. These patients were divided into four groups as per the performed implant revision: (1) bicondylar total knee arthroplasty to rotating hinge implant, (2) rotating hinge to rotating hinge implant, (3) rotating hinge to full hinge implant, and (4) full hinge to full hinge implant. The mean follow-up (FU) was six years (range 3 to 9; standard deviation = 1.9), whereas a minimum FU of three years was required for inclusion. Survivorship and group analysis were performed, and the functional outcome was assessed using postoperative Oxford Knee Scores at the latest FU (60-point scale with lower scores representing less pain and greater function). Furthermore, in all cases, femoral bone morphology was determined as per the Citak classification system. RESULTS: At the final FU, the overall surgical revision rate was 23% (37/161 patients) with nine percent (15/161 patients) suffering a periprosthetic joint infection relapse. Group 1 consisted of 51, group 2 consisted of 67, group 3 consisted of 24, and group 4 consisted of 19 patients. The lowest overall revision rate was found in group 2 (16%, n = 11), compared with 28% (n = 14) in group 1, 29% (n = 7) in group 3, and 26% (n = 5) in group 4; however, no significant differences were found (P = .902). The functional outcome (Oxford Knee Score) was clinically constant in all groups, with 32 points in group 1, 37 points in group 2, 33 points in group 3, and 35 points in group 4 (P = .107). Concerning the number of patients with aseptic loosening as per bone morphology, 74% (14/19) of all aseptic loosening cases appeared in femoral bone type C morphologies according to Citak (75% in group 1, 56% in group 2, 100% in group 3, and 100% in group 4). CONCLUSIONS: The results obtained suggest a generally high overall revision rate (25%) with a good infection control rate (91%). Although we were unable to work out a specific group of patients with a statistically significant differing outcome, it is interesting to see that hinged implants can reach more or less the same functional outcome and revision rates as nonhinged implants, when it comes to revision surgeries. In this study, a relatively high number of aseptic failures contributed to a high overall revision rate. In this context, the bone morphology, measured as per the Citak classification system, could be confirmed as a risk factor for aseptic failures also in septic patients. Therefore, further research might focus on revision knee implant design.
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Artroplastia de Reemplazo de Rodilla , Prótesis de la Rodilla , Artroplastia de Reemplazo de Rodilla/efectos adversos , Humanos , Articulación de la Rodilla/diagnóstico por imagen , Articulación de la Rodilla/cirugía , Prótesis de la Rodilla/efectos adversos , Diseño de Prótesis , Falla de Prótesis , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Although open-surgical techniques for the reconstruction of the posterolateral corner (PLC) are well established, the use of arthroscopic procedures has recently increased. When compared with open surgical preparation, arthroscopic orientation in the PLC is challenging and anatomic relations may not be familiar. Nevertheless, a profound knowledge of anatomic key structures and possible structures at risk as well as technical variations of arthroscopic approaches are mandatory to allow a precise and safe surgical intervention. MATERIALS AND METHODS: In a cadaveric video demonstration, an anterolateral (AL), anteromedial (AM), posteromedial (PM) and posterolateral (PL) portal, as well as a transseptal approach (TSA) were developed. Key structures of the PLC were defined and sequentially exposed during posterolateral arthroscopy. Finally, anatomic relations of all key structures were demonstrated. RESULTS: All key structures of the PLC can be visualized during arthroscopy. Thereby, careful portal placement is crucial in order to allow an effective exposure. Two alternatives of the TSA were described, depending on the region of interest. The peroneal nerve can be visualized dorsal to the biceps femoris tendon (BT), lateral to the soleus muscle (SM) and about 3 cm distal to the fibular styloid (FS). The distal attachment of the fibular collateral ligament (FCL) can be exposed on the lateral side of the fibular head (FH). The fibular attachment of the popliteofibular ligament (PFL) is exposed at the tip of the FS. CONCLUSION: Arthroscopy of the posterolateral recessus allows full visualization of all key structures of the posterolateral corner, which provides the basis for anatomic and safe drill channel placement in PLC reconstruction. A sufficient exposure of relevant anatomic landmarks and precise portal preparation reduce the risk of iatrogenic vascular and peroneal nerve injury.
