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.

Protocol and descriptive epidemiology of the SIGASCOT Italian multicentric registry of revision ACL reconstruction: a 1-year pilot study.

The aim of the present study was to present the demographic and baseline results of the first year of course of the SIGASCOT Italian registry of Revision ACL reconstruction.The data of the patients undergoing revision ACL reconstruction, enrolled in by 20 SIGASCOT members from March 2015 to May 2016, were extracted from the Surgical Outcome System (SOS). Overall, 126 patients were enrolled; 18 were excluded due to incomplete data. Mean age at surgery was 30.4 ± 9.3 years (median 29; 23-38), mean BMI was 22.6 ± 2.3 kg/m2 and 77% were males. Revision was performed with a single-bundle technique in 94%, using allograft in 57% of cases and autograft in 43%. Only 28% had both menisci intact, and meniscal repair or replacement was performed in 25% of patients for medial meniscus and 8% for lateral meniscus. During the first year of enrollment, the SIGASCOT Italian ACL revision registry was able to collect the data of more than 100 patients. The revision ACL reconstruction was usually performed with a single-bundle technique, using allograft and autograft almost in the same extent.

Opening wedge high tibial osteotomy using a monoaxial dynamic external fixator.

PURPOSE: To prospectively assess midterm results in 37 patients (41 knees) who were treated with opening wedge high tibial osteotomy (OW-HTO) with the use of a monoaxial dynamic external fixator (MDEF) for medial knee osteoarthritis. METHODS: Clinical and subjective evaluations were performed using the IKDC and KOOS evaluation forms and the modified Knee Society Clinical Rating System (KSS). Pin tract infections were evaluated according to Checketts-Otterburns classification. Radiographic evaluation included long-standing AP lower limb, standard lateral, Rosenberg and Merchant views. RESULTS: Thirty-six patients (40 knees) were evaluated at a mean follow-up period of 7 years. Ten patients (25 %) developed a minor pin tract infection. Subjective KOOS and IKDC scores showed statistically significant improvement. Clinical evaluation with IKDC and KSS forms showed no patient with instability or a range-of-motion deficit worst than pre-operatively. At MDEF removal, the mechanical axis was on average 4.5° valgus; anatomical axis 6.8° valgus; the Mikulicz' line crossed the tibial plateau on average at 64 % of the width of the tibial plateau measured from medial; the posterior slope 5°; the metaphyseal varus 4.3°; and the Insall/Salvati ratio 1.02. At latest follow-up, five patients had a loss of correction of 1°-2° on mechanical axis and one patient had a loss of correction of 3° on mechanical axis and 4 % of mechanical axis on tibial plateau. CONCLUSIONS: The use of a MDEF to perform an OW-HTO showed a good maintenance of correction achieved with satisfactory midterm outcome results in all patients but three who underwent total knee replacement. The only severe post-operative complication was one case of non-union in a heavy smoker. LEVEL OF EVIDENCE: Prospective and therapeutic study, Level IV.

Patellofemoral function after total knee arthroplasty: gender-related differences.

The purpose of the study was to evaluate patellofemoral results in 2 comparable groups of 50 patients, men and women, undergoing total knee arthroplasty. The average follow-up was 6 years. The implant was posteriorly stabilized with a dome patellar arthroplasty. The patients were studied using Knee Society knee and functional scores and the Hospital for Special Surgery (HSS) patellar score. Radiologic study included standard and weight-bearing axial views and a computed tomographic scan to assess component rotation. The 2 groups achieved satisfactory and similar knee scores; women had a significantly lower functional and patellar scores. The incidence of lateral patellar tilt, subluxation, and lateral impingement was decreased in weight-bearing axial views compared with non-weight bearing. Medial bony impingement was evident only in weight-bearing views and correlated with pain (P < .05).

Radiographic evaluation of the tunnel position in single and double bundle anterior cruciate ligament reconstruction.

