Clinical Outcome Measures in Arthroscopic Meniscectomy: Clinician versus Patient Completed Knee Scores / Medidas de desfechos clínicos na meniscectomia artroscópica: Pontuações de joelho segundo médicos e pacientes

Abstract Objective The aim of the present study was to investigate the difference between clinician-completed and patient-completed outcome scores in detecting improvement following arthroscopic meniscectomy in patients with meniscal tears of the knee. Methods Thirty-four patients with meniscal tears were prospectively assessed using 9 clinical outcome measures. The five clinician-completed knee scores included the Tegner Activity Score, the Lysholm Knee Score, the Cincinnati Knee Score, the International Knee Documentation Committee (IKDC) Examination Knee Score, and the Tapper and Hoover Meniscal Grading Score. The four patient-completed knee scores included the IKDC Subjective Knee Score, the Knee Outcome Survey - Activities of Daily Living Scale (KOS-ADLS), the Short Form-12 Item Health Survey (SF-12), and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Twenty-nine of the 34 patients underwent an arthroscopic meniscectomy and were reassessed with all 9 outcome scores upon their follow-up review. Results A significant longitudinal improvement was observed in 4 of the 5 clinician-completed scores (Tegner [p< 0.001], Lysholm [p= 0.004], Cincinnati [p = 0.002] and Tapper and Hoover [p< 0.001], but not in the IKDC Examination [p= 0.332]. However, the IKDC Subjective score (p= 0.021) was the only patient-completed score to demonstrate significant improvement postoperatively. Conclusion Overall, clinician-completed scoring systems were found to be inconsistent with those of patient-completed instruments. The mode of administering outcome measures can have a significant influence on the outcome results both for research and for clinical practice. A combination of both a clinician-completed with a patient-completed instrument may be a more balanced approach to assessing and quantifying meniscus tears and the outcome following arthroscopic meniscectomy.

Resumo Objetivo O objetivo do presente estudo foi investigar a diferença entre instrumentos de desfechos preenchidos por médicos e pacientes na detecção de melhora após a meniscectomia artroscópica para tratamento de rupturas de menisco. Métodos Trinta e quatro pacientes com rupturas de menisco foram avaliados de forma prospectiva usando 9 medidas de desfechos clínicos. Os cinco instrumentos de avaliação de joelho respondidos por médicos foram o Escore de Atividade de Tegner, o Escore de Joelho de Lysholm, o Escore de Joelho de Cincinnati, o Escore de Exame do Joelho do International Knee Documentation Committee (IKDC, na sigla em inglês) e o Escore de Classificação do Menisco de Tapper e Hoover. Os quatro instrumentos de avaliação do joelho respondidos por pacientes foram o Escore Subjetivo do Joelho do IKDC, a Pesquisa de Desfecho de Joelho - Escala de Atividades de Vida Diária (KOS-ADLS, na sigla em inglês), o Formulário Curto de Pesquisa em Saúde de 12 Itens (SF-12, na sigla em inglês) e o Escore de Desfecho de Osteoartrite e Lesões no Joelho (KOOS, na sigla em inglês). Vinte e nove dos 34 pacientes foram submetidos a uma meniscectomia artroscópica e reavaliados com todos os 9 instrumentos na sua consulta de acompanhamento. Resultados Uma melhora longitudinal significativa foi observada em 4 dos 5 instrumentos respondidos por médicos (Tegner [p< 0,001], Lysholm [p= 0,004], Cincinnati [p= 0,002] e Tapper e Hoover [p< 0,001], mas não no IKDC [p= 0,332]). Por outro lado, o Escore Subjetivo do Joelho do IKDC (p= 0,021) foi o único instrumento respondido por pacientes a demonstrar melhora pós-operatória significativa. Conclusão De modo geral, os instrumentos respondidos por médicos foram considerados inconsistentes em relação àqueles respondidos por pacientes. O modo de administração dos instrumentos pode ter influência significativa nos resultados, tanto para fins de pesquisa quanto para a prática clínica. A combinação de um instrumento respondido pelo médico com um instrumento respondido pelo paciente pode ser uma abordagem mais equilibrada para a avaliação e a quantificação das rupturas do menisco e do desfecho após a meniscectomia artroscópica.

Relationship between Knee Symptoms and Biological Features in Recreational Runners / Relação entre sintomatologia no joelho e as características biológicas em corredores recreacionais

Abstract Objective The main objective of the present study was to compare the subjective perception of pain and symptoms of anterior knee pain with the different body mass index (BMI) classifications. The secondary objective was to verify the association between biological and anthropometric variables with the results of subjective questionnaires. Methods A total of 126 recreational runners from both genders, aged between 20 and 59 years old, were recruited. Data regarding the biological variable (age), anthropometric variables (weight, height), visual analog scale (VAS), and Lysholm and Kujala questionnaires scores were collected. Information was obtained with a digital platform, available through a single link, allowing volunteers to answer these questions using electronic devices. Normality was verified by the Shapiro-Wilk test. T-tests and Wilcoxon tests were used to compare mean values. The association between variables was determined by the Pearson linear correlation. Results There were significant differences in height between overweight and grade 1 obesity subjects (p = 0.029), in weight and BMI comparing normal weight subjects and both overweight and grade 1 obesity subjects (p < 0.001 and p < 0.05, respectively). An unclear significant correlation was observed between BMI values and specific questionnaires and subjective scale scores (p < 0.05). Conclusion Recreational runners who present high BMI values are more likely to experience knee pain than those with normal BMI values.

