Opening-Wedge High Tibial Osteotomy: Review of 100 Consecutive Cases.

PURPOSE: We report intermediate-term outcomes of a large consecutive series of medial opening-wedge tibial osteotomies. METHODS: One hundred consecutive patients who underwent medial high tibial osteotomy from 2004-2013 were retrospectively reviewed. Charts were reviewed for patient age and gender, knee pain and range of motion, smoking status, and body mass index. Operative reports were reviewed for bone graft type, degree of correction, and osteotomy fixation method. Radiographs were evaluated for lateral cortical or intra-articular fracture, osteotomy healing, and preoperative and postoperative tibiofemoral angles. RESULTS: Eighty-nine osteotomies (89%) in 83 patients were included in the study. Most procedures were performed for medial knee arthritis. The mean age at surgery was 48.1 years, and the mean follow-up period was 4.0 years. The mean tibiofemoral alignment was 3.2° of varus preoperatively and 6.4° of valgus postoperatively. Plate and screw fixation was used in all cases. Bone grafting methods included autograft, allograft, iliac crest aspirate, platelet-rich plasma, and demineralized bone matrix. Of the osteotomies, 83 (93%) healed uneventfully. Five nonunions and 1 delayed union occurred. Allograft combined with demineralized bone matrix and/or platelet-rich plasma was associated with nonunion (P = .02). Lateral cortical fracture was associated with repeat surgery for nonunion or alignment loss (P = .02). Pain was minimal or mild in 65% of patients, moderate in 16%, and severe in 19%. Osteotomy fixation with a small 4-screw plate was associated with increased postoperative pain (P = .01). Seven patients underwent arthroplasty an average of 5 years after osteotomy. The need for arthroplasty was associated with longer follow-up (P = .02) and use of a smaller plate (P = .04). CONCLUSIONS: Uncomplicated osteotomy union occurred in 93% of medial opening-wedge high tibial osteotomies. Allograft mixed with demineralized bone matrix and/or platelet-rich plasma was associated with nonunion. At intermediate follow-up, 65% of patients had minimal or mild pain. Seven patients had undergone arthroplasty. Fixation with a smaller plate was associated with increased postoperative pain and the need for subsequent arthroplasty. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Autografts commonly used in anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction is among the most common orthopaedic procedures in the United States, with >200,000 performed annually. Much has been published regarding the use of autograft versus allograft. Bone-patellar tendon-bone is the most frequently used autograft, but hamstring and quadriceps tendon grafts are common alternatives. Each graft has distinct advantages and disadvantages, and selection is individualized. Fixation methods vary by graft type. Fixation resulting in a construct that is too rigid may restrict knee range of motion. Donor site morbidity must be considered, as well. Autograft harvest may result in anterior knee pain, kneeling pain, anterior knee numbness, muscle weakness, and patellar fracture. Appropriate graft selection is essential to optimize outcomes.

Anterior cruciate ligament reconstruction using quadriceps tendon autograft: intermediate-term outcome.

PURPOSE: The purpose of this study was to compare the intermediate-term outcomes of anterior cruciate ligament (ACL) reconstruction by use of bone-patellar tendon-bone (BPTB), quadriceps tendon with a bone plug (BQT), and quadriceps tendon without a bone plug (QT). METHODS: We evaluated 198 primary ACL reconstructions in 191 patients at a mean of 55.6 months postoperatively. Assessment included side-to-side comparison of range of motion, arthrometer values, presence of effusion, anterior knee pain, and numbness. Comparisons were made between QT and BQT patients and between men and women. The results were compared with data from 30 patients in a previous study who had undergone ACL reconstruction by the same surgeon (W.R.S.) with BPTB. RESULTS: Range of motion averaged -3.2 degrees +/- 2.2 degrees of extension to 134.3 degrees +/- 10.2 degrees of flexion for the operative extremity compared with -3.6 degrees +/- 2.07 degrees to 134.2 degrees +/- 10.6 degrees for the contralateral extremity at final follow-up. KT-1000 manual maximum measurements (MEDmetric, San Diego, CA) of the operative extremity averaged 0.94 mm more than those of the normal contralateral knee. When compared with BPTB autograft, the quadriceps tendon autograft showed significantly better results, with less anterior knee pain (4.56% v 26.7%), less anterior numbness (1.5% v 53.3%), a higher percentage of arthrometer measurements showing a side-to-side difference of 0 to 3 mm (88% v 68%), and better extension (mean loss, 0.55 degrees v 2.77 degrees ). There was no significant difference between the 2 groups with regard to loss of flexion, Lachman test, pivot-shift test, presence of effusion, or number of failures. CONCLUSIONS: Central quadriceps tendon autograft, QT or BQT, produces equivalent results when compared directly with BPTB autograft in arthroscopically assisted ACL reconstruction. There was no difference in results between men and women with a quadriceps tendon autograft, either with or without the use of a bone plug. ACL reconstruction using quadriceps tendon autograft is an effective surgical option that reduces donor-site morbidity. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Collateral ligament augmentation versus reconstruction using allograft tissue.

Injuries to the collateral ligaments of the knee are very common. Recognition of collateral ligament laxity is extremely important, especially when associated with a cruciate ligament injury. Reconstruction of the collaterals are necessary when addressing these combined instabilities.

Indications for allografts.

Allografts continue to be popular in orthopaedic reconstruction procedures of the knee. Approximately 1 million musculoskeletal allografts were distributed in the United States in 2004 alone. Ligament allografts, osteochondral allografts, and meniscal transplants have all demonstrated success in knee reconstructions. The advantages of allograft tissue include the lack of donor site morbidity, shorter operative times, ease of sizing, and a lack of clinically significant immunologic reactions. These advantages should be weighed against the risk for disease transmission, increased cost, and increased time of graft incorporation. Throughout the consent process, comprehensive patient education is imperative to assist in this important decision.

Evaluation of small-intestinal submucosa implants for repair of meniscal defects in dogs.

OBJECTIVE: To assess the effects of porcine small intestinal submucosa (SIS) implants on the healing of meniscal lesions in dogs. ANIMALS: 16 adult Greyhounds of both sexes. PROCEDURE: Unilateral osteotomy was performed at time 0 to disrupt the medial collateral ligament attachment, and two (1 cranial and 1 caudal) 4-mm circular defects were created in the avascular portion of the medial meniscus. One defect was filled with an SIS graft, and the other defect remained empty (control). Three months later, the identical procedure was performed on the contralateral limb. Three months after the second surgery, dogs were euthanatized, and meniscal tissue specimens from both stifle joints were collected for gross, histologic, biomechanical, and biochemical evaluations. RESULTS: Regenerative tissue was evident in 4 (2 SIS-implanted and 2 control) of 16 defects examined histologically. In 3 defects, this thin bridge of tissue was composed of immature haphazardly arranged fibrous connective tissue with a relatively uniform distribution of fibroblasts. Aggregate modulus, Poisson ratio, permeability, and shear modulus were not significantly different between control and SIS-implanted defects either 3 or 6 months after surgery. Hydroxyproline content also did not differ between SIS-implanted and control defects at 3 or 6 months. CONCLUSIONS AND CLINICAL RELEVANCE: Implantation of porcine SIS into experimentally induced meniscal lesions in dogs did not promote tissue regeneration.