Aim To evaluate tunnel positioning on radiographs in singlebundle (SB) and double-bundle (DB) anterior cruciate ligament (ACL) reconstruction, to evaluate if measurement is accurate and reproducible. Methods Radiographs of 30 SB and 30 DB ACL reconstruction were reviewed by two examiners who measured tunnel positioning with the quadrant method on the femur (a=depth, b=height) and the Amis and Jakob method on the tibia. Intra- and inter-observer reliability were evaluated with intra-class correlation coefficient (ICC). Results A radiographic analysis was completed in all patients in a SB-group and in 27 in a DB-group (p>0.05). Intra-observer reliability was almost perfect on femoral (ICC: a=0.85, b=0.83) and tibial (ICC=0.87) side in the SB-group. In the DB-group, it was almost perfect for tibial anteromedial (AM) and posterolateral (PL) bundles (ICC: AM=0.84, PL=0.81) and for femoral PL bundle (ICC: a=0.83, b=0.82), and substantial for femoral AM bundle (ICC: a=0.78, b=0.74). Inter-observer reliability was almost perfect on tibial (ICC=0.81) and femoral (ICC: a=0.81, b=0.87) side in the SB-group, and substantial on tibial (ICC: AM=0.71, PL=0.77) and femoral (ICC: AM a=0.73, b=0.78; PL a=0.74, b=0.76) side in the DB-group. Standard deviation (SD) was low (±9%) with respect to the centre of tunnel(s). Conclusion The quadrant method and the Amis and Jakob method are accurate and reproducible measurement methods. Also, as SD was low, an outside-in approach with a front-entry guide, which is free-hand positioned, can be postulated as a reliable method to locate the femoral tunnel in SB reconstruction and the AM bundle in DB reconstruction.

Double-bundle "anatomic" anterior cruciate ligament reconstruction: a cadaveric study of tunnel positioning with a transtibial technique.

PURPOSE: The aim of this study was to examine whether a double-bundle anterior cruciate ligament (ACL) reconstruction with a transtibial approach could position the tibial and femoral tunnels accurately in the native bundle attachments. METHODS: In 21 fresh-frozen knees the tibial and femoral attachments of the anteromedial (AM) and posterolateral (PL) bundles were outlined. The AM tibial tunnel guidewire was drilled with the 65 degree Howell tibial guide (Arthrotek, Warsaw, IN) located against the femur in the extended knee. The PL tibial wire was drilled through a prototype attachment to the Howell guide. Of the knees, 14 were available for the femoral part of the study. The AM femoral guidewire used an aimer offset 3 mm from the over-the-top position. The PL wire was drilled transtibially at 70 degrees of flexion, with external rotation and posterior drawer loads being applied. The plateaus and condyles were photographed and the wire positions measured. RESULTS: With regard to the tibia, 17 of 21 AM wires were in the AM bundle attachment (at 61% and 36% of the natural ACL posteroanterior and mediolateral length, respectively) and 19 of 21 PL wires were in the PL bundle attachment (at 28% and 36% of the posteroanterior and mediolateral length, respectively). With regard to the femur, 12 of 14 AM wires and 9 of 14 PL wires were in the correct native bundle attachment. The AM wire was 3% more shallow than the center of the AM attachment (P = .03) and 6% more superior (P < .001), where 100% was the diameter of the posterior lateral condyle. The PL wire was 4% more shallow than the center of the PL attachment (P = .026) and 6% more superior (P < .001). CONCLUSIONS: Anatomic and reproducible tibial guidewire positioning was achieved. Femoral wires were reproducibly positioned, but both were superior to and more shallow than the natural ACL bundle attachments, so further development or a different approach is appropriate. CLINICAL RELEVANCE: The double-bundle reconstruction aims to restore anterior drawer and rotational stability. This technique ensures anatomic tibial positioning. Further improvements are needed with regard to the femur.

Use and Effectiveness of the Cadaver-Lab in Orthopaedic and Traumatology Education: An Italian Survey.

