Female gender and medial meniscal lesions are associated with increased pain and symptoms following anterior cruciate ligament reