Mid-term outcomes of posterior capsular release for fixed flexed deformity after total knee arthroplasty.

Fixed flexion deformity also called flexion contracture is relatively rare, but a very demanding functional limitation that both surgeons and patients may have to deal with. The purpose of the present study was to evaluate the functional outcomes after posteromedial capsular release in case of fixed flexed deformity > 15 o . Between June 2011 and November 2018, 15 patients (6 males and 9 females) were treated with open posterior capsular release through medial approach for fixed flexion deformity of the knee > 15 o and prospectively followed with a minimum follow-up of 2 years. Primary outcome was knee extension measured with a manual goniometer and secondary outcome treatment related complications. All patients reported inability to walk and clinical semiology of pain and swelling. The mean age of the study population at surgery was 61.7 years with a mean BMI of 30.9 kg/m2. Complete data were recorded for all patients. Statistically significant improvement was found in clinical and functional assessment tools analyzed from baseline to the latest follow-up (p<0.05). More precisely, the mean postoperative fixed flexion deformity was decreased from 23.57 o to 2.86 o . No adverse effect or major complications were recorded during follow-up. Posterior open release via posteromedial was shown to be an efficient and safe salvage procedure to deal with persistent fixed flexion deformity of more than 15 o following TKA at two years follow-up. However, future studies with a higher number of participants and longer follow-up should be conducted to validate our data.

Low healing rates and moderate functional outcome after arthroscopic superior capsular reconstruction using a porcine xenograft.

PURPOSE: In the absence of arthropathy, symptomatic massive irreparable rotator cuff tears contribute to a therapeutic challenge for orthopedic surgeons. The concept of superior capsular reconstruction (SCR) was introduced as an option for these challenging cases. The purposes of this study were to evaluate the clinical outcome scores when using a decellularized porcine xenograft and to evaluate the graft healing and incorporation. METHODS: A multicentric retrospective study of consecutive SCR's performed between 2016 and 2019 by four surgeons in four centers. Preoperative and postoperative Constant score, Subjective shoulder value (SSV) and Visual analog scale for pain (VAS) were recorded. Graft healing was evaluated by ultrasound or magnetic resonance imaging (MRI). RESULTS: A total of 28 shoulders were retrospectively analyzed with an average follow-up of 24 ± 9 months. One infection and four revisions (14%) to reversed shoulder arthroplasty (RSA) were reported at the final follow-up. The absolute Constant score showed a moderate, but significant improvement from 40 ± 12 to 57 ± 20 (P = 0.001). A significant improvement in pain scores was observed (P < 0.001). For patients undergoing SCR as a primary surgery, an average postoperative Constant score of 62 ± 16 was observed. This was in contrast to 43 ± 22 for patients who underwent SCR after failed rotator cuff repair. Although a strong trend in absolute differences was observed in regard to the Constant score, they did not reach statistical significance. For all other recorded outcome scores, a significant difference was reported between these groups. Graft healing was observed in (7/22) 30% of the patients. In the case of graft incorporation, an absolute constant score of 70 ± 9 was observed compared to 48 ± 21 in the graft failure group (P = 0.003). All cases with graft healing were considered to have a successful clinical outcome. This compared to only (7/15) 47% in the case of graft failure. CONCLUSIONS: In these series, SCR with a dermal xenograft successfully alleviated pain, but provided only a moderate improvement in functional outcome. In the case of graft healing, satisfactory clinical outcomes and patient satisfaction were observed. The present study indicates the benefit of performing SCR as a primary surgery, yet warns against using SCR as a salvage option for failed rotator cuff repair. In this group, the use of dermal xenografts is limited by the low healing rates and high complication rate. LEVEL OF EVIDENCE: IV. Retrospective case series, treatment study.

An Ultrasound-guided Percutaneous Surgical Technique for Trigger Finger Release Using a Minimally Invasive Surgical Knife.