Purpose The purpose of this study is to provide basic information on the availability and current use of cadaver laboratories in the education of orthopaedic residents and trainees and to determine the interest for the implementation of this type of training. Methods All Orthopaedic residents and trainees who attended a cadaver laboratory organized by SIGASCOT (Italian Society of the Knee, Arthroscopy, Sports Traumatology, Cartilage and Orthopaedic Technology) between 2013 and 2016 were asked to complete a survey on the availability and current use of cadaver laboratories in the education of Orthopaedic residents and trainees. The survey was sent via e-mail to 102 Orthopaedic residents and trainees. All data were analyzed and all responses are presented as counts, percentages, or means. Results Thirty-eight (37.2%) Orthopaedics and traumatology residents and trainees completed the survey and were included in this analysis. Eighteen trainees (18/38; 44.3%) attended a cadaver laboratory focused on lower limb surgery, whereas 20 (20/38; 52.7%) on upper limb surgery. Twenty participants (55.7%) perceived skills laboratory sessions as extremely beneficial to the understanding and becoming familiar with the normal surgical anatomy; moreover, 16 (45.7%) participants considered the cadaver laboratory extremely beneficial to the understanding of a specific surgical technique and very beneficial (44.4%) to become confident with arthroscopic or other specific surgical instruments. Over 60% of participants perceived cadaver laboratory to be very to extremely beneficial to increase confidence and speed in the operating room (OR), and more than a half of them considered skills laboratory sessions to be extremely beneficial to increase participation and decrease the occurrence of damages in the real surgical activity. Conclusion Orthopaedic residents and trainees found the addition of a cadaver laboratory for teaching surgical skills a significant benefit to both their overall education and surgical skills training. Level of Evidence Level IV, survey study.

Validation of the 65 degrees Howell guide for anterior cruciate ligament reconstruction.

PURPOSE: To study in cadaver knees the position of the tibial tunnel in anterior cruciate ligament (ACL) reconstruction using the 65 degrees Howell guide (Arthrotek, Ontario, CA). TYPE OF STUDY: Controlled laboratory study in vitro. METHODS: Twenty-one fresh-frozen cadaver knees were used. The ACL was resected and its tibial attachment was demarcated. To drill the guidewire, we used the Howell 65 degrees tibial guide, which references off of the intercondylar roof in extension to avoid impingement. The intra-articular position of the wire was digitized with a digital camera and referred to a transverse axis passing through the over-the-back position and a sagittal axis passing through the lateral aspect of the medial spine. The percentage position of the wire within the ACL attachment was also calculated, taking the posterior and medial limits as the 0% positions. RESULTS: All the wires were within the ACL attachment: 17 were in the ACL posterolateral bundle attachment and the other 4 in the anteromedial. The average distance of the wire from the transverse and sagittal axes was 12 mm (SD, 3 mm) anterior and 1 mm (SD, 1 mm) lateral, respectively. The wire was positioned at 38% (SD, 16%) of the length of the ACL attachment and at 40% (SD, 17%) of the width. Eighty percent of the wires were positioned at between 35% and 48% of the attachment length. CONCLUSIONS: The 65 degrees Howell guide, which positions the tibial tunnel in extension to avoid roof impingement, ensures anatomic positioning of the graft on the tibial side and reproducibility can be expected. CLINICAL RELEVANCE: This study proves that a commonly used drill guide succeeds in placing the ACL graft in the tibial anatomic attachment.

Anterior cruciate ligament reconstruction: bone-patellar tendon-bone compared with double semitendinosus and gracilis tendon grafts. A prospective, randomized clinical trial.

BACKGROUND: The choice of graft for anterior cruciate ligament reconstruction is a matter of debate, with patellar and hamstring tendons being the two most popular autologous graft options. The objective of this study was to determine in a prospective, randomized clinical trial whether two grafts (bone-patellar tendon-bone or doubled hamstring tendons) fixed with modern devices affect the two-year minimum clinical and radiographic outcomes of anterior cruciate ligament reconstruction. METHODS: One hundred and twenty patients with a chronic unilateral rupture of the anterior cruciate ligament underwent arthroscopically assisted reconstruction with use of either autologous bone-patellar tendon-bone or doubled hamstring tendon grafts, in a strictly alternating manner. Both groups were comparable with regard to demographic data, preoperative activity level, mechanism of injury, interval between the injury and the operation, and the amount of knee laxity present preoperatively. The same well-proven surgical technique and aggressive controlled rehabilitation was used. An independent observer, who was blinded with regard to the involved leg and the type of graft, performed the outcome assessment with use of a visual analog scale, the new International Knee Documentation Committee form, the Knee Injury and Osteoarthritis Outcome Score, the Functional Knee Score for Anterior Knee Pain, and an arthrometric and an isokinetic dynamometric evaluation. Radiographs were also made. RESULTS: At the two-year follow-up evaluation, no differences were found in terms of the visual analog score, the Knee Injury and Osteoarthritis Outcome Score, the new International Knee Documentation Committee subjective and objective evaluation scores, the KT-1000 side-to-side laxity measurements, the Functional Knee Score for Anterior Knee Pain, muscle strength recovery, or return to sports activities. In the bone-patellar tendon-bone group, we found a higher prevalence of postoperative kneeling discomfort (p < 0.01) and an increased area of decreased skin sensitivity (p < 0.001). In the hamstring tendon group, we recorded a higher prevalence of femoral tunnel widening (p < 0.01). In this group, a correlation was also found between medial meniscectomy and an increased prevalence of pivot-shift glide (p = 0.035). CONCLUSIONS: We believe that, with use of accurate and proven surgical and rehabilitation techniques, both grafts are an equivalent option for anterior cruciate ligament reconstruction.

