Sufficient MRI graft structural integrity at 9 months after anterior cruciate ligament reconstruction with hamstring tendon autograft.

PURPOSE: To assess the MRI-measured structural integrity of hamstring autograft at 9 months after anterior cruciate ligament reconstruction (ACLR) surgery. METHODS: A prospective cohort study was conducted including 34 patients (mean age 36.8 ± 11.8 years; 73.5% males) who underwent ACLR with hamstring autograft. In addition, 36 patients (mean age 39.2 ± 10.5 years; 69.4% males) without any ACL injury were also reviewed and served as control group. The primary outcome used for examining graft maturity at 9 months after ACLR was the MRI-based signal-to-noise quotient (SNQ) of reconstructed ACL. SNQ values were stratified into 3 different categories: excellent: < 0.1; good: ≥ 0.1 and ≤ 0.19; fair: ≥ 0.2. The KT-1000 knee arthrometer was used to measure the side-to-side difference in the anterior tibial translation between the ACLR knee and the contralateral healthy knee in the ACLR group. RESULTS: Reconstructed ACLs were found with a mean SNQ of 0.078 ± 0.061, while almost all ACL-reconstructed patients (97%; 33 out of 34) were found with excellent or good SNQ values (< 0.019). The mean KT-1000 in the ACLR group was 0.071 mm ± 0.926 mm, while there were no patients in the ACLR cohort with a KT-1000 value > 3 mm. The mean 9-months MRI-based SNQ of ACLR group was significantly higher compared to the mean MRI-based SNQ of the control group (p < 0.001). Multiple regression analysis showed no correlation between SNQ and age, gender, time from injury to ACLR, graft size, or simultaneous treatment of additional intra-articular knee lesions. CONCLUSIONS: In this cohort of 34 ACL-reconstructed patients, 97% of hamstring tendon autografts demonstrated excellent/good MRI signal intensity and excellent functional results (KT-1000 < 3 mm) at 9 months after surgery. Based on this finding, it is suggested that return to sports after ACLR with hamstring autograft can be considered safe at 9 months post surgery. Furthermore, while structural integrity of the graft has been achieved at this time point, statistical differences found in SNQ values of ACL-reconstructed patients compared to ACLs of healthy individuals highlight the continuing process of graft maturation and remodelling. LEVEL OF EVIDENCE: Level III.

Outcomes and Patient Safety in Overlapping vs. Nonoverlapping Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

INTRODUCTION: Overlapping surgery is defined as two cases occurring in separate operating rooms (ORs), where the same attending surgeon conducts the critical surgical portions of each case at different times. Although it has been suggested that this established practice may improve the utilization of resources, allow for more opportunities to teach surgical trainees, and facilitate timely access to care, there is still no consensus on its use in elective orthopaedic surgery, such as total joint arthroplasty (TJA). METHODS: A systematic review and meta-analysis of the literature was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify articles investigating the use of overlapping and single operating room TJA. Relevant data, including surgical time, intraoperative complications, postoperative complications, mortality rate, revision rate, and readmission rate, were extracted and recorded. RESULTS: Six articles were included (35,938 patients: 17,677 overlapping and 18,261 nonoverlapping). Overall revision rates were 1.2% and 1.1% for the overlapping and nonoverlapping cohorts, respectively (odds ratio [OR] = 1.19; 95% confidence interval [CI]: 0.93 to 1.53). The overall intraoperative complication rate was 1.6% for both cohorts (OR = 0.98; 95% CI: 0.79 to 1.23), and the overall postoperative orthopaedic complication rates were 2.0% and 1.95% within the overlapping and nonoverlapping OR cohorts, respectively (OR = 1.07; 95% CI: 0.89 to 1.29). The readmission rate was 4.6% in the overlapping group and 4.2% in the nonoverlapping group (OR = 0.88; 95% CI: 0.70 to 1.11). Two studies with comparable groups reported markedly increased surgical time in the overlapping group compared with the nonoverlapping group. DISCUSSION: Overlapping surgery was found to be as safe as nonoverlapping surgery in patients undergoing TJA. Although overlapping TJA surgery is associated with satisfactory short-term revision rates, prolonged follow-up is required to further assess the medium-term and long-term outcomes of overlapping surgery compared with nonoverlapping surgery. Finally, although overlapping TJA surgery might be associated with increased OR time, this difference is not clinically relevant.