Triggering of the finger at the A1 pulley is one of the most frequent pathologies encountered in hand surgery and a common cause of hand pain. Open release of the A1 pulley is currently still regarded as the golden-standard procedure. Nevertheless, there is an increasing interest in minimally invasive percutaneous techniques for the treatment of this condition. Current techniques range from percutaneous needle techniques without imaging, to the use of hook knives, with ultrasound guidance. Because of concerns about possible complications or incomplete releases, hand surgeons remain wary. The objective of this study was to introduce a new ultrasound-guided percutaneous surgical technique for trigger finger release, using a second-generation minimally invasive surgical knife. In this series of 78 releases, complete resolution of the symptoms was found in 98.7% of the cases. One recurrence of triggering was observed. There were no tendon injuries, infections, or neurovascular lesions recorded. This paper contains technical pearls and possible pitfalls to ensure the surgeon of a complete release and to avoid complications. A video of the technique was also included as Supplemental Digital Content (http://links.lww.com/BTH/A143). We can conclude that the procedure can be considered as safe and highly effective for the treatment of triggering at the A1 pulley.

Free vascularized second metatarsophalangeal joint transfer for scaphotrapezial joint reconstruction after distal scaphoid excision and carpal collapse: A case report.

Treatment of the destroyed scaphotrapezial (ST) joint in young patients is challenging due to the limited available options as they might not tolerate the stiffness, loss of grip strength and long-term complications of partial fusions, bone resections, and interposition implants or arthroplasties. This report presents the results of a free osteocutaneous joint transfer used to reconstruct the ST joint in a young patient suffering from ST destruction and carpal collapse. This 34-year-old patient was previously treated for a right scaphoid nonunion with distal scaphoid excision and interposition implant that evolved to destruction of the ST space, symptomatic carpal collapse associated and a ST height loss of 7 mm. The DASH score was 34 and the grip strength of 32 kg. The patient was treated with an osteocutaneous vascularized free transfer from the second metatarsophalangeal joint vascularized by the first dorsal metatarsal artery and anastomosed to the palmar carpal branch of the radial artery and a palmar superficial vein. After 3.5 months, the patient returned to full duty work as a mechanic. At the last follow-up, 3 years after the surgery, the patients had complete range of motion without clinical nor radiological degenerative changes. There were no postoperative complications. The DASH score was 3 and the grip strength was 53 kg. This reconstructive procedure allows to recreate a functional ST joint and to correct a carpal collapse avoiding degenerative wrist changes. It may be proposed to young patients who aim to recover a near normal function of their wrist.

Which Fracture Types Are Associated with Widening of the Scapholunate Distance? A CT-Scan Study of Acute Intraarticular Distal Radius Fractures.

Background: Scapholunate injuries in distal radius fractures may frequently be overlooked. The aims of this study were to measure the scapholunate distance in intraarticular distal radius fractures and to find out which fracture types were associated with an increased scapholunate width. Methods: Measurements of the scapholunate distance were performed on computed tomography scans of 143 intraarticular distal radius fractures in 140 patients. The fractures were classified according to the AO classification. The morphology of AO type B fractures was further analysed according to the Bain classification. Results: In 43 AO type B fractures mean scapholunate distance measured 2.1 mm and in 100 type C fractures 1.6 mm. The difference between partial and complete intraarticular fractures was significant. A trend towards a greater scapholunate distance was found in AO type B1 and radial styloid oblique fractures. Conclusions: In this study, partial intraarticular distal radius fractures, especially with a sagittal split, had a greater scapholunate distance and may be at risk for ligamentous injury.

Efficacy of total knee arthroplasty (TKA) revision surgery depends upon the indication for revision : a systematic review.