Resumo Objetivo O principal objetivo do presente estudo foi comparar a percepção subjetiva de dor e sintomas de dor anterior no joelho com as diferentes classificações de índice de massa corporal (IMC). O objetivo secundário foi verificar a associação entre as variáveis biológica e antropométrica com os resultados apresentados pelos sujeitos nos questionários subjetivos. Métodos Foram recrutados 126 corredores recreacionais de ambos os gêneros, com idades entre 20 e 59 anos. Foram coletados dados referentes à variável biológica idade, e as variáveis antropométricas peso e altura, além da escala visual analógica (EVA) e os questionários Lysholm e Kujala. As informações foram obtidas por meio de plataforma digital, disponibilizado em um único link, para que fossem respondidos através de dispositivos eletrônicos pelos próprios voluntários. A normalidade foi verificada por meio do teste Shapiro-Wilk. Foi utilizado o teste-T e o teste de Wilcoxon para comparação das médias. A associação entre as variáveis foi determinada pela correlação linear de Pearson. Resultados Houve diferença significativa entre a estatura do grupo sobrepeso e o grupo obesidade grau 1 (p = 0,029), e o peso do grupo peso normal para os grupos sobrepeso e obesidade grau 1 (p < 0,001), e entre as médias do IMC (p < 0,05). Foi observada correlação significativa não clara entre o IMC e os questionários específicos e a escala subjetiva (p < 0.05). Conclusão Os corredores recreacionais que possuem IMC acima dos valores de normalidade estão mais predispostos a apresentar dor no joelho do que aqueles com IMC normal.

Adaptación transcultural al Español y Validación de la Escala de Lysholm para evaluar la funcionalidad de la rodilla / Cross-cultural adaptation to Spanish and Validation of Lysholm knee Score

Introducción La escala de Lysholm fue desarrollada en 1982 y modificada en 1985 con el fin de evaluar la funcionalidad de los pacientes con lesiones ligamentarias; desde entonces ha sido ampliamente utilizada para evaluar subjetivamente a los pacientes en relación con su capacidad funcional. El propósito de este estudio fue realizar su traducción y adaptación transcultural al español colombiano y desarrollar la validación psicométrica a través de la evaluación de la consistencia interna y fiabilidad test-retest. Materiales y métodos Previa identificación de la escala original de interés, se realizó traducción (inglés-español), adaptación cultural y re-traducción (español-inglés) por expertos lingüistas nativos, quienes valoraron la similitud del contenido de ambos productos (original y retraducido). Asimismo, dicha última versión fue valorada por 40 pacientes con enfermedad de rodilla (lesión meniscal, ruptura de ligamento cruzado anterior, condromalacia y gonartrosis), quienes confirmaron comprender el texto. Posteriormente fue evaluada la consistencia interna mediante la prueba de alfa de Cronbach para todos los ítems, y el coeficiente correlación intraclase­puntaje total del sub-constructo a través de una muestra aleatoria (n=93), la cual validó la estructura factorial de la escala. Resultados El alfa de Cronbach fue de 0,737 y el coeficiente de correlación interclase fue de 0,844, asociado a una concordancia inter-observador alta (Gamma=0,752). El gráfico de Bland-Altman no demostró diferencias sistemáticas entre las mediciones Discusión La presente versión al español (colombiano) de la escala Lysholm es una herramienta válida para medir la funcionalidad en pacientes con lesiones meniscales del ligamento cruzado anterior, condromalacia patelofemoral y gonartrosis en países de habla hispana (preferentemente en Colombia).

Background The Lysholm scale was developed in 1982 and modified in 1985 in order to assess the functionality of patients with knee ligament injuries; since then it has been widely used to subjectively evaluate patients in relation to their functional capacity. The purpose of the study was to carry out its translation and cross-cultural adaptation to Colombian Spanish and to develop psychometric validation through the evaluation of internal consistency and test-retest reliability. Methods After identifying the original scale of interest, translation (English-Spanish), cultural adaptation and re-translation (Spanish-English) were carried out by native linguist experts, who assessed the similarity of the content of both products (original and retranslated). Likewise, this latest version was evaluated by 40 patients with knee disease (meniscal injury, anterior cruciate ligament rupture, chondromalacia and gonarthrosis), who confirmed that they understood the text. Subsequently, the internal consistency was evaluated using Cronbach's alpha test for all items, and the intraclass correlation coefficient ­ ??total score of the sub-construct through a random sample (n=93), which validated the factorial structure of the scale. Results Cronbach's alpha was 0.737 and the interclass correlation coefficient was 0.844, associated with a high inter-observer agreement (Gamma=0.752). The Bland-Altman plot did not show systematic differences between the measurements Discussion This Spanish (Colombian) version of the Lysholm scale is a valid tool to measure functionality in patients with meniscal lesions of the anterior cruciate ligament, patellofemoral chondromalacia and gonarthrosis in Spanish-speaking countries (preferably in Colombia).

Reconstrucción del ligamento cruzado anterior con autoinjerto vs aloinjerto / COMPARATION OF THE RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT WITH AUTOGRAFT VS. ALLOGRAFT

Introducción: La reconstrucción del ligamento cruzado anterior (LCA) se basa en reemplazar la ruptura del ligamento con un injerto, fijando los extremos de la tibia y fémur, mediante la colocación de un injerto, de tipo autoinjerto o aloinjerto. Objetivo general: Comparar la reconstrucción ligamentaria del cruzado anterior con autoinjerto vs aloinjerto. Material y métodos: Estudio cuasiexperimental, comparativo, longitudinal, prospectivo, heterodémico y unicéntrico, que se realizó en la consulta externa del Hospital Ángeles de Puebla, durante el periodo del 1 de noviembre a abril del 2018, evaluando en el postoperatorio inmediato y a los 9 meses con la escala de Lysholm, escala visual Análoga (EVA) y Escala de Tegner. Resultados: se analizaron a 50 pacientes, 25 pacientes se les realizó autoinjerto en el 80% menores de 29 años y el 20% mayores de 30 años, el 68% fueron del sexo masculino, 32% femenino, el 52% presentaron afectaciones en el lado derecho y el 80% fue por lesión deportiva. Los pacientes con aloinjerto fueron 25, 60% menores de 29 años y 40% mayores de 30 años, el 56% del sexo masculino, el 44% del femenino, 56% con afectación del lado izquierdo y el 60% por accidente. Se empleó la prueba estadística U de Mann Whitney para comparar la funcionalidad articular basal y a los 9 meses con la Escala Funcional de Lysholm, identificando que los pacientes con aloinjerto tuvieron mayor funcionalidad (p=0.0001), menor intensidad de dolor empleando la escala de EVA (p=0.050) y mayor nivel de actividad con la escala de Tegner, pero no significativa (p=0.148). Conclusiones: Se concluye que los pacientes con reconstrucción del ligamento cruzado anterior con aloinjerto, tuvieron mayor funcionalidad articular, evaluado por la escala de Lysholm, menor intensidad de dolor por escala EVA y se recupero el nivel de actividad física con la Escala de Tegner