Preoperative Opioid Use Is Associated With Higher Revision Rates in Total Joint Arthroplasty: A Systematic Review.

BACKGROUND: Although preoperative opioid use has been associated with poor postoperative patient-reported outcome measures and delayed return to work in patients undergoing total joint arthroplasty, direct surgery-related complications in patients on chronic opioids are still not clear. Thus, we sought to perform a systematic review of the literature to evaluate the influence of preoperative opioid use on postoperative complications and revision following primary total joint arthroplasty. METHODS: Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we queried PubMed, EMBASE, the Cochrane Library, and the ISI Web of Science for studies investigating the influence of preoperative opioid use on postoperative complications following total hip arthroplasty and total knee arthroplasty up to May 2020. RESULTS: After applying exclusion criteria, 10 studies were included in the analysis which represented 87,165 opioid users (OU) and 5,214,010 nonopioid users (NOU). The overall revision rate in the OU group was 4.79% (3846 of 80,303 patients) compared to 1.21% in the NOU group (43,719 of 3,613,211 patients). There was a higher risk of aseptic loosening (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.11-1.53, P = .002), periprosthetic fractures (OR 1.89, 95% CI 1.53-2.34, P < .00001), and dislocations (OR 1.26, 95% CI 1.14-1.39, P < .00001) in the OU group compared to the NOU group. Overall, 5 of 6 studies reporting on periprosthetic joint infection (PJI) rates showed statistically significant correlation between preoperative opioid use and higher PJI rates. CONCLUSION: There is strong evidence that preoperative opioid use is associated with a higher overall revision rate for aseptic loosening, periprosthetic fractures, and dislocation, and an increased risk for PJI. LEVEL OF EVIDENCE: Level III, systematic review.

Graft Inclination Angles in Anterior Cruciate Ligament Reconstruction Vary Depending on Femoral Tunnel Reaming Method: Comparison Among Transtibial, Anteromedial Portal, and Outside-In Retrograde Drilling Techniques.

PURPOSE: To compare graft coronal and sagittal inclination angles in anterior cruciate ligament (ACL) reconstruction performed by different femoral tunnel drilling techniques with respect to intact native ACL. METHODS: In total, 72 patients were prospectively enrolled in the study. The inclusion criteria were complete ACL rupture and patient age between 18 and 55 years. Reconstructions were performed using 4 different femoral tunnel drilling technique: transtibial (TT), anteromedial portal with rigid (AMP-RR) or flexible (AMP-FR) reamer, and outside-in retrograde drilling (OI) techniques. Eighteen patients with intact native ACL were included as controls. Sagittal and coronal graft inclination angles were measured by magnetic resonance imaging 6 months after the procedure by 1 radiologist blinded in regards to the used technique. RESULTS: OI and AMP-FR techniques allowed for the maintenance of native-like ACL inclination in both the sagittal and coronal planes, whereas TT and AMP-RR increased the sagittal angle by a mean of 9.5° (P < .001) and 6.7° (P = .003), respectively, compared with native ACLs. AMP-RR and TT also showed increased sagittal graft inclination compared with AMP-FR (+6.1°, P = .009 and +9.0°, P < .001, respectively) and OI-drilling techniques (+5.5°, P = .024 and +8.4°, P < .001, respectively). No differences were observed among study groups in terms of coronal graft inclination. CONCLUSIONS: The study hypothesis was partially confirmed, since OI and AMP-FR techniques, but not AMP-RR, using an independent portal for femoral drilling produce a more anatomic graft inclination on the sagittal plane with respect to TT. LEVEL OF EVIDENCE: II, prospective comparative study.

Advances in modern osteotomies around the knee : Report on the Association of Sports Traumatology, Arthroscopy, Orthopaedic surgery, Rehabilitation (ASTAOR) Moscow International Osteotomy Congress 2017.