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Tendones Isquiotibiales , Articulación de la Rodilla , Artroscopía , Peroné , Humanos , Articulación de la Rodilla/cirugía , Ligamentos ArticularesRESUMEN
BACKGROUND: Despite the growing number of studies reporting on periprosthetic joint infection (PJI), there is little information on one-stage exchange arthroplasty for the revision of infected rotating-hinge prostheses, which can be among the most difficult PJI presentations to treat. QUESTIONS/PURPOSES: After one-stage direct exchange revision for an infected rotating-hinge TKA prosthesis, and using a multimodal approach for infection control, we asked: (1) What is the survivorship free from repeat revision for infection and survivorship free from reoperation for any cause? (2) What is the clinical outcome, based on the Oxford Knee Score, of these patients at the latest follow-up? METHODS: Between January 2011 and December 2017, we treated 101 patients with infected rotating-hinge knee prostheses at our hospital. All patients who underwent a one-stage exchange using another rotating-hinge implant were potentially eligible for this retrospective study. During that period, we generally used a one-stage approach when treating PJIs. Eighty-three percent (84 of 101) of patients were treated with one-stage exchange, and the remainder were treated with two-stage exchange. Of the 84 treated with one-stage exchange, eight patients died of unrelated causes and were therefore excluded, one patient declined to participate in the study, and another eight patients were lost before the minimum study follow-up of 2 years or had incomplete datasets, leaving 80% (67 of 84) for analysis in this study. The included study population consisted of 60% males (40 of 67) with a mean age of 64 ± 8 years and a mean (range) BMI of 30 ± 6 kg/m2 (21 to 40). The mean number of prior surgeries was 4 ± 2 (1 to 9) on the affected knee. Fifteen percent (10 of 67) of knees had a preoperative joint communicating sinus tract, and 66% (44 of 67) had experienced a prior PJI on the affected knee. The antimicrobial regimen was chosen based on the advice of our infectious disease consultant and individually adapted for the organism cultured. The mean follow-up duration was 6 ± 2 years. Kaplan-Meier survivorship analysis was performed using the endpoints of survivorship free from repeat revision for infection and survivorship free from all-cause revision. The functional outcome was assessed using the Oxford Knee Score (on a 12- to 60-point scale, with lower scores representing less pain and greater function), obtained by interviewing patients for this study at their most recent follow-up visit. Preoperative scores were not obtained. RESULTS: The Kaplan-Meier analysis demonstrated an overall survivorship free from reoperation for any cause of 75% (95% CI 64% to 87%) at the mean follow-up of 6 years postoperatively. Survivorship free from any repeat operative procedure for infection was 90% (95% CI 83% to 97%) at 6 years. The mean postoperative Oxford Knee Score was 37 ± 11 points. CONCLUSION: With an overall revision rate of about 25% at 6 years and the limited functional results based on the poor Oxford Knee Scores, patients should be counseled to have modest expectations concerning postoperative pain and function level after one-stage exchange of an infected rotating-hinge arthroplasty. Nevertheless, patients may be informed about a reasonable chance of PJI eradication and might opt for this approach as a means to try to avoid high transfemoral amputation or joint arthrodesis, which in this population often is associated with the inability to ambulate at all. Regarding the relatively high number of patients with aseptic loosening, future studies might focus on implant design of revision knee systems as well. A longer course of oral antibiotics after such procedures may also be warranted to limit the chance of reinfection but requires further study. LEVEL OF EVIDENCE: Level IV, therapeutic study.