Introduction: The reconstruction of the anterior cruciate ligament (ACL) is based on replacing the rupture of the ligament with a graft, fixing the ends of the tibia and the femur, by means of the placement of a graft, autograft or allograft type. Course objective: To compare the anterior cruciate ligament reconstruction with autograft vs allograft. Material and methods: Quasi-experimental, comparative, longitudinal, prospective, heterodémic and unicentric study, which was carried out in the outpatient clinic of Hospital Angeles de Puebla, during the period from November 1 to April 2018, evaluating in the immediate postoperative period and at 9 months with the Lysholm scale, Analog Visual Scale (EVA) and Tegner Scale. Results: 50 patients were analyzed, 25 patients underwent autograft in 80% in 29 years and 20% in 30 years, 68% were men, 32% women, 52% had affectations in the right side and 80% were due to injuries Sports Patients with allograft were 25, 60% younger than 29 years and 40% older than 30 years, 56% men, 44% women, 56% left side and 60% accidental. The Mann Whitney U statistical test was used to compare the baseline joint functionality and at 9 months the Lysholm Functional Scale, identifying that patients with allograft had greater functionality (p=0.0001), less pain intensity using the EVA scale (p=0.050) and higher level of activity with the Tegner scale (p=0.148) Conclusions: It is concluded that patients with reconstruction of the anterior cruciate ligament with allograft, had greater efficiency in joint functionality, evaluated by the Lysholm scale and with less pain intensity

Comparative Study of Function and Quality of Life in Patients with Fracture of the Tibial Plateau Operated with Locked or Conventional Plates / Função e qualidade de vida de pacientes com fratura do planalto tibial operados com placa bloqueada ou convencional: estudo comparativo

Abstract Objective To compare clinical, functional, and quality of life outcomes between patients with tibial plateau fractures operated with locked or conventional plates, and to compare the costs of these implants. Methods This was a comparative cross-sectional study of a consecutive series of patients with tibial plateau fractures treated surgically from August 2015 to June 2016. Patients < 18 years old, those unable to answer the questionnaires or to attend the outpatient reassessment, polytrauma patients, those with associated injuries on the ipsilateral limb, and patients who had not undergone treatment with bone plates were excluded. The present study compared the costs of the implants for the hospital, quality of life (with the 12-Item Short Form Health Survey [SF-12]), Lysholm score, pain scale, and clinical and radiological parameters. Results A total of 45 patients with tibial plateau fractures were admitted, and 11 cases were excluded. Two cases were lost to follow-up; therefore, 32 remained for the analysis (94%). The mean follow-up time was of 15.1 months (standard deviation [SD] = 4.8 months). In group A (locked plates), there were 22 patients (69%), at an average hospital cost of BRL 4,125.39/patient (SD = 1,634.79/patient) for the implants. In group B (conventional plates) there were 10 patients (31%), at an average cost of BRL 438.53 (SD = 161.8/patient) (p < 0.00001). For the other parameters, no differences were observed, except for a greater articular depression in group A (2.7 mm ± 3.3 mm versus 0.5 mm ± 1.6 mm; p = 0.02; TE = 0.90). Conclusion The costs of locked implants for the treatment of tibial plateau fractures are significantly higher than those of conventional implants, without any clinical, quality of life, radiological, or functional advantages of the locked implants demonstrated in the present series.

Resumo Objetivos Comparar resultados clínicos, funcionais e de qualidade de vida de pacientes com fratura do planalto tibial operados com placa bloqueada ou convencional e comparar os custos hospitalares dos implantes. Métodos Estudo comparativo de coortes transversal, retrospectivo, em uma série consecutiva de pacientes com fratura do planalto tibial tratados cirurgicamente entre agosto de 2015 e junho de 2016. Foram excluídos: menores de 18 anos; indivíduos incapazes de responder os questionários ou de comparecer para reavaliação; politraumatizados ou comlesões associadas no mesmomembro; pacientes não tratados complaca ou conservadoramente. Os autores compararam os custos dos implantes, a qualidade de vida (SF-12), o escore de Lysholm, a escala visual de dor e os parâmetros clínicos e radiográficos. Resultados Foramobservadas 45 fraturas no período, das quais 11 foramexcluídas. Dos 34 pacientes, dois não compareceram à entrevista (seguimento de 94%). O tempo de seguimento foi 15,1 ± 4,8 meses.Ogrupo A (placa bloqueada) incluiu 22 pacientes (69%), comcusto hospitalarmédio dos implantes de R$ 4.125,39 (dp = R$1.634,79/paciente). O grupo B (placa convencional) incluiu dez pacientes (31%), a um custo médio de R$ 438,53 (dp = R$ 161,8/paciente; p < 0,00001). Para os demais parâmetros avaliados, não foram observadas diferenças significativas entre os grupos, exceto por ummaior degrau articular no grupo A (2,7 mm ± 3,3 mm vs. 0,5 mm ± 1,6 mm; p = 0,02; TE = 0,90). Conclusão O custo dos implantes bloqueados para o tratamento das fraturas do planalto tibial é significativamente superior aos implantes convencionais, embora não tenham apresentado vantagem clínica, radiográfica, funcional ou de qualidade de vida, nos pacientes dessa amostra.