The number of revision total knee arthroplasty (TKA) surgeries has increased over the years and it is expected that its number will keep rising. Most frequent reasons for revision are known to be aseptic loosening, infection, instability, periprosthetic frac- ture, arthrofibrosis and component malposition. The influence of the indication for revision on the outcome scores is not fully understood. Therefore, this work will evaluate and review the existing literature regarding outcome scores after revision TKA surgery. We conducted a sensitive and comprehensive search for published and unpublished studies relevant to the review question. We restricted our search to English studies published between January 2008 and December 2018. Our systematic review was done according to PRISMA guidelines. We withheld 19 studies (1419 knees) for inclusion. Of these, 9 papers reported outcome scores after TKA revision for aseptic loosening, 10 reported on revision for instability, 10 reported on stiffness or arthrofibrosis and 4 papers reported on component malposition. Although we found some papers suggesting that there is no difference in postoperative outcome scores depending on the aetiology of revision surgery, the majority of the included studies suggest differently. This review suggests there is a tendency for relative higher outcome scores after revision for aseptic loosening. Revision for malrotation might give comparable postoperative outcome scores and satisfaction ratios. Revision for instability tends to give lower postoperative outcome scores than aseptic loosening, although certain subgroups of instability show comparable results. Lowest postoperative scores might be found after revision for stiffness and arthrofibrosis.

Tunnel placement in ACL reconstruction surgery: smaller inter-tunnel angles and higher peak forces at the femoral tunnel using anteromedial portal femoral drilling-a 3D and finite element analysis.

PURPOSE: Recent studies have emphasized the importance of anatomical ACL reconstruction to restore normal knee kinematics and stability. Aim of this study is to evaluate and compare the ability of the anteromedial (AM) and transtibial (TT) techniques for ACL reconstruction to achieve anatomical placement of the femoral and tibial tunnel within the native ACL footprint and to determine forces within the graft during functional motion. As the AM technique is nowadays the technique of choice, the hypothesis is that there are significant differences in tunnel features, reaction forces and/or moments within the graft when compared to the TT technique. METHODS: Twenty ACL-deficient patients were allocated to reconstruction surgery with one of both techniques. Postoperatively, all patients underwent a computed tomography scan (CT) allowing 3D reconstruction to analyze tunnel geometry and tunnel placement within the native ACL footprint. A patient-specific finite element analysis (FEA) was conducted to determine reaction forces and moments within the graft during antero-posterior translation and pivot-shift motion. RESULTS: With significantly shorter femoral tunnels (p < 0.001) and a smaller inter-tunnel angle (p < 0.001), the AM technique places tunnels with less variance, close to the anatomical centre of the ACL footprints when compared to the TT technique. Using the latter, tibial tunnels were more medialised (p = 0.007) with a higher position of the femoral tunnels (p = 0.02). FEA showed the occurrence of higher, but non-significant, reaction forces in the graft, especially on the femoral side and lower, however, statistically not significant, reaction moments using the AM technique. CONCLUSION: This study indicates important, technique-dependent differences in tunnel features with changes in reaction forces and moments within the graft. LEVEL OF EVIDENCE: II.

Peak stresses shift from femoral tunnel aperture to tibial tunnel aperture in lateral tibial tunnel ACL reconstructions: a 3D graft-bending angle measurement and finite-element analysis.

PURPOSE: To investigate the effect of tibial tunnel orientation on graft-bending angle and stress distribution in the ACL graft. METHODS: Eight cadaveric knees were scanned in extension, 45°, 90°, and full flexion. 3D reconstructions with anatomically placed anterior cruciate ligament (ACL) grafts were constructed with Mimics 14.12®. 3D graft-bending angles were measured for classic medial tibial tunnels (MTT) and lateral tibial tunnels (LTT) with different drill-guide angles (DGA) (45°, 55°, 65°, and 75°). A pivot shift was performed on 1 knee in a finite-element analysis. The peak stresses in the graft were calculated for eight different tibial tunnel orientations. RESULTS: In a classic anatomical ACL repair, the largest graft-bending angle and peak stresses are seen at the femoral tunnel aperture. The use of a different DGA at the tibial side does not change the graft-bending angle at the femoral side or magnitude of peak stresses significantly. When using LTT, the largest graft-bending angles and peak stresses are seen at the tibial tunnel aperture. CONCLUSION: In a classic anatomical ACL repair, peak stresses in the ACL graft are found at the femoral tunnel aperture. When an LTT is used, peak stresses are similar compared to classic ACL repairs, but the location of the peak stress will shift from the femoral tunnel aperture towards the tibial tunnel aperture. CLINICAL RELEVANCE: the risk of graft rupture is similar for both MTTs and LTTs, but the location of graft rupture changes from the femoral tunnel aperture towards the tibial tunnel aperture, respectively. LEVEL OF EVIDENCE: I.