Corrective lower limb osteotomies are innovative and efficient therapeutic procedures for restoring axial alignment and managing unicompartmental knee osteoarthritis. This review presents critical insights into the up-dated clinical knowledge on osteotomies for complex posttraumatic or congenital lower limb deformities with a focus on high tibial osteotomies, including a comprehensive overview of basic principles of osteotomy planning, biomechanical considerations of different implants for osteotomies and insights in specific bone deformity correction techniques. Emphasis is placed on complex cases of lower limb osteotomies associated with ligament and multiaxial instability including pediatric cases, computer-assisted navigation, external fixation for long bone deformity correction and return to sport after such osteotomies. Altogether, these advances in the experimental and clinical knowledge of complex lower limb osteotomies allow generating improved, adapted therapeutic regimens to treat congenital and acquired lower limb deformities.

Italian consensus statement for the use of allografts in ACL reconstructive surgery.

PURPOSE: Graft choice for primary anterior cruciate ligament reconstruction (ACL-R) is debated, with considerable controversy and variability among surgeons. Autograft tendons are actually the most used grafts for primary surgery; however, allografts have been used in greater frequency for both primary and revision ACL surgery over the past decade. Given the great debate on the use of allografts in ACL-R, the "Allografts for Anterior Cruciate Ligament Reconstruction" consensus statement was developed among orthopedic surgeons and members of SIGASCOT (Società Italiana del Ginocchio, Artroscopia, Sport, Cartilagine, Tecnologie Ortopediche), with extensive experience in ACL-R, to investigate their habits in the use of allograft in different clinical situations. The results of this consensus statement will serve as benchmark information for future research and will help surgeons to facilitate the clinical decision making. METHODS: In March 2017, a formal consensus process was developed using a modified Delphi technique method, involving a steering group (9 participants), a rating group (28 participants) and a peer-review group (31 participants). Nine statements were generated and then debated during a SIGASCOT consensus meeting. A manuscript has been then developed to report methodology and results of the consensus process and finally approved by all steering group members. RESULTS: A different level of consensus has been reached among the topics selected. Strong agreement has been reported in considering harvesting, treatment and conservation methods relevant for clinical results, and in considering biological integration longer in allograft compared to autograft. Relative agreement has been reported in using allograft as the first-line graft for revision ACL-R, in considering biological integration a crucial aspect for rehabilitation protocol set-up, and in recommending a delayed return to sport when using allograft. Relative disagreement has been reported in using allograft as the first-line graft for primary ACL-R in patients over 50, and in not considering clinical results of allograft superior to autograft. Strong disagreement has been reported in using allograft as the first-line graft for primary ACL-R and for skeletally immature patients. CONCLUSIONS: Results of this consensus do not represent a guideline for surgeons, but could be used as starting point for an international discussion on use of allografts in ACL-R. LEVEL OF EVIDENCE: IV, consensus of experts.

Hamstring tendon autografts do not show complete graft maturity 6 months postoperatively after anterior cruciate ligament reconstruction.

PURPOSE: In this prospective, double-center cohort study, we aim to assess how the anterior cruciate ligament (ACL) signal intensity on magnetic resonance imaging (MRI) potentially varies between a group of patients with anatomic ACL reconstruction using autogenous hamstring grafts 6 months postoperatively and a healthy ACL control group, and how MRI-based graft signal intensity is related to knee laxity. METHODS: Sixty-two consecutive patients who underwent ACL reconstruction using quadrupled hamstring tendon autograft were prospectively invited to participate in this study, and they were evaluated with MRI after 6 months of follow-up. 50 patients with an MRI of their healthy ACL (Clinica Luganese, Lugano, Switzerland) and 12 patients of their contralateral healthy knee (Department of Orthopaedic and Trauma Surgery, Medical University of Vienna, Austria) served as the control group. To evaluate graft maturity, the signal-to-noise quotient (SNQ) was measured in three regions of interest (ROIs) of the proximal, mid-substance and distal ACL graft and the healthy ACL. KT-1000 findings were obtained 6 months postoperatively in the ACL reconstruction group. Statistical analysis was independently performed to outline the differences in the two groups regarding ACL intensity and the correlation between SNQ and KT-1000 values. RESULTS: There was a significant difference in the mean SNQ between the reconstructed ACL grafts and the healthy ACLs in the proximal and mid-substance regions (p = 0.001 and p = 0.004). The distal region of the reconstructed ACL showed a mean SNQ similar to the native ACL (n.s). Patients with a KT-1000 between 0 and 1 mm showed a mean SNQ of 0.1; however, a poor correlation was found between the mean SNQ and KT-1000 findings, probably due to the small sample size of patients with higher laxity. CONCLUSION: After 6 months of follow-up, hamstring tendon autografts for anatomic ACL reconstruction do not show equal MRI signal intensity compared to a healthy ACL and should therefore be considered immature or at least not completely healed even if clinical laxity measurement provides good results. However, in the case of a competitive athlete, who is clinically stable and wants to return to sports at 6 months, performing an MRI to confirm the stage of graft healing might be an option. LEVEL OF EVIDENCE: Prospective, comparative study II.