The functional outcome of arthroscopic anterior cruciate ligament reconstruction in patients using different graft tension during tibial fixation

Background@# Anterior Cruciate Ligament (ACL) reconstruction is commonly performed to restore knee kinematics and halt the progression of osteoarthritis. A primary variable that could infl uence the outcome of ACL reconstruction is the tension applied to the graft at the time of fi xation. If the tension is too great, an abnormal compressive force could potentially develop across the tibiofemoral joint, hindering knee motion, and subjecting the articular surfaces to increased stress. If the tension in the graft is too low, the graft will not be effective in restoring normal kinematics. The Tegner Lysholm Knee Scale is a functional scoring for patients with ligamentous injuries. It is a patient-reported measure of knee function and is important for comprehensive assessment conditions in both the clinical and research context. Our objective was to compare which tension technique (15 lbs graft tension using a Mitek Tensioner™ vs maximal sustained two-hand technique) would yield better functional outcome at 6 months and 12 months postoperatively using the Tegner Lysholm Knee Scale. @*Methods @#Twenty-nine patients who underwent arthroscopic ACL reconstruction at the University of Santo Tomas Hospital Private Division were randomly divided equally into two groups (group A or group B). During tibial fi xation, group A would receive 15 lbs graft tension using a Mitek Tensioner and group B would receive graft tension using the maximal sustained two-handed pull technique. The patients underwent a standard rehabilitation protocol at an institution of their choice and a Lysholm Scoring Scale and Tegner activity scale were self-administered at 6 months and 12 months after the surgery in order to assess their functional outcome.@*Results @#The results showed that the functional outcome scores of group A were higher than group B. The yielded p-value was 0.10 (6 months), 0.07 (12 months) for group A and 0.27 (6 months), 0.46 (12 months) for group B. The results showed no suffi cient evidence of a signifi cant difference between the effects of arthroscopic ACL reconstruction with 15 lbs weight using a Mitek Tensioner (group A) and graft tension using the maximal sustained two-handed pull technique (group B) in the knee functional outcome of patients at 6 months and 12 months postoperatively@*Conclusion@#The functional outcome scores of patients who underwent ACL reconstruction using different graft tension did not show signifi cant results. Further re-evaluation of patients’ functional outcome score is necessary after 12 months postoperatively. The desired tensioning technique of the ACL surgeon would be at his/her convenience knowing beforehand the pros and cons of each technique.

Functional Effects of Single Semitendinosus Tendon Harvesting in Anatomic Anterior Cruciate Ligament Reconstruction: Comparison of Single versus Dual Hamstring Harvesting

BACKGROUND: This study aimed to determine the effects of single semitendinosus tendon (ST) harvesting for anterior cruciate ligament (ACL) reconstruction by comparing outcomes of single ST and semitendinosus-gracilis tendon (ST-G) harvesting. METHODS: ACL reconstruction with ST-G harvesting (D group, n = 60) or single ST harvesting (S group, n = 60) were included according to inclusion criteria. Subjective assessments included subjective International Knee Documentation Committee score, Lysholm score, and Tegner activity scale score. Objective assessments included isokinetic strength and functional tests. These tests were completed at 36 months of follow-up. Magnetic resonance imaging (MRI) and second-look arthroscopy findings were evaluated. In the S group, regeneration properties were assessed by serial ultrasonography (US). RESULTS: The S group showed significantly less deep flexor strength deficit than the D group (p < 0.001). Deep flexor power deficits showed significant correlation with the shift of musculotendinous junction of the ST. There was significant difference in the cocontraction test between the groups (p = 0.012), and the S group tended to show better results in other functional tests at the last follow-up. There were no significant differences in graft tension and synovial coverage on second-look arthroscopy between the groups. In the S group, the regeneration rates assessed by US at the joint line and distal insertion were 81.7% and 80%, respectively at 6 months of follow-up. CONCLUSIONS: The S group showed significantly less deficit in deep flexor strength and tended to show better clinical results at the last follow-up than the D group. In the S group, more than 80% showed good regeneration at the 6-month follow-up. Hence, single ST harvesting is effective in minimizing flexor weakness and functional deficits and shows great potential for regeneration.

The role of microfractures with tibial osteotomy in the treatment of knee osteoarthritis with a varus deformity / O papel das microfraturas associadas a osteotomia tibial no tratamento da gonartrose com geno varo

ABSTRACT Objective: To evaluate the microfracture intervention with tibial valgus osteotomy associated in the treatment of varus gonarthrosis. Methods: From November 2005 to May 2013, 129 patients with medial gonarthrosis, varus deformity (8°-12°), and range of movement greater than 90° were evaluated. Patients with advanced gonarthrosis (Alhbäck 3, 4, and 5), Outerbridge lesion inferior to IV, previous knee surgery, body mass index greater than 35 kg/m2, and/or cruciate ligament injuries were not included. All patients were treated with videoarthroscopy followed by tibial valgus osteotomy. In the group osteotomy associated with microfracture (n = 56, mean age = 39.3), tibial valgus osteotomy and microfracture techniques to address chondral defects were used. In the isolated osteotomy group (n = 73, mean age = 41.4), only this procedure was performed. Post-surgical follow-up was 24 months, with four evaluations in the first 6 months, proceeding to biannual twice-a-year evaluation in the subsequent period. The Lysholm scale was used for functional monitoring. Results: There was a significant improvement in the pain, limping, and squatting domains of the Lysholm scale but only in the isolated osteotomy group. A greater variance of results was observed in the osteotomy group associated to microfracture, in addition to an increased risk of functional deterioration (OR = 8.64). Conclusion: The association of microfractures and tibial valgus osteotomy was correlated to lower functional outcomes than tibial valgus osteotomy alone, and may be related to the risk of worsening in the first two postoperative years.

RESUMO Objetivo: Avaliar a intervenção de microfratura associada a osteotomia tibial valgizante no tratamento de gonartrose medial com geno varo. Métodos: Entre novembro de 2005 e maio de 2013, foram avaliados 129 pacientes portadores de gonartrose medial, geno varo entre 8° e 12° e arco de movimento superior a 90°. Não foram incluídos pacientes com gonartrose avançada (Alhbäck 3, 4 e 5), lesão Outerbridge inferior a IV, cirurgia prévia na articulação, índice de massa corpórea superior a 35 kg/m2 e/ou lesão de ligamentos cruzados. Todos os pacientes foram submetidos a videoartroscopia do joelho seguida de osteotomia tibial valgizante. No grupo osteotomia tibial valgizante associado a microfratura (n = 56, média de idade = 39,3) foram associadas as técnicas de osteotomia tibial valgizante e microfratura nos defeitos condrais. No grupo osteotomia tibial valgizante isolada (n = 73, média de idade = 41,4), apenas esse procedimento foi feito. O acompanhamento pós-cirúrgico foi de 24 meses, com quatro avaliações ambulatoriais nos primeiros seis meses, passou-se a avaliações semestrais no período subsequente. A escala de Lysholm foi usada no acompanhamento funcional. Resultados: Uma melhoria significativa nos domínios dor, claudicação e agachamento da escala de Lysholm foi observada apenas no grupo osteotomia tibial valgizante isolada. Maior variância de resultados foi observada no grupo osteotomia tibial valgizante associada a microfratura e uma razão de chances de pioria de 8,64. Conclusão: A associação das microfraturas e osteotomia tibial valgizante tem resultado funcional inferior à osteotomia tibial valgizante isolada, pode ainda estar relacionada ao risco de pioria nos primeiros dois anos de pós-operatório.