Correction to: Peak stresses shift from femoral tunnel aperture to tibial tunnel aperture in lateral tibial tunnel ACL reconstructions: a 3D graft-bending angle measurement and finite-element analysis.

Unfortunately, one of the co-author's name was missed in the original online publication of this article. The name should be included as sixth author in the author group.

The anterior cruciate ligament: a study on its bony and soft tissue anatomy using novel 3D CT technology.

PURPOSE: The purpose of this study is twofold: first, to visualize both the tibial and femoral bony insertion surfaces and second, to describe the anterior cruciate ligament (ACL) geometrically, using novel 3D CT imaging. In addition, new concepts of best-fit cylinder and central axis are introduced and evaluated. METHODS: Eight unpaired knees of embalmed cadavers were used in this study. Following the dissection process, the ACL was injected with a contrast medium for CT imaging. The obtained CT images in extension, 45°, 90° and full flexion were segmented and rendered in 3D allowing morphological and morphometric analysis of the ACL. Anatomical footprint centres, femoral and tibial footprint surface area, best-fit ACL-cylinder intersection area, best-fit ACL-cylinder/footprint coverage ratio, best-fit ACL-cylinder central axis projections at the tibial and femoral footprint in the four positions were used to describe the anatomy of the ACL, based on the Bernard, Hertel and Amis grid. RESULTS: Based on these parameters, with the best-fit cylinder representing the bulk of the ACL, a changing fibre-recruitment pattern was seen with a moving position of the central axis from posterior to anterior on the femoral and tibial footprint, going from extension to flexion. Furthermore, the numerical data show an increase in tibial footprint coverage by the best-fit cylinder through the ACL when the knee is progressively flexed, whereas an inverse relationship was seen on the femoral side. CONCLUSION: This study is the first to describe the detailed anatomy of the human ACL with respect to its course and footprints using a 3D approach. It confirms the large difference and inter-patient variability between the tibial and femoral footprint area with the former being significantly smaller. The best-fit cylinder concept illustrates the recruitment pattern of the native ACL where in extension the postero-lateral fibres are recruited and in flexion rather the antero-medial bundle, which can be valuable information in reconstructive purposes. The best-fit cylinder and central axis concept offers additional insights into the optimal tunnel placement at the tibial and femoral footprint in order to cover the largest portion of the native ACL soft tissue, aiming for optimal ACL reconstruction.

In-vivo evaluation of the kinematic behavior of an artificial medial meniscus implant: A pilot study using open-MRI.

BACKGROUND: In this pilot study we wanted to evaluate the kinematics of a knee implanted with an artificial polycarbonate-urethane meniscus device, designed for medial meniscus replacement. The static kinematic behavior of the implant was compared to the natural medial meniscus of the non-operated knee. A second goal was to evaluate the motion pattern, the radial displacement and the deformation of the meniscal implant. METHODS: Three patients with a polycarbonate-urethane implant were included in this prospective study. An open-MRI was used to track the location of the implant during static weight-bearing conditions, within a range of motion of 0° to 120° knee flexion. Knee kinematics were evaluated by measuring the tibiofemoral contact points and femoral roll-back. Meniscus measurements (both natural and artificial) included anterior-posterior meniscal movement, radial displacement, and meniscal height. FINDINGS: No difference (P>0.05) was demonstrated in femoral roll-back and tibiofemoral contact points during knee flexion between the implanted and the non-operated knees. Meniscal measurements showed no significant difference in radial displacement and meniscal height (P>0.05) at all flexion angles, in both the implanted and non-operated knees. A significant difference (P ≤ 0.05) in anterior-posterior movement during flexion was observed between the two groups. INTERPRETATION: In this pilot study, the artificial polycarbonate-urethane implant, indicated for medial meniscus replacement, had no influence on femoral roll-back and tibiofemoral contact points, thus suggesting that the joint maintains its static kinematic properties after implantation. Radial displacement and meniscal height were not different, but anterior-posterior movement was slightly different between the implant and the normal meniscus.

