Treatment of Patellofemoral Instability and Chondral Lesions.

Lateral patellar instability is one of the most common knee disorders among adolescents. Numerous anthropometric features, including trochlear dysplasia, patella alta, high tibial tubercle-to-trochlear groove distance, and coronal and rotational plane malalignment, are considered primary risk factors for patellar dislocation, and the understanding of their complex interplay is continuously evolving. Because of the multifactorial nature of patellar instability, there is a lack of consensus regarding many aspects of surgical intervention. Medial patellofemoral ligament reconstruction is considered to be the essential procedure in preventing recurrent instability. However, there is growing interest in addressing underlying anatomic risk factors that contribute to patellar instability. It is important to discuss the diagnosis and management of patellar instability, surgical considerations in medial patellofemoral ligament reconstruction, mitigation/correction of anatomic risk factors, and treatment of associated chondral lesions.

Meniscal Allograft Survivorship and Outcomes 20 Years After Implantation.

PURPOSE: To evaluate meniscal allograft survivorship and outcomes 20 years after implantation. METHODS: Fifty-six meniscal allograft patients at a minimum 20 years following implantation comprised the study group. Forty-eight (85.7%) were able to be contacted regarding the function of their knee and if any additional surgeries were performed. RESULTS: Of the 48 patients, 21 required surgical treatment of the graft. Thirteen patients had isolated partial meniscectomy. Eight patients had knee arthroplasty with 1 having prior partial graft removal and one also had a high tibial osteotomy. The average time to arthroplasty was 12.7 years. The graft survivorship was 56.2%. The activity levels at follow-up varied widely, but in general did not deteriorate compared to those preoperatively. Only 1 patient stated they would not have undergone the procedure. CONCLUSIONS: Meniscal allografts were able to provide subjective improvement at 20 years after surgery and while not as durable as the native meniscus, the overall graft survivorship was 56.2% after implantation. LEVEL OF EVIDENCE: Retrospective case series, Level of evidence IV.

Editorial Commentary: Meniscal Allografts Can Be for Grandparents Too.

Meniscal allografts have come a long way since they were first thought to be a salvage procedure before a knee arthroplasty. The surgical procedure and indications have shown significant change, but the variable of patient age has not. Most clinical series report that patients should be <50-55 years of age to be considered as candidates. While outcomes are better for younger patients, good results can be obtained even when the upper age is extended beyond the current accepted limit.

Meniscal Allograft Transplantation: Does Surgical Technique Influence Clinical Outcomes?

PURPOSE OF REVIEW: Meniscal allograft transplantation is intended to address painful knees with symptoms that can be attributed to meniscal deficiency through injury or meniscectomy. Initially viewed as an experimental procedure, refinements in patient selection and surgical technique have led to improved clinical outcomes with wider acceptance. Our intention with this paper is to provide a review of meniscal allograft transplantation, with the focus on the different surgical techniques employed and their influence on outcomes. RECENT FINDINGS: The main debate regarding surgical technique is using bone or only soft tissue for fixation of the meniscal horns. Biomechanical and other basic science studies show improved function and less extrusion when the grafts are secured with bone. However, several clinical studies show no difference in outcomes. Long-term studies have shown improved success with less graft extrusion and may illustrate the important function of bone fixation. Many clinical studies, including those with long-term outcomes, have shown meniscal allografts can decrease patient pain and improve function. It is a technically challenging procedure with good clinical outcomes regardless of the method of graft fixation. Bone fixation provides less extrusion which is associated with improved graft function and decreased rate of joint deterioration. Further study is needed to determine if other methods to decrease extrusion are able to improve graft function and outcomes.

High failure rate for electrothermal shrinkage of the lax anterior cruciate ligament: a multicenter follow-up past 2 years.

PURPOSE: The purpose of this study was to prospectively evaluate the midterm results (beyond 2 years) of thermal shrinkage on both lax native anterior cruciate ligament (ACL) and lax reconstructions and determine the effectiveness of this procedure. METHODS: This is a multicenter study in which 64 patients from 2 sites underwent electrothermal shrinkage for a lax ACL, both native and previous reconstructions. They were followed up past 2 years with KT-1000 measurements (MEDmetric, San Diego, CA). Failure criteria included subsequent operations for instability or KT-1000 measurements greater than 5 mm. Three patients were lost to follow-up. RESULTS: Among the 61 patients followed up past 2 years, failure occurred in 31 (50.8%). The failure rate for lax grafts alone was 78.9%, and there was a failure rate of 38.1% for lax native ligaments. CONCLUSIONS: Electrothermal shrinkage of lax native or reconstructed ACLs is not an appropriate treatment.