Conventional versus Smart Wireless Navigation in Total Knee Replacement: Similar Outcomes in a Randomized Prospective Study.

Purpose The development of new computer-assisted navigation technologies in total knee arthroplasty (TKA) has attracted great interest; however, the debate remains open as to the real reliability of these systems. We compared conventional TKA with last generation computer-navigated TKA to find out if navigation can reach better radiographic and clinical outcomes. Methods Twenty patients with tricompartmental knee osteoarthritis were prospectively selected for conventional TKA ( n = 10) or last generation computer-navigated TKA ( n = 10). Data regarding age, gender, operated side, and previous surgery were collected. All 20 patients received the same cemented posterior-stabilized TKA. The same surgical instrumentation, including alignment and cutting guides, was used for both the techniques. A single radiologist assessed mechanical alignment and tibial slope before and after surgery. A single orthopaedic surgeon performed clinical evaluation at 1 year after the surgery. Wilcoxon's test was used to compare the outcomes of the two groups. Statistical significance was set at p < 0.05. Results No significant differences in mechanical axis or tibial slope was found between the two groups. The clinical outcome was equally good with both techniques. At a mean follow-up of 15.5 months (range, 13-25 months), all patients from both groups were generally satisfied with a full return to daily activities and without a significance difference between them. Conclusion Our data showed that clinical and radiological outcomes of TKA were not improved by the use of computer-assisted instruments, and that the elevated costs of the system are not warranted. Level of Evidence This is a Level II, randomized clinical trial.

Prevalence of Associated Lesions in Anterior Cruciate Ligament Reconstruction: Correlation With Surgical Timing and With Patient Age, Sex, and Body Mass Index.

BACKGROUND: Knee instability resulting from anterior cruciate ligament (ACL) rupture is an important risk factor for the onset of meniscal tears and cartilage injuries. A delay of the ligament reconstruction further increases this risk. There is currently no agreement on the right time for surgical ACL reconstruction. PURPOSE: To verify the correlation of time to ACL reconstruction, patient age, sex, and body mass index (BMI) with the prevalence of meniscal tears and cartilage injuries, as well as to identify the proper surgical timing to decrease the risk of developing associated injuries. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The medical records of 988 patients who underwent primary ACL reconstruction between January 2010 and May 2014 were analyzed to collect data on the prevalence of meniscal tears and cartilage injuries, surgical timing, and patient sex, age, and BMI. Logistic regression was performed to estimate the association between the prevalence of intra-articular lesions and the independent variables of surgical timing, sex, age, and BMI. RESULTS: The risk of developing at least an associated lesion increased by an average of 0.6% for each month of delay of surgical reconstruction. The odds ratio (OR) for developing an intra-articular lesion was 1.989 (95% CI, 1.403-2.820) in those waiting more than 12 months for ACL reconstruction. A 12-month delay for the intervention nearly doubled the risk of developing a medial meniscal tear (OR, 1.806 [95% CI, 1.317-2.475]) but did not modify the risk for the lateral meniscus (OR, 1.183 [95% CI, 0.847-1.653]). Concerning cartilage lesions, the risk after a 12-month delay increased in the medial compartment (femoral condyle: OR, 2.347 [95% CI, 1.499-3.676]; tibial plateau: OR, 5.574 [95% CI, 1.911-16.258]). In the lateral femoral condyle, the risk became significant in patients who underwent surgery more than 60 months after ACL injury as compared with those treated in the first 3 months (OR, 5.949 [95% CI, 1.825-19.385]). Lateral tibial plateau lesions did not seem to increase significantly. Male sex was a risk factor for the onset of lateral meniscal tears (OR, 2.288 [95% CI, 1.596-3.280]) and medial tears (OR, 1.752 [95% CI, 1.280-2.399]). Older age (OR, 1.017 [95% CI, 1.006-1.029]) and increased BMI (OR, 1.120 [95% CI, 1.072-1.169]) were risk factors for the occurrence of at least 1 associated lesion. CONCLUSION: ACL reconstruction within 12 months of injury can significantly reduce the risk of meniscal tears and chondral lesions. The close association between BMI and prevalence of associated lesions suggests that attention be paid to patients with an elevated BMI when considering the timing of ACL reconstruction surgery.