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Artritis Infecciosa/cirugía , Artroplastia de Reemplazo de Rodilla/efectos adversos , Prótesis de la Rodilla/efectos adversos , Infecciones Relacionadas con Prótesis/cirugía , Reoperación/estadística & datos numéricos , Anciano , Artritis Infecciosa/etiología , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Reoperación/métodos , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
PURPOSE: This study aimed to compare the biomechanical properties of the popliteus bypass against the Larson technique for the reconstruction of a combined posterolateral corner and posterior cruciate ligament injury. METHODS: In 18 human cadaver knees, the kinematics for 134 N posterior loads, 10 Nm varus loads, and 5 Nm external rotational loads in 0°, 20°, 30°, 60,° and 90° of knee flexion were measured using a robotic and optical tracking system. The (1) posterior cruciate ligament, (2) meniscofibular/-tibial fibers, (3) popliteofibular ligament (PFL), (4) popliteotibial fascicle, (5) popliteus tendon, and (6) lateral collateral ligament were cut, and the measurements were repeated. The knees underwent posterior cruciate ligament reconstruction, and were randomized into two groups. Group PB (Popliteus Bypass; n = 9) underwent a lateral collateral ligament and popliteus bypass reconstruction and was compared to Group FS (Fibular Sling; n = 9) which underwent the Larson technique. RESULTS: Varus angulation, posterior translation, and external rotation increased after dissection (p < 0.01). The varus angulation was effectively reduced in both groups and did not significantly differ from the intact knee. No significant differences were found between the groups. Posterior translation was reduced by both techniques (p < 0.01), but none of the groups had restored stability to the intact state (p < 0.02), with the exception of group PB at 0°. No significant differences were found between the two groups. The two techniques revealed major differences in their abilities to reduce external rotational instability. Group PB had less external rotational instability compared to Group FS (p < 0.03). Only Group PB had restored rotational instability compared to the state of the intact knee (p < 0.04) at all degrees of flexion. CONCLUSION: The popliteus bypass for posterolateral reconstruction has superior biomechanical properties related to external rotational stability compared to the Larson technique. Therefore, the popliteus bypass may have a positive influence on the clinical outcome. This needs to be proven through clinical trials.
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Traumatismos de la Rodilla/cirugía , Procedimientos de Cirugía Plástica/métodos , Ligamento Cruzado Posterior/lesiones , Ligamento Cruzado Posterior/cirugía , Anciano , Anciano de 80 o más Años , Fenómenos Biomecánicos , Cadáver , Femenino , Peroné/cirugía , Humanos , Inestabilidad de la Articulación/cirugía , Articulación de la Rodilla/fisiopatología , Articulación de la Rodilla/cirugía , Ligamentos Articulares/cirugía , Masculino , Persona de Mediana Edad , Ligamento Cruzado Posterior/fisiopatología , Rango del Movimiento Articular , Robótica , Rotación , Tendones/cirugía , Tibia/cirugíaRESUMEN
PURPOSE: Valgus deformities of the lower extremity influence patellofemoral joint kinematics. However, studies examining the clinical outcome after treatment of patellar instability and maltracking due to valgus deformity are rare in recent literature. This study's purpose is to analyze the clinical results after combined distal femoral osteotomy (DFO) for treatment of patellar instability. METHODS: From 2010 to 2016, 406 cases of patellofemoral instability and maltracking were treated. Twenty cases of recurring (≥ 2) patellar dislocations with genu valgum and unsuccessful conservative treatment were included in the study. A radiological analysis was performed, and anteroposterior (AP), lateral and