Biologic resurfacing of the patella: current status.

The techniques of biologic resurfacing of the patella, like other joint surfaces, are still evolving. Currently none of them is free from criticism. In this regard it is our hope that progress in the basic science will offer in the near future new and more optimistic therapeutic possibilities (i.e., the restoration of a reparative cartilage that is structurally and functionally comparable to the native one). The greater expectancies come perhaps from the present experimental investigations about the combined use of tissue-engineered implants embedded with staminal cells and growth factors. Many problems remain to be solved, however, before reliable applicability in humans. From a general point of view, stem cells obtained from various sources (e.g., adult bone marrow, umbilical cord) offer the same finalities as the embryonic stem cells, without the ethical obstacles related to the latter. Therefore, it may be that restoration of part or all of the articular surface of a joint will be possible by way of these mesenchymal progenitors that have the ability to differentiate into the chondrogenic and osteogenic lines, which is required for the restoration of the various layers of a normal articular cartilage and subchondral bone.

Femoral tunnel in revision anterior cruciate ligament reconstruction.

The failure rate after anterior cruciate ligament (ACL) reconstruction performed by expert surgeons is estimated to be in the range of 10-15%, and only 60% of patients undergoing this surgery are able to resume sporting activities comparable to those they engaged in prior to the traumatic incident. Incorrect femoral tunnel placement is one of the main causes of failed ACL reconstruction and this must be remembered when undertaking revision surgery. There are various possible errors that can be committed and, to plan revision surgery correctly, it is fundamental to study the position of the existing femoral tunnel(s) both on classic anteroposterior and lateral plain radiographs and on computed tomography scans with frontal, sagittal, and coronal sections, and also using three-dimensional reconstruction. In-depth anatomical knowledge and familiarity with the various possible surgical techniques are also mandatory for a successful surgical outcome.

Comparison between single-and double-bundle anterior cruciate ligament reconstruction: a prospective, randomized, single-blinded clinical trial.

BACKGROUND: Double-bundle ACL reconstruction popularity is increasing with the aim to reproduce native ACL anatomy and improve ACL reconstruction outcome. However, to date, only a few randomized clinical studies have been published. PURPOSE: The aim of this study was to prospectively compare the clinical results of single- and double-bundle ACL reconstruction. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: Seventy patients with a chronic unilateral ACL rupture who underwent arthroscopically assisted ACL reconstruction using a hamstring graft were randomized to receive a single- (SB) or double-bundle (DB) reconstruction. Both groups were comparable with regard to preoperative data. A double-incision surgical technique was adopted in both groups. The graft was fixed by looping the hamstring tendons around a bony (DB) or a metallic (SB) bridge on the tibial side and with interference screws reinforced with a staple on the femur. The same rehabilitation protocol was adopted. Outcome assessment was performed by a blinded, independent observer using the visual analog scale (VAS) score, the new International Knee Documentation Committee (IKDC) form, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and KT-1000 arthrometer evaluation. RESULTS: All the patients reached a minimum follow-up of 2 years. No differences between the 2 groups were observed in terms of KOOS and IKDC subjective score. A statistically significant difference in favor of the DB group was found with the VAS (P < .03). The objective IKDC final scores showed statistically significantly more "normal knees" in the DB group than in the SB group (P = .03). There was 1 stability failure in the DB group and 3 in the SB group. The KT-1000 arthrometer data showed a statistically significant decrease in the average anterior tibial translation in the DB group (1.2 mm DB vs 2.1 mm SB; P < .03). The incidence of a residual pivot-shift glide was 14% in DB and 26% in SB (P = .08). CONCLUSION: In the 2-year minimum follow-up, DB ACL reconstructions showed better VAS, anterior knee laxity, and final objective IKDC scores than SB. However, longer follow-up and accurate instrumented in vivo rotational stability assessment are needed.