Reconstrucción de esquina posteromedial: reporte de 30 casos / Posteromedial corner reconstruction: a report of 30 cases

OJETIVO: Reportar la experiencia, después de 1 año de seguimiento, de una serie de 30 pacientes sometidos a reconstrucción de la esquina posteromedial (EPM) con la técnica descrita por La Prade. MÉTODO: Cohorte retrospectiva de 30 pacientes con lesión de EPM operados por el mismo equipo quirúrgico. Criterios de inclusión: diagnóstico clínico, radiografía con estrés y resonancia magnética compatibles con lesión de EPM, inestabilidad grado III luego de 3 meses de tratamiento ortopédico, técnica de reconstrucción de La Prade, al menos 12 meses de seguimiento. Criterios de exclusión: discordancia entre clínica e imagenología, inestabilidad grado I o II, y otra técnica quirúrgica. Evaluación con IKDC y Lysholm antes de la cirugía, a los 6 y 12 meses de seguimiento postcirugía. RESULTADOS: 30 pacientes cumplieron los criterios de inclusión. Promedio de edad 43 años (24­69). Veintiocho pacientes presentaron lesiones de alta energía, 20 pacientes fueron diagnosticados en agudo, mientras que 10 fueron diagnosticados luego de malos resultados en reconstrucción de otros ligamentos. Veintiocho presentaron lesiones asociadas: 11 casos asociados a lesión de ligamento cruzado anterior, 3 casos asociados a lesión de ligamento cruzado posterior, 3 casos en asociación con lesiones meniscales, 9 casos con lesión asociada de ligamento cruzado anterior y posterior, y 2 casos en asociación con ligamento cruzado anterior, posterior y ligamento colateral lateral. Promedio de tiempo hasta la reconstrucción de EPM fue de 5 meses (rango 2­32). Puntuación en Lysholm e IKDC (preoperatorio 18,2 y 24,3 respectivamente), mejoraron a 76,7 y 70,7 después de 1 año de seguimiento. Al fin del seguimiento, el rango articular promedio era 113° (90­140), la mayoría de los pacientes (24) tuvieron estabilidad tipo A según IKDC. CONCLUSIÓN: La reconstrucción de lesiones de EPM mejora los resultados clínicos en pacientes con inestabilidad crónica posteromedial de rodilla. Se observó mejoría en la estabilidad y scores funcionales de todos los pacientes.

OBJETIVE: Report the experience, after 1-year follow-up, of 30 patients with La Prade's anatomical reconstruction of posteromedial corner (PMC) injuries. METHODS: Retrospective cohort study. 30 patients with PMC injuries operated by the same surgical team. Inclusion criteria: clinical presentation, stress radiographs and MRI compatible with PMC injury, grade III chronic instability in spite of at least 3 months of orthopedic treatment, La Prade's anatomical technique reconstruction, 12 months follow-up at least. Exclusion criteria: discordance between clinical and image studies, grade I or II medial instability, any other surgical technique. IKDC and Lysholm at the preoperative evaluation, 6 and 12 months after surgery. RESULTS: Thirty patients met the inclusion criteria. Mean age 43 years (24­69). 28 patients presented high-energy mechanism of injury. Twenty patients were diagnosed in the acute setting, while 10 had a delayed diagnosis after poor results of other ligament reconstruction. Majority (28) had associated injuries: 11 cases PMC + anterior cruciate ligament (ACL) injury, 3 PMC + posterior cruciate ligament (PCL) injury, 3 PMC + meniscal tears, 9 PMC + ACL + PCL injuries, and 2 PMC + ACL + PCL + lateral collateral ligament injuries. Mean time for PMC reconstruction was 5 months (range 2­32). Preoperative Lysholm and IKDC scores (18,2 and 24,3 respectively) improved to 76,7 and 70,7 after 1-year follow-up. At the end of follow-up, average ROM was 113° (90­140), most patients (24) had type A IKDC stability. CONCLUSION: Acceptable results were achieved following reconstruction of PMC injuries in patients with chronic posteromedial knee instability. We observed instability and functional scores improvement in all patients.

Outcome of Arthroscopic Treatment of Mucoid Degeneration of the Anterior Cruciate Ligament

BACKGROUND: Mucoid degeneration of the anterior cruciate ligament is a rare pathological entity. Several authors have identified this condition, described their experiences, and suggested their own guidelines for management. The aim of this study was to detail the clinical, radiological, arthroscopic, and pathological findings of mucoid degeneration of the anterior cruciate ligament and report the clinical outcomes following arthroscopic treatment. METHODS: A historical cohort of patients who underwent arthroscopic total or partial excision of the anterior cruciate ligament due to mucoid degeneration between 2011 and 2014 were reviewed. The minimum follow-up was 3 years. Demographic, radiological, and histological findings, type of surgery, and clinical pre- and postoperative data were analyzed. The visual analogue scale score, the International Knee Documentation Committee score, and the Tegner Lysholm Knee Score were collected preoperatively, postoperatively, and during the follow-up period. RESULTS: Seventeen females (67%) and eight males (33%) were included in the final analysis. The mean age at the time of surgery was 57 years (range, 31 to 78 years). Partial resection of the anterior cruciate ligament was done in seven cases and a complete resection in 18 cases. No reconstruction was performed at the same time. A positive Lachman test and a negative pivot shift were noted after surgery in all cases. Anterior cruciate ligament reconstruction was required in only one young patient due to disabling instability. At last follow-up, the mean visual analogue scale score, International Knee Documentation Committee score, and Tegner Lysholm Knee score improved (p < 0.01). CONCLUSIONS: Our study provides further evidence that arthroscopic total or partial excision of anterior cruciate ligament is a safe and effective treatment for mucoid degeneration of the anterior cruciate ligament, improving patient satisfaction and function without causing clinical instability in daily activities. However, young patients should be forewarned about the risk of instability, and an anterior cruciate ligament reconstruction could be necessary.