long leg standing radiographs were analyzed, and the leg axis was pre- and postoperatively measured. At least 12 months postoperatively, the clinical leg axis, range of motion (ROM), apprehension sign, Zohlen sign, and J-sign were physically examined. Pain level and knee function were objectified on a visual analogue scale (VAS). The Lysholm, Kujala, and Tegner scores, re-dislocation rate, and patient satisfaction were also examined. RESULTS: 20 combined DFOs on 18 patients with a median age of 23 years (15-55 years) were performed. The preoperative mechanical leg axis was 6.5° ± 2.0° valgus, and the mean tibial tuberosity to trochlear groove (TT-TG) distance was 19.1 ± 4.8 mm. All patients reported multiple dislocations. Intraoperatively, 71% presented III°-IV° cartilage lesions, located retropatellarly in 87% and correlating negatively with the postoperative Lysholm score (r = - 0.462, p = 0.040). The leg axis was corrected by 7.1° ± 2.6°, and in 17 cases, the tibial tubercle was additionally medialized by 10 ± 3.1 mm. All patellae were re-stabilized with medial patellofemoral ligament reconstruction. After a median period of 16 (12-64) months, the pain level decreased from 8.0 ± 1.4 to 2.3 ± 2.1 (VAS p ≤ 0.001) and knee function improved from 40.1 ± 17.9 to 78.5 ± 16.6 (Kujala p ≤ 0.001), 36.1 ± 19.5 to 81.6 ± 11.7 (Lysholm p ≤ 0.001), and 2.0 (1-5) to 4.0 (3-6) (median Tegner p ≤ 0.001). No re-dislocation was observed. CONCLUSION: Combined DFO is a suitable treatment for patellar instability and maltracking due to genu valgum, as it leads to very low re-dislocation rates, a significant reduction of pain, and a significant increase of knee function with good-to-excellent results in the short-term follow-up. However, a high prevalence of substantial cartilage lesions is observed, causing postoperative limitations of knee function. LEVEL OF EVIDENCE: IV, retrospective cohort study.
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Fémur/cirugía , Genu Valgum/cirugía , Inestabilidad de la Articulación/cirugía , Osteotomía , Articulación Patelofemoral/fisiopatología , Adolescente , Adulto , Estudios de Cohortes , Femenino , Genu Valgum/fisiopatología , Humanos , Inestabilidad de la Articulación/fisiopatología , Ligamentos Articulares/cirugía , Masculino , Persona de Mediana Edad , Evaluación del Resultado de la Atención al Paciente , Estudios Retrospectivos , Escala Visual Analógica , Adulto JovenRESUMEN
PURPOSE: Postoperative knee stiffness is a common issue in multiligament knee injuries (MLKIs). This study aims to compare outcomes between MLKI patients who underwent postoperative arthroscopic lysis of arthrofibrosis (LOA) for limited range of motion (ROM) and those who did not. METHODS: Thirty-one patients (10 IIIM, nine IIIL and 12 IV) were included in this retrospective clinical study with acute type III or IV knee dislocations, while two patients were lost to follow up. Thirteen patients underwent LOA at a mean of 18.7 ± 8.4 weeks (Group A), while 18 did not require this intervention (Group B). Patient-reported outcome measures (IKDC, Lysholm, VAS) and ROM were evaluated. RESULTS: The average follow up period was 31.0 ± 10.2 months. The mean time to LOA was 19.4 ± 7.6 weeks and a significant increase in ROM was observed after LOA (flexion: before LOA: 83.8° ± 19.2, after LOA: 119.6° ± 9.9; P < 0.0001). There were no significant differences between groups regarding clinical scores (Lysholm: Group A 85.0 ± 13.4, Group B 84.6 ± 14.5; IKDC: Group A 74.3 ± 10.8, Group B 76.7 ± 14.7) and ROM (flexion: Group A 118.6° ± 9.8, Group B 124.3° ± 12.8). There were no complications regarding LOA. CONCLUSIONS: Patients, whether undergoing LOA or not, performed equally well in terms of ROM and clinical scores at final follow up, while timing of LOA appears less critical. LOA is a simple, durable and safe method of treating ROM deficits in patients treated for acute knee dislocation, with very good results.