Combined chronic anterior cruciate ligament and posterior cruciate ligament reconstruction: functional and clinical results.

PURPOSE: Multiligamentous injury to the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) is an uncommon but debilitating event. Patients with combined ligament injuries typically complain of painful, debilitating knee instability that restricts their sports and daily activities. The purpose of this retrospective study was to evaluate functional and clinical outcomes of patients with chronic ACL and PCL deficiency who underwent simultaneous single-stage arthroscopic reconstruction of the central pivot. METHODS: Medical records of 20 consecutive patients with chronic ACL and PCL deficiency who underwent simultaneous single-stage arthroscopic reconstruction of the central pivot were retrospectively reviewed. All patients had received either an allograft (group A) or a semitendinosus-gracilis graft for ACL repair and a bone-patellar tibial-bone graft for PCL repair (group B). Functional outcomes, after the initial follow-up period at 24-month FU, were assessed with concentric isokinetic knee extensor-flexor testing at 60 and 180°/s. The secondary aim was to compare long-term clinical recovery by the administration of the IKDC (International Knee Document Committee) Knee Ligament Evaluation Form, the Lysholm Knee Scoring Scale and the Cincinnati Knee Rating Scale. RESULTS: The mean per cent quadriceps strength deficit in the operated as compared to the healthy knee was 13.5 % in group A and 15 % in group B (angular velocity 60°/s) and 13.5 % in group A and 9.4 % in group B (angular velocity 180°/s). The mean per cent flexor strength deficit in the operated as compared to the healthy knee was 10.4 % in group A and 12.3 % in group B (angular velocity 60°/s) and 12.2 % in group A and 9 % in group B (angular velocity of 180°/s). The flexor-quadriceps ratio was 49.4 % in group A and 48.8 % in group B in the healthy knee and 53.2 % in group A and 53.8 % in group B in the operated knee (angular velocity 60°/s) and 63.9 % in group A and 60.7 % in group B in the healthy knee and 65 % in group A and 64.9 % in group B in the operated knee (angular velocity 180°/s). Lysholm outcome was 93.9 ± 3.9 in group A and 89.1 ± 7.6 in group B (n.s). Cincinnati score was 89.6 ± 7.3 in group A and 91.0 ± 6.9 in group B (p = 0.791). IKDC results were group A in six patients (60 %), group B in three patients (30 %) and group C in one patient (10 %) in the allograft group and group A in seven patients (70 %) and group B in three patients (30 %) for autologous group. CONCLUSIONS: The results of this study suggest that one-stage arthroscopic bicruciate ligament reconstruction can restore good knee joint function. Surgical treatment should be followed by a comprehensive rehabilitation programme with specific goals, objectives and strategies, including pain management and assessment of progress in recovery of joint function and perception of knee stability. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Arthrometric stability of horizontal versus vertical single-bundle arthroscopic anterior cruciate ligament reconstruction.

The anteroposterior (AP) stability of standard anterior cruciate ligament (ACL) reconstruction, referred to as "vertical," was compared with that of a modified femoral position, referred to as "horizontal," which is lower than and anterior to an operative knee at 90° flexion. Two consecutive series of 50 patients underwent vertical and horizontal arthroscopic single-bundle ACL reconstruction, respectively. For vertical reconstruction, the clock position was chosen, placing the graft at 10:30 in right knees and 1:30 in left knees, 1 to 2 mm anterior to the posterior femoral cortical cortex and at the back of the resident ridge. In the horizontal reconstruction, the transplant replaced the original ligament insertion at approximately the 9:30 o'clock position in right knees and the 2:30 o'clock position in left knees, approximately 2 mm in front of the posterior femoral cortical cortex. One year after surgery, the results of stabilometric evaluation revealed good performance after horizontal transplant. The mean clinical results changed from 1.0 (±1.3) mm for vertical to 0.7 (±1.3) mm for horizontal reconstruction.