High Tibial Osteotomy versus Unicompartmental Knee Arthroplasty for Medial Compartment Arthrosis with Kissing Lesions in Relatively Young Patients

PURPOSE: The purpose of this study is to compare the clinical and radiographic outcomes of high tibial osteotomy (HTO) and unicompartmental arthroplasty (UKA) in advanced medial compartment arthritis accompanied by kissing lesions in relatively young patients. MATERIALS AND METHODS: Forty-five patients were divided into the HTO (n=23) and UKA (n=22) groups. Clinically, we evaluated the Lysholm knee scoring scale, visual analogue scale, Hospital for Special Surgery, and Western Ontario and McMaster Universities Osteoarthritis index scores preoperatively, 6 and 12 months postoperatively, and at the final follow-up. Radiographically, we measured the femoral-tibial angle and mechanical axis deviation preoperatively and at the final follow-up. RESULTS: All clinical outcomes gradually improved in both groups from the postoperative period to the final follow-up. At the final follow-up, all clinical outcomes were slightly better in the UKA group than in the HTO group; however, differences were not statistically significant. CONCLUSIONS: HTO is comparable to UKA in terms of clinical outcomes. Thus, the results of this study suggest that HTO might be a good alternative treatment to UKA for medial unicompartmental arthritis accompanied by kissing lesions in relatively young patients.

A Comparison of Results after Anterior Cruciate Ligament Reconstruction in over 40 and under 40 Years of Age: A Meta-Analysis

PURPOSE: Anterior cruciate ligament (ACL) injury is one of the most common injuries that occur in the knee, and ACL reconstruction (ACLR) is commonly performed for preventing aggravation of degenerative changes and restoring of knee stability in young, athletic patients. This metaanalysis has a purpose of evaluating the clinical and arthrometrical outcomes of ACLR in a group of middle age patients (40 years and older) and comparing with patients under 40 years of age. METHODS: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science, and SCOPUS electronic databases were searched for relevant articles comparing the outcomes of ACLR between younger and older than 40 years of age until December 2016. Data searching, extraction, analysis, and quality assessment were performed based on the Cochrane Collaboration guidelines. Clinical outcomes were evaluated and compared between groups. The results were presented as mean difference for continuous outcomes with 95% confidence intervals whereas risk ratio for binary outcomes. RESULTS: Seven studies were included in the meta-analysis. Based on International Knee Documentation Committee classification, side-to-side difference, Tegner activity score, Lysholm knee score, there were no significant clinical and mechanical differences between the groups. CONCLUSIONS: This meta-analysis confirmed that after ACLR, middle age (>40 years) and young age (<40 years) patients did not present with significant difference in clinical and arthrometric results.

Factors Affecting the Extent of Graft Tendon Synovialization after Double-Bundle Anterior Cruciate Ligament Reconstruction: Based on Second-Look Arthroscopic Findings

BACKGROUND: We aimed to examine the factors that influence synovialization of the grafted tendon after double-bundle anterior cruciate ligament (ACL) reconstruction based on second-look arthroscopic findings. METHODS: Out of 205 knees that were treated between August 2008 and May 2016 with double-bundle ACL reconstruction using bio-absorbable cross-pins and Endobuttons for femoral tunnel fixation, we enrolled 65 knees (64 patients) that underwent second-look arthroscopy with hardware removal at 1 year postoperatively. Measured clinical outcomes included the Lysholm score and Tegner activity score that were evaluated preoperatively and during the final follow-up. We analyzed the relationship between synovial coverage and patient age, length of the preserved remnant tissue on the tibial side, type of bundle (anteromedial or posterolateral), type of graft (autograft or allograft), and time from injury to surgery. RESULTS: The area of synovial coverage showed a significant statistical correlation with patient age and the length of the preserved remnant tissue on the tibial side. The average synovial coverage was significantly better for the anteromedial bundle than for the posterolateral bundle, better for the autograft than for the allograft reconstruction, and better when treated in the acute stage than in the chronic stage. However, synovialization of grafted tendon did not correlate to clinical outcomes. CONCLUSIONS: While we were able to identify several factors influencing synovialization of the grafted tendon after double-bundle ACL reconstruction, including patient age, length of preserved remnant tissue of the torn ACL, type of bundle, type of graft, and time from injury to surgery, we found no evidence that increased synovialization improves clinical outcomes at 1 year postoperatively.

Estudio comparativo de reconstrucción de ligamento cruzado anterior con y sin lesiones condrales; resultados funcionales a largo plazo / Anterior cruciate ligament reconstruction with and without chondral lesions; long term functional results

INTRODUCCIÓN: La lesión del ligamento cruzado anterior (LCA), es una patología frecuente, y el éxito de la reconstrucción depende de diversos factores, tales como la técnica quirúrgica empleada, la edad del paciente, índice masa corporal, nivel de actividad y lesiones asociadas. El objetivo de este estudio es comparar los resultados funcionales a largo plazo de pacientes con lesiones condrales tratadas y sin lesiones condrales sometidos a la reconstrucción de LCA (RLCA), con autoinjerto semitendinoso-gracilis (ST-G). MATERIALES Y MÉTODOS: Estudio analítico retrospectivo. Cuarenta y nueve pacientes (34 hombres y 15 mujeres), fueron sometidos a la RLCA con autoinjerto ST-G. Se compararon dos grupos. Grupo RLCA + LC: 24 pacientes con lesiones condrales ICRS grado III y IV tratadas en el mismo acto quirúrgico y grupo RLCA: 25 pacientes sin lesiones condrales concomitantes. Las edades promedio fueron de 32 y 28 años en cada grupo respectivamente. La funcionalidad de los pacientes a largo plazo fue evaluada con el test de Lysholm, IKDC y retorno deportivo. Se compararon los promedios de los scores funcionales según cada grupo con Test de Mann-Whitney. La asociación entre ambos grupos y el retorno deportivo se analizó con Test de Chi2. Los análisis estadísticos se realizaron con Stata IC 13. RESULTADOS: El seguimiento promedio fue de 106,8 meses (rango: 86­125). Los resultados funcionales obtenidos al comparar el grupo RLCA + LC vs grupo RLCA fueron significativamente peores en el primero, con un promedio del score de Lysholm de 84,87 vs 94,52 (p = 0.0001) e IKDC de 84,43 vs 92,08 (p = 0,004), respectivamente. El retorno deportivo de cada grupo fue de 70,8% y 88% (p = 0,136). CONCLUSIÓN: La funcionalidad a largo plazo de los pacientes con una RLCA y que tengan alguna LC profunda tratada concomitante, es significativamente inferior que aquellos pacientes con RLCA aislada. No existen diferencias significativas en el porcentaje de retorno deportivo entre ambos grupos.