Single-and double-incision double-bundle ACL reconstruction.

Double-bundle anterior cruciate ligament (ACL) reconstruction is intended to replicate the anatomy and the function of the anteromedial and posterolateral bundles of the native ACL to improve patients' satisfaction and knee stability. We prospectively assigned 75 consecutive patients with an isolated ACL lesion to one of three sequential groups of 25 patients each. Group I received a single-bundle, single-incision transtibial ACL reconstruction. Groups II and III received a double-bundle reconstruction with a single-incision transtibial technique or a double-bundle, twoincision outside-in technique, respectively. We obtained subjective International Knee Documentation Committee and Knee Injury and Osteoarthritis Outcome Score evaluations and objective International Knee Documentation Committee scores and KT-1000 measurements preoperatively and at followup. All patients reached a minimum followup of 2 years. KT side-to-side difference in Groups I, II, and III were 2.4, 1.6 and 1.4 mm, respectively. Group III had fewer patients with a positive pivot shift than Group I. The double-bundle double-incision outside-in ACL reconstruction resulted in improved anteroposterior stability and less residual pivot shift than single-incision single-bundle technique.

Minimally invasive total knee arthroplasty: is it for everybody?

The development of new instrumentation and techniques has led to the rapid advancement of less invasive surgical approaches in total knee arthroplasty (TKA). Compared to the standard approach, minimally invasive surgery (MIS) in TKA was shown to reduce postoperative pain, blood loss, and hospitalization time, and to improve functional recovery. Growing experience with MIS-TKA has defined the proper indications for this technique. With a limited exposure, the skin, capsular tissues, and bone surfaces receive higher stresses because of the retraction required. Several complications relating to the MIS learning curve are now being reported. The reliability of a TKA procedure performed through a mini-incision, and its success, seems to depend on patient selection, surgeon experience, and surgical environment.

Femoral attachment of the anterior cruciate ligament.

Endoscopic anterior cruciate ligament (ACL) reconstruction is one of the most popular orthopaedic procedures. Correct tunnel positioning is a prerequisite to success. Current surgical techniques are unable to duplicate the complex anatomy and function of the native ACL. Surgery mainly aims at restoring anteroposterior laxity. The ACL is not isometric and only a few fibers are nearly isometric over the full range of motion. However, a nearly isometric behaviour of the ACL graft is desirable. Isometry is mainly influenced by femoral attachment; thus the femoral tunnel position has a greater effect than the tibial on graft length changes. The purpose of this article is to describe the anatomy of the femoral ACL insertion and to discuss the surgical techniques used to replicate it.

Anterior cruciate ligament reconstruction with double-looped semitendinosus and gracilis tendon graft directly fixed to cortical bone: 5-year results.

Forty-three patients who had undergone an anterior cruciate ligament (ACL) reconstruction using a doubled semitendinosus and gracilis graft were prospectively reviewed at 5-year follow-up. All had suffered subacute or chronic tears of the ligament. At surgery, the femoral tunnel was drilled first through the antero-medial portal. The correct position of the femoral and tibial guide wire was checked fluoroscopically. A cortical fixation to the bone was achieved in the femur with a Mitek anchor, directly passing the two tendons in the slot of the anchor, and in the tibia with an RCI screw, supplemented with a spiked washer and bicortical screw. Rehabilitation was aggressive, controlled and without braces. The International Knee Documentation Committee (IKDC) form, KT-1000 arthrometer, and Cybex dynamometer were employed for clinical evaluation. A radiographic study was also performed. At the 5-year follow-up all the patients had recovered full range of motion and 2% of them complained of pain during light sports activities. Four patients (9.5%) reported giving-way symptoms. The KT-1000 side-to-side difference was on average 2.1 mm at 30 lb, and 68% of the knees were within 2 mm. The final IKDC score showed 90% satisfactory results. There was no difference between the 2-year and 5-year evaluations in terms of stability. Extensor and flexor muscle strength recovery was almost complete (maximum deficit 5%). Radiographic study showed a tunnel widening in 32% of the femurs and 40% of the tibias. A correlation was found between the incidence of tibial tunnel widening and the distance of the RCI screw from the joint (the closer the screw to the joint, the lower the incidence of widening). In conclusion, we can state that, using a four-strand hamstring graft and a cortical fixation at both ends, we were able to achieve satisfactory 5-year results in 90% of the patients.