Posterior cruciate ligament reconstruction with "all-inside" technique: a technical note.

INTRODUCTION: posterior cruciate ligament (PCL) injuries are an increasingly recognized cause of knee instability in the practice of orthopaedic surgery and sports medicine. Clinical interest in these injuries has been increasing over the last several decades as knowledge and understanding of the biomechanical consequences and surgical reconstruction options have progressed. These injuries can be extremely challenging for the treating physician as substantial controversy exists regarding the optimal management of this problem. There has also been increasing interest and recognition of the importance of secondary stabilizing structures, including the posterolateral and posteromedial corner injuries as well as the issues with malalignment that must also be addressed at the time of PCL surgery to optimize results. Thanks to the continuous research for a correct anatomical placement and new systems of fixation, we can now perform the tibial and femoral bone tunnel more easily and safely by retrograde out-in approach with a special "drill-pin". CONCLUSION: this technique provides a graduated precise execution of the tunnels. New methods were also developed to determine the so-called "second-generation cortical suspensory fixations" that have the feature of being "Adjustable": shortens implant by pulling on strands to allow cinching graft passing and tensioning button to regulate their length after fixation and then to create tension in the new graft, once introduced into the joint.

Definition and classification of early osteoarthritis of the knee.

With the emerging interest in regenerative medicine and tissue engineering, new treatment modalities being developed for joint disorders including joint surface lesions and articular cartilage defects. The clinical outcome of these novel approaches appears rather unpredictable and is due to many reasons but definitely also linked to the patient profile. As a typical example, symptomatic articular cartilage lesions can be presented in an otherwise normal joint, or associated with several other joint tissue alterations including meniscal lesions and abnormalities of the underlying bone. The outcome of novel treatments may well be influenced by the status of the whole joint, and the potential to develop osteoarthritis. To better identify the patients at risk and responders to certain treatments, it is of use to define and most importantly classify patients with "early osteoarthritis". Here, classification criteria for this group of patients are presented, allowing a more defined and accurate inclusion in clinical trials in the future.

Prophylactic use of antibiotic-loaded bone cement in primary total knee replacement.

Despite significant advances in intraoperative antimicrobial procedures, deep infection remains the most devastating complication following total joint arthroplasty. Clinical studies' results and safety profile of antibiotic-loaded bone cement are discussed in this review. Antibiotic bone cement prophylaxis is a safe and effective strategy in reducing the risk of deep infection following primary total joint arthroplasty.

Infectious and thromboembolic complications of arthroscopic shoulder surgery.

HYPOTHESIS: This study investigates the rate of infectious and thromboembolic complications in shoulder arthroscopy and their association with pharmacologic prophylaxis. MATERIALS AND METHODS: On behalf of the Italian Society for Knee Surgery, Arthroscopy, Sport Traumatology, Cartilage and Orthopaedic Technologies (SIGASCOT), we asked the members to complete an on-line Web survey about their experiences and strategies of prophylaxis in shoulder arthroscopy. RESULTS: In the period 2005-2006, 9385 surgeries were performed. We report 15 infections and 6 DVTs. The overall rate of infections was 0.0016 (1.6/1000) and the rate of DVTs was 0.0006 (0.6/1000) CONCLUSION: The association between infection and antibiotic prophylaxis was significant (P=0.01); however, the risk of DVTs was not decreased with heparin prophylaxis. LEVEL OF EVIDENCE: Level 3.

Quantification of active ROM after arthroscopic Bankart repair with rotator interval closure.