INTRODUCTION: Anterior cruciate ligament injury is a frequent sports injury, and successful reconstruction depends on diverse factors, such as surgical technique, age, body mass index, level of activity and other concomitant cartilage and meniscal lesions. The objective of this study is to retrospectively compare the long term clinical outcomes of ACL hamstring tendon autograft reconstruction with and without concomitant cartilage injuries. MATERIALS AND METHODS: Forty nine patients (34 men and 15 women) underwent single bundle transtibial ACL reconstruction and were divided in two groups (Group 1: 24 patients with chondral lesions grade III and IV of the ICRS, and Group 2: 25 patients without chondral lesions). Mean age of both groups was 32 and 28 years, respectively. Clinical outcome was evaluated with Lysholm test, IKDC and return to previous level of sport activities. Mean values of of funcional outcome scores between both groups were compared with Mann-Whitney test. Return to previous level of activity in both groups was analyzed with Chi-2 test. The statistical analysis was performed with Stata IC 13. RESULTS: The mean follow-up period was 106.8 months (range: 86­125). Mean Lysholm test for group 1 vs group 2 was 84.87 and 94.52 (p < 0.001), mean IKDC was 84.43 and 92.08 (p < 0.001), and return to previous sports was 70.8% vs 88% (p = 0.136) for each group. CONCLUSION: Long term clinical outcomes in patients with chondral lesions that underwent ACL reconstruction were significantly lower than patient with isolated ACL injuries. No statistical differences were found in the return to previous sport activities.

Comparison of Poly-L-Lactic Acid and Poly-L-Lactic Acid/Hydroxyapatite Bioabsorbable Screws for Tibial Fixation in ACL Reconstruction: Clinical and Magnetic Resonance Imaging Results

BACKGROUND: The purpose of this study was to compare the clinical and radiological results of 2 different tibial fixations performed using bioabsorbable screws with added hydroxyapatite (HA) and pure poly-L-lactic acid (PLLA) screws in anterior cruciate ligament (ACL) reconstruction. METHODS: A total of 394 patients who underwent arthroscopic ACL reconstruction between March 2009 and June 2012 were retrospectively reviewed. Of those, 172 patients who took the radiological and clinical evaluations at more than 2 years after surgery were enrolled and divided into 2 groups: PLLA group (n = 86) and PLLA-HA group (n = 86). Both groups were assessed by means of the Lysholm score, International Knee Documentation Committee (IKDC) subjective knee score, and Tegner activity score. Stability was evaluated using the KT-2000 arthrometer. Magnetic resonance imaging was performed to evaluate tibial tunnel widening, screw resorption, osteoingeration, and foreign body reactions. RESULTS: The PLLA-HA group showed significant reduction in the extent of tibial tunnel widening and foreign body reactions and significant increase in screw resorption compared to the pure PLLA group (p < 0.001 for both). In contrast, postoperative Lysholm score, Tegner activity score, IKDC score, and side-to-side difference on the KT-2000 arthrometer showed no significant differences between groups (p = 0.478, p = 0.906, p = 0.362, and p = 0.078, respectively). The PLLA group showed more significant widening in the proximal tibial tunnel than the PLLA-HA group (p = 0.001). In the correlation analysis, proximal tibial tunnel widening revealed a positive correlation with knee laxity (r = 0.866) and a negative correlation with Lysholm score (r = −0.753) (p < 0.01 for both). CONCLUSIONS: The HA added PLLA screws would be advantageous for tibial graft fixation by reducing tibial tunnel widening, improving osteointegration, and lowering foreign body reactions. Even though no clinically significant differences were noted between the pure PLLA group and PLLA-HA group, widening of the proximal area of the tibial tunnel showed a tendency to increase knee laxity measured using the KT-2000 arthrometer.

Comparative Study of Clinical and Radiographic Outcomes of High Tibial Osteotomy in Patients with Kissing Lesions and Non-Kissing Lesions

PURPOSE: High Outerbridge grade lesions of the articular cartilage have been associated with poor outcomes of high tibial osteotomy (HTO). However, there has been no report on the efficacy of HTO in the presence of kissing lesions. The purpose of this study was to compare clinical and radiographic outcomes of HTO between kissing lesion and non-kissing lesion groups. MATERIALS AND METHODS: Of the patients with medial compartment osteoarthritis and varus deformity treated with HTO between 2007 and 2012, 21 cases with kissing lesions and 22 cases without kissing lesions were selected. Clinical outcomes were assessed using the Lysholm knee scoring scale score, visual analogue scale score, Hospital for Special Surgery score, Western Ontario and McMaster Universities score, and Tegner activity score. Radiographic outcomes were assessed using the femoral-tibial angle, mechanical axis deviation, medial proximal tibial angle, posterior tibial slope angle, and joint space width. RESULTS: Clinical outcomes were improved in both groups from the postoperative assessment to the final follow-up, which showed no statistically significant difference between groups at the final follow-up. No statistically significant differences were observed with regard to radiographic assessment. CONCLUSIONS: Since both groups showed favorable short-term clinical and radiographic outcomes, HTO might be an alternative treatment option for degenerative osteoarthritis with kissing lesions in relatively young patients.