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Purpose: There is a high risk of increasing the posterior tibial slope (PTS) during medially opening-wedge high tibial osteotomy (mowHTO). Most recently, the idea of intentional simultaneous coronal and sagittal correction, using uniplanar cutting techniques has emerged. This study aims to examine the influences of variable hinge positioning and osteotomy gap height on the sagittal and coronal plane. Methods: Twenty uniplanar mowHTOs were performed in standardised (left) solid-foam proximal tibia models. In the different models, hinge position was rotated stepwise by 10°, between 90° (cutting straight medial to lateral) and 0° (cutting straight anterior to posterior) (n = 10). Additionally, gap heights of 5 and 10 mm were produced and analysed. Logistic regression analysis was performed to calculate a predictive regression formula for the relation between gap height, hinge rotation and the changes of medial proximal tibia angle (MPTA), medial and lateral PTS. Results: Between cutting angles of 90 and 20°, the MPTA was mainly influenced by the gap height (0.95° MPTA per 1 mm gap height), but not by the cutting angle. Between 20 and 0°, the MPTA was decreased by 3.6° per 10° of rotation, but not by the gap height. Between cutting angles of 90 and 10°, the PTS was increased linearly by 0.97° per 10° of rotation and by 0.61° per 1 mm gap height. Conclusion: In mowHTO with lateral hinge positions, the MPTA is mainly influenced by gap height. Changes of PTS can be avoided by a straight lateral hinge position. In posterior hinge locations (0-20°), changes of MPTA are mainly caused by hinge rotation, but not by gap height. Level of Evidence: Level III, Case-control study.
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BACKGROUND: Knee dislocation (KD) is a rare but severe injury of the knee joint, with a high rate of concomitant neurovascular injuries. The severity of the ligamentous injury, which is classified according to the Schenck classification, the mechanism of injury, concomitant injuries and individual factors determine the treatment strategy in KD. TREATMENT STRATEGY: Furthermore, a clear differentiation between high-velocity (HV) and low-velocity (LV) injuries is necessary. Generally, surgical treatment within 7-10 days should be aspired. Herein, the one-stage hybrid treatment using augmented ligament sutures (ligament bracing) in combination with primary ligament reconstruction (posterolateral and ACL) leads to very good functional results in the mid-term. Ultra-low-velocity (ULV) dislocations and those with concomitant peroneal lesions require a modified approach, due to a limited prognosis. During rehabilitation, the individual progress must be closely monitored and follow an early functional approach. In approximately 20% of all cases, early arthroscopic arthrolysis shows a high success rate.
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Traumatismos en Atletas , Luxación de la Rodilla , Humanos , Traumatismos en Atletas/cirugía , Resultado del Tratamiento , Articulación de la Rodilla/cirugía , Luxación de la Rodilla/cirugía , Ligamento Cruzado Anterior/cirugíaRESUMEN
Varus malalignment combined with an increased posterior tibial slope (PTS) in the ACL deficient knee is a frequent pathology; yet, treatment for this condition remains challenging. The presented biplanar osteotomy technique allows to simultaneously address both components of malalignment in a single step. A detailed preoperative planning is best achieved by means of a digital planning software and constant intraoperative imaging is performed to verify the correction angle. A bony wedge is resected along with the extension osteotomy according to the preoperative planning and the medial-opening tibial osteotomy site is filled with bone allograft. Two bicortical lag screws are placed in anterior-posterior direction to secure the extension osteotomy, whereas a plate fixation is used for the medial-open osteotomy.