Several series report patients homogeneously treated using arthroscopic Bankart repair exclusively, or in some cases arthroscopic Bankart repair with rotator interval closure. Current international literature has few reports on arthroscopic Bankart repair with rotator interval closure procedures undertaken on a homogeneous series of patients. The purpose of this study was to evaluate the residual active range of motion (ROM) and clinical outcome in this patient population. Fourteen patients affected by recurrent anterior instability were consecutively treated. Rowe, Walch-Duplay, and UCLA scores, as well as differences in active ROM of both shoulders (treated and contralateral), were recorded. A significant reduction in active external rotation was noted along the side of the arm (P<.001) and at 90 degrees of abduction (P=.007). The average reduction was 12.14 degrees and 7.21 degrees, respectively, which represents 17.8% and 8% of the arc of motion of the opposite side in external rotation. No significant differences were found for flexion, abduction, and internal rotation. According to Walch-Duplay and Rowe scores, 71.4% and 85.7% of patients had excellent or good results. Arthroscopic Bankart repair with rotator interval closure results in a reduction of external rotation and provides satisfactory stability results.

Unicameral bone cyst of the humeral head: arthroscopic curettage and bone grafting.

Arthroscopic surgery has improved greatly over the past decade. Treatment of various juxta-articular disorders around the shoulder have benefited from endoscopic approaches. Cystic lesions of the shoulder on the scapular side have been treated in this way. This article describes a case of a 29-year-old patient with a unicameral bone cyst on the posterior aspect of the humeral head. Arthroscopic visualization using an accessory posteroinferior portal localized the cyst through the bare area of the humeral head. A cannulated burr was used to create an opening through the cortical wall between the cyst and the joint, and a careful curettage was performed. The cavity was filled with a demineralized bone matrix enriched with autologous blood packed into an arthroscopic cannula and delivered through the accessory portal. The patient reported pain relief immediately postoperatively and at follow-up. This case demonstrates the feasibility of arthroscopic treatment of a simple bone cyst of the humeral head. We believe that the knowledge of the juxta-articular anatomy allows the applications of scope-assisted procedures to be expanded, maximizing the results of a technique that allows a shorter recovery and less painful rehabilitation.

Distal realignment and patellar autologous chondrocyte implantation: mid-term results in a selected population.

The aim of this prospective observational study was to assess the 3-year clinical outcome of distal realignment and membrane-seeded autologous chondrocyte implantation (MACI) in selected patients with patellofemoral malalignment and large, isolated, patellar cartilage lesions. Twelve patients (14 knees; 6 females, 6 males; mean age 31 years) with Fulkerson type II patellofemoral malalignment (lateralized and tilted patella) and Outerbridge grade III-IV isolated patellar cartilage lesions were treated. All had tibial tuberosity and trochlear sulcus >20 mm on a preoperative CT scan and a cartilage defect >3 cm2. Patients with Outerbridge grade III-IV trochlear cartilage lesions, those with rheumatic, infective or neoplastic conditions, or ligament instability, diabetes or obesity and those aged >40 years were excluded. Follow-up was at 36 months. Patients were enrolled after diagnostic arthroscopy. Cartilage was harvested and sent for culture. After a mean period of 30 days (range 25-40) patients underwent transfer of the tibial tuberosity according to Fulkerson associated with a MACI procedure. Clinical assessment was performed with the Kujala, Lysholm, Tegner and Modified Cincinnati scores. The Patient Satisfaction Survey was administered at 36 months. Consistently improved knee function and activity levels were reflected by significantly increased Kujala, Lysholm, Tegner and Modified Cincinnati scores at 36 months. The significant clinical improvement support the value of associating distal realignment and autologous chondrocyte implantation in treating large, isolated, patellar cartilage lesions associated with patellofemoral malalignment.

Double-bundle reconstruction of the anterior cruciate ligament using the transtibial technique.

We present an arthroscopic surgical procedure for double-bundle transtibial anterior cruciate ligament reconstruction with 2 tibial and femoral tunnels using autologous semitendinosus and gracilis tendons. The first aim is to attempt to create the femoral tunnels correctly through the tibial tunnels. To achieve this, a new tibial guide was used that permitted the simultaneous preparation of the anteromedial and posterolateral tibial tunnels. The intra-articular landmark is the tibial spine region, whereas the extra-articular landmarks are the anterior profile of the medial collateral ligament and the anterior tibial apophysis. We also describe transverse femoral fixation with biopins (1 for each femoral tunnel) after the preparation of the 2 tibial and femoral tunnels.