Allograft Anterior Cruciate Ligament Reconstruction in Patients Younger than 25 Years.

Purpose The purpose of this study was to evaluate the outcomes for patients younger than 25 years who had anterior cruciate ligament (ACL) reconstructions with allograft tissue. Methods A total of 52 ACL reconstructions performed with fresh-frozen, nonirradiated tibialis or Achilles allografts in active patients younger than 25 years. Outcome evaluations included the International Knee Documentation Committee (IKDC) objective and subjective forms, KT-1000 arthrometry and Lysholm. Results Forty-two patients were available for follow-up at an average follow-up of 65 months (range, 33-99 months). The average age at surgery was 17 years and 7 months (range, 11 years 10 months-24 years 8 months). Objective and subjective data were obtained from 37 patients with 1 requiring revision, and 5 patients had only subjective data. IKDC objective results were 29-A and 5-B. KT-1000 differences were 0 mm for 4 patients, 1 mm for 23, 2 mm for 8, 3 mm for 1, and > 5 mm for 1 patient. The average IKDC subjective score was 90.2 ± 15.0 and average Lysholm score was 90.0 ± 11. Conclusion The result of our study found that using nonirradiated Achilles or tibialis tendon allografts for ACL reconstructions in active patients younger than 25 years can achieve good outcomes, with a low rate of failure.

Radiofrequency electrothermal shrinkage of the anterior cruciate ligament.

The efficacy of electrothermal collagen shrinkage in the treatment of patients with anterior cruciate ligament laxity was evaluated. Eighteen patients who had continuity of the anterior cruciate ligament but had symptomatic laxity were treated with arthroscopic electrothermal shrinkage of the anterior cruciate ligament using a monopolar radiofrequency probe. The mean length of follow-up in patients whose stability was maintained was 20.5 months. Seven of the patients had undergone previous reconstruction, four with patellar tendon graft and three with quadrupled hamstring tendon graft. Laxity was chronic in nine patients and acute in nine. The KT-1000 arthrometer results at 1 month postoperatively revealed decreased anterior excursion, with an average side-to-side difference of 1.9 mm. However, 11 patients had a failed result at an average 4.0 months. Of the seven patients with successful results, six had native ligaments and had been treated for acute laxity and one had a patellar tendon graft and had been treated for chronic laxity. Even with the short-term follow-up in our study, it is evident that thermal shrinkage using radiofrequency technology has limited application for patients with anterior cruciate ligament laxity. Although it may be useful in treating patients with an acutely injured native anterior cruciate ligament, further study is needed to see if the ligament stretches out over time or is at increased risk of reinjury.

Update on advanced surgical techniques in the treatment of traumatic focal articular cartilage lesions in the knee.

Considerable interest has been developed over the past several years in expanding the treatment of symptomatic femoral condylar articular cartilage lesions in active patients. Multiple surgical techniques have been reported and evolving technologies, equipment and approaches continue to expand. The purpose of this paper is to review the presentation of focal articular cartilage lesions including treatment indications, current surgical options and postoperative protocols emphasizing advanced techniques used to preserve or restore hyaline cartilage tissue. The various surgical options are discussed and the advantages and disadvantages are reviewed and highlighted in a clinical practice guideline algorithm.

Allograft meniscal transplantation: background, techniques, and results.

In the early arthritic knee, meniscal allograft transplantation alleviates pain and provides for a measurable improvement in functional level in appropriately selected postmeniscectomy patients. The allograft heals readily to the host, develops a normal appearance, and repopulates with the host cells. The allograft functions similarly to autograft tissue in its load-sharing properties. Theoretically, restoration of normal meniscal anatomy should decelerate or prevent further degenerative changes; however, this particular indication remains investigational. Basic science and clinical results support the intermediate-term efficacy of allograft meniscus transplantation in symptomatic meniscectomized patients as long as relevant comorbidities are corrected and significant coexisting arthritis is absent. Excellent pain relief and improved function can be achieved when rigid indications are adhered to.

Anterior cruciate ligament thermal shrinkage.

Heat has been used as a therapeutic form of treatment in the field of medicine since ancient times. Electrothermal energy delivered by radiofrequency has the advantages of being able to be used by even the casual arthroscopist and being relatively inexpensive. One of the expanded uses is treating ligament laxity, including the anterior cruciate.