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Osteoartritis de la Rodilla , Humanos , Osteoartritis de la Rodilla/diagnóstico por imagen , Osteoartritis de la Rodilla/cirugía , Articulación de la Rodilla/cirugía , Tibia/diagnóstico por imagen , Tibia/cirugía , Osteotomía/métodos , Placas ÓseasRESUMEN
INTRODUCTION: Precise fibular tunnel placement in posterolateral corner (PLC) reconstruction is crucial in restoring rotational and lateral stability. Despite the recent progress of arthroscopic PLC reconstruction techniques, landmarks for arthroscopic fibular tunnel placement and a comparison to open tunnel placement have not yet been described. This study aimed to (1) identify reasonable soft-tissue and bony landmarks, which can be identified by either arthroscopy, fluoroscopy, or open surgery in anatomic fibular tunnel placement and (2) to compare accuracy and reliability of arthroscopic fibular tunnel placement with open surgery. MATERIALS AND METHODS: In a retrospective study, 41 magnetic resonance images (MRIs) of the knee were analyzed with emphasis on distances of an ideal anatomic fibular tunnel to 11 soft-tissue and bony landmarks. Subsequently, in eight cadaver knees, the ideal fibular tunnel was created arthroscopically and with a standard open technique from antero-latero-inferior to postero-medio-superior with a 2-mm K-wire. Positions of both tunnels were compared on postinterventional computed tomography scans. RESULTS: Based on MRI measurements, the anatomic tunnel entry should be 14.50 (±2.18) mm distal to the tip of the fibular styloid and 10.76 (±1.37) mm posterior to the anterior edge of the fibula. The anatomic fibular tunnel exit was located 12.89 (±2.35) mm below the tip of the fibular head. Arthroscopic fibular tunnel placement was reliable in all cases. Instead, in five out of the eight cases with open surgery, the fibular tunnel crossed the defined safety distance to the closest cortical edge/tibiofibular joint (distance < 8 mm). CONCLUSIONS: Reliable soft-tissue and bony landmarks of the fibular head allow arthroscopic anatomic fibular tunnel placement in PLC surgery, which shows a lower risk of tunnel malposition compared with open surgical techniques. Future studies will have to show whether clinical results of arthroscopic PLC reconstruction are in line with this study's technical results. LEVEL OF EVIDENCE: Level III.
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Peroné , Articulación de la Rodilla , Humanos , Peroné/cirugía , Estudios Retrospectivos , Reproducibilidad de los Resultados , Articulación de la Rodilla/cirugía , ArtroscopíaRESUMEN
Background: There is evidence on the clinical effectiveness of the Lemaire technique for lateral extra-articular tenodesis (LET) in patients undergoing revision anterior cruciate ligament reconstruction (ACLR), but the best fixation technique is unknown. Purpose: To compare the clinical outcomes of 2 fixation techniques after revision ACLR: (1) onlay anchor fixation, which would avoid tunnel conflict and physis injury, and (2) transosseous tightening and interference screw fixation. Pain at the area of LET fixation was also assessed. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective 2-center study of patients with first-time revision ACLR and either LET with anchor fixation (aLET) with a 2.4-mm suture anchor or LET with transosseous fixation (tLET). Outcomes at minimum 12-month follow-up were assessed with the International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, visual analog scale for pain at the LET fixation area, Tegner score, and anterior tibial translation (ATT). A subgroup analysis within the aLET group investigated passing the graft over or under the lateral collateral ligament (LCL). Results: In total, 52 patients were included (26 patients in each group); the mean ± SD follow-up was 13.7 ± 3.4 months. No statistically significant differences were detected between the groups with respect to patient-reported outcome scores, clinical examination, or instrumented testing (side-to-side difference in ATT at 30° of flexion; aLET, 1.5 ± 2.5 mm; tLET, 1.6 ± 1.7 mm). Clinical failure was detected in 1 patient with aLET and none with tLET. Subgroup analysis revealed a small, nonsignificant flexion deficit in knees in which the iliotibial band strand was passed under (n = 42) or over (n = 10) the LCL. No clinically relevant tenderness was detected at the area of LET fixation in any group (aLET, 0.6 ± 1.3; tLET, 0.9 ± 1.7; over the LCL, 0.2 ± 0.6; under the LCL, 0.9 ± 1.6). Conclusion: Onlay anchor fixation and transosseous fixation of the LET were equivalent with respect to outcome scores and instrumented ATT testing. Clinically, there were minor differences in passage of the LET graft over or under the LCL.