Arthroscopic Meniscectomy for Medial Meniscus Horizontal Cleavage Tears in Patients under Age 45

PURPOSE: The purpose of this study was to evaluate the demographics, clinical features, and outcomes of arthroscopic partial meniscectomy (APM) for isolated medial meniscus horizontal cleavage tears (MMHCTs) in patients under 45 years of age. MATERIALS AND METHODS: We retrospectively reviewed 98 patients (100 knees) under 45 years who underwent APM for MMHCTs. Clinical outcomes were assessed using International Knee Document Committee (IKDC) subjective core, Tegner activity scale, visual analog scale (VAS) pain score, and a question on the symptom relief. RESULTS: 79% were male and 70% had no trauma. The mean symptom duration was 10 months. At arthroscopy, a flap tear was identified in 75%. At a mean of 19-month follow-up, the IKDC subjective score, Tegner activity scale, and VAS pain score were significantly improved compared to the preoperative values (p=0.025, p=0.043, and p=0.032, respectively). While 85% were free of symptoms, 15% had persistent pain. No significant differences in outcomes were observed based on the tear type and the presence of flap tears. No progression or development of radiographic degenerative changes was observed in all knees. CONCLUSIONS: Demographics of MMHCTs under age 45 showed a male dominance and higher frequency of non-traumatic tears. APM was beneficial to symptomatic HCTs in this cohort during the short-term follow-up. Type of HCTs and combined flap tears did not affect clinical outcomes.

Open Wedge High Tibial Osteotomy and Combined Arthroscopic Surgery in Severe Medial Osteoarthritis and Varus Malalignment: Minimum 5-Year Results

PURPOSE: To evaluate the radiologic and functional outcomes of medial open wedge high tibial osteotomy (HTO) combined with arthroscopic procedure in patients with medial osteoarthritis. MATERIALS AND METHODS: From June 1996 to March 2010, 26 patients (32 knees) who underwent medial open wedge osteotomy and arthroscopic operation for medial osteoarthritis were retrospectively reviewed. Measurements included hip-knee-ankle (HKA) angle, femorotibial angle, medial proximal tibial angle, posterior tibial slope angle, and Kellgren-Lawrence grade. Clinical evaluation was performed using Lysholm knee scoring scale and knee and function score of the American Knee Society. RESULTS: Differences between the mean preoperative and postoperative measurements were significant in all angles including the HKA angle (−5.7° and +5.5°), femorotibial angle (−1.9° and +9.8°), and medial proximal tibial angle (82.9° and 90.5°) (p<0.05). Mean Lysholm knee scoring scale was 63.6 preoperatively and 88.7 at the last follow-up, mean Knee Society knee score was 61.2 and 86.6, and mean function score was 59.3 and 87.2, respectively. All differences were significant (p<0.05). CONCLUSIONS: Medial open wedge HTO in combination with arthroscopic procedure is an effective treatment method for medial osteoarthritis to treat varus deformity and an intra-articular lesion.

The Efficacy of Arthroscopic Debridement with Continuous Irrigation in Failed Arthroscopic Debridement for Septic Arthritis of the Knee / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to evaluate the efficacy of arthroscopic debridement with continuous irrigation in patients with septic arthritis of the knee after failed primary arthroscopic treatment. MATERIALS AND METHODS: Among 69 patients undergoing arthroscopic debridement for septic arthritis of the knee from March 2008 to March 2013, 14 patients (5 male, 9 female; mean age, 68.9±11.3 years) with failed arthroscopic debridement for septic arthritis of the knee were reviewed retrospectively (mean follow-up period, 49.2±23.2 months). All 14 patients underwent re-do of the arthroscopic debridement, then continuous irrigation. Continuous irrigation following arthroscopic debridement was maintained for a mean 8.4±2.5 days. For clinical evaluation, Lysholm knee score and visual analogue scale (VAS) were used at 1 month, 3 months, and 12 months after surgery. During the entire follow-up period, recurrence of infection and operation-related complication were also assessed. RESULTS: Symptom improvement was observed in 12 cases (85.7%) of the 14 cases. Lysholm knee score was improved from 36.1±7.9 to 84.2±9.2 at 12 months after surgery (p<0.05). VAS was improved from 8.9±1.3 to 2.1±1.2 at 12 months after surgery (p<0.05). Synovial fluid cultures yielded positive findings in 9 of the 14 cases with the same bacteria in primary surgery. During the follow-up period, septic arthritis relapsed in 2 of the 5 cases with negative finding of cultures. After reoperation was performed in those 2 cases, no recurrence was observed to final follow-up. There was no complication related operation in any cases. CONCLUSION: Arthroscopic debridement combined with continuous irrigation is a safe and effective procedure for failed arthroscopic debridement for septic arthritis of the knee.

Repair and Kennedy LAD Augmentation to Posterior Cruciate Ligament Injury / 대한정형외과학회잡지

The significance of the posterior cruciate ligament (PCL) in the stability of the knee and the necessity for surgical repair of its tears are still controversial. The purpose of this study is to present the short term results of surgical repair and Kennedy LAD augmentation for 15 cases with PCL injury. In 14 patients (15 knees), the torn PCL was repaired with pullout suture technique and Kennedy LAD augmentation was done from june 1993 to june 1994. The follow-up period ranged from 12 months to 25 months (average, 18months). The main causes of injuries were traffic accidents in 12. Thirteen of the patients were men and one was a woman, ranging in age from 17 to 52 years(average, 35 years). 10 knees were acute injury and repaired at average 9 days after injury. There were 11 cases that had combined injuries(4 ACL injuries, 4 meniscus injuries, 3 MCL injuries etc). In eight knees, the tear was in mid substance area and in five it was near femoral attach site and in two it was near tibial attach site. Postoperative results were evaluated by roentgenographic evaluation of posterior sagging and Lysholm knee score. 11 knee were stable but 4 knees were unstable posteriorly during postoperative follow-up period. 3 chronic injuried knees were included in 4 posteriorly unstable knees. There are 7 combined knee injuries in 11 stable knees and no combined injuries in unstable knees and average Lysholm knee score was 89.7 in stable knees and 90 in unstable knees and there was no significant difference between two groups. On the based of this study, surgical repair with pollout suture technique and augmentation with Kennedy LAD in acute PCL injury is a one of the good method for preventing posterior sagging but more longer follow-up period and more cases must be needed to accept this method.