Reliability of a semi-automated 3D-CT measuring method for tunnel diameters after anterior cruciate ligament reconstruction: A comparison between soft-tissue single-bundle allograft vs. autograft.

BACKGROUND: Post-operative widening of tibial and/or femoral bone tunnels is a common observation after ACL reconstruction, especially with soft-tissue grafts. There are no studies comparing tunnel widening in hamstring autografts versus tibialis anterior allografts. The goal of this study was to observe the difference in tunnel widening after the use of allograft vs. autograft for ACL reconstruction, by measuring it with a novel 3-D computed tomography based method. METHODS: Thirty-five ACL-deficient subjects were included, underwent anatomic single-bundle ACL reconstruction and were evaluated at one year after surgery with the use of 3-D CT imaging. Three independent observers semi-automatically delineated femoral and tibial tunnel outlines, after which a best-fit cylinder was derived and the tunnel diameter was determined. Finally, intra- and inter-observer reliability of this novel measurement protocol was defined. RESULTS: In femoral tunnels, the intra-observer ICC was 0.973 (95% CI: 0.922-0.991) and the inter-observer ICC was 0.992 (95% CI: 0.982-0.996). In tibial tunnels, the intra-observer ICC was 0.955 (95% CI: 0.875-0.985). The combined inter-observer ICC was 0.970 (95% CI: 0.987-0.917). Tunnel widening was significantly higher in allografts compared to autografts, in the tibial tunnels (p=0.013) as well as in the femoral tunnels (p=0.007). CONCLUSIONS: To our knowledge, this novel, semi-automated 3D-computed tomography image processing method has shown to yield highly reproducible results for the measurement of bone tunnel diameter and area. This series showed a significantly higher amount of tunnel widening observed in the allograft group at one-year follow-up. LEVEL OF EVIDENCE: Level II, Prospective comparative study.

The posterior cruciate ligament: a study on its bony and soft tissue anatomy using novel 3D CT technology.

PURPOSE: The bony insertion sites of the PCL have been studied and described extensively using 2D technology such as macroscopic images, plain radiograph, computerized tomography (CT) and MRI. The purpose of this study is to visualize both the tibial and the femoral bony insertion sites but also the soft tissue anatomy of the native PCL using novel 3D CT imaging. In addition, new concepts of best-fit cylinder and central axis are introduced and evaluated. METHODS: Nine unpaired knees of embalmed cadavers were used in this study. Following the dissection process, the PCL was injected with a contrast medium for computed tomography (CT) imaging. The obtained CT images were segmented and rendered in 3D allowing morphological and morphometric analysis of PCL. Femoral and tibial footprint surface area, best-fit PCL-cylinder intersection area, best-fit PCL-cylinder/footprint coverage ratio, best-fit PCL-cylinder central axis projections at the tibial and femoral footprint were used to describe the anatomy of the PCL. RESULTS: Mean footprint surface area of the tibial and femoral footprint were 189.1 and 293.3 mm², respectively. The mean diameter of the best-fit cylinder was 10.5 mm. The mean coverage of the best-fit cylinder on the tibial and femoral footprint was 76.5 and 46.5, respectively. The best-fit cylinder central axis was located in the anterolateral AL bundle footprint on the femur and more centrally in the PCL footprint on the tibia. CONCLUSION: This study is the first to describe the detailed anatomy of the human PCL with respect to its course and footprints using a 3D approach. It confirms the large difference between the tibial and the femoral footprint area with the former being significantly smaller. In addition, a large inter-patient variability is observed. The best-fit cylinder and central axis concept offer additional insights into the optimal tunnel placement at the tibia and femoral footprint in order to cover the largest portion of the native PCL soft tissue.