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(1) The malposition of the femoral tunnel in medial patellofemoral ligament (MPFL) reconstruction can lead to length changes in the MPFL graft, and an increase in medial peak pressure in the patellofemoral joint. It is the cause of 36% of all MPFL revisions. According to Schöttle et al., the creation of the drill canal should be performed in a strictly lateral radiograph. In this study, it was hypothesized that positioning the image receptor to the knee during intraoperative fluoroscopy would lead to a relevant mispositioning of the femoral tunnel, despite an always adjusted true-lateral view. (2) A total of 10 distal femurs were created from 10 knee CT scans using a 3D printer. First, true-lateral fluoroscopies were taken from lateral to medial at a 25 cm (LM25) distance from the image receptor, then from medial to lateral at a 5 cm (ML5) distance. Using the method from Schöttle, the femoral origin of the MPFL was determined when the femur was positioned distally, proximally, superiorly, and inferiorly to the image receptor. (3) The comparison of the selected MPFL insertion points according to Schöttle et al. revealed that the initial determination of the point in the ML5 view resulted in a distal and posterior shift of the point by 5.3 mm ± 1.2 mm when the point was checked in the LM25 view. In the opposite case, when the MPFL insertion was initially determined in the LM25 view and then redetermined in the ML5 view, there was a shift of 4.8 mm ± 2.2 mm anteriorly and proximally. The further positioning of the femur (distal, proximal, superior, and inferior) showed no relevant influence. (4) For fluoroscopic identification of the femoral MPFL, according to Schöttle et al., attention should be paid to the position of the fluoroscopy in addition to a true-lateral view.
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(1) Background: In treating medial unicompartmental gonarthrosis, medial open wedge high tibial osteotomy (mOWHTO) reduces pain and is intended to delay a possible indication for joint replacement by relieving the affected compartment. This study aimed to investigate the influence of the osteotomy height with different hinge points in HTO in genu varum on the leg axis. (2) Methods: Fifty-five patients with varus lower leg alignment obtained full-weight bearing long-leg radiographs were analyzed. Different simulations were performed: Osteotomy height was selected at 3 and 4 cm distal to the tibial articular surface, and the hinge points were selected at 0.5 cm, 1 cm, and 1.5 cm medial to the fibular head, respectively. The target of each correction was 55% of the tibial plateau measured from the medial. Then, the width of the opening wedge was measured. Intraobserver and interobserver reliability were calculated. (3) Results: Statistically significant differences in wedge width were seen at an osteotomy height of 3 cm below the tibial plateau when the distance of the hinge from the fibular head was 0.5 cm to 1.5 cm (3 cm and 0.5 cm: 8.9 +/- 3.88 vs. 3 cm and 1.5 cm: 11.6 +/- 4.39 p = 0.012). Statistically significant differences were also found concerning the wedge width between the distances 0.5 to 1.5 cm from the fibular head at the osteotomy height of 4 cm below the tibial plateau. (4 cm and 0.5 cm: 9.0 +/- 3.76 vs. 4 cm and 1.5 cm: 11.4 +/- 4.27 p = 0.026). (4) Conclusion: A change of the lateral hinge position of 1 cm results in a change in wedge width of approximately 2 mm. If hinge positions are chosen differently in preoperative planning and intraoperatively, the result can lead to over- or under-correction.
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Knee dislocation is a devastating form of multiligament injury of the knee. Due to its high complexity, there is a large number of different diagnostic and treatment strategies. With the aim of providing evidence-based treatment recommendations, the S2e guideline on knee dislocation is aimed at all professional groups involved in diagnostics and therapy (orthopaedic and trauma surgeons, physiotherapists, outpatient/inpatient surgeons, sports physicians, etc.) as well as those affected (patients with knee dislocation) and service providers (health insurance companies, pension insurance companies). In addition to the presentation of conceptual differences between the injury entities, this includes the special features of diagnostic testing, options for conservative and surgical therapy as well as aspects of follow-up treatment - against the background of the interdisciplinary treatment approach to a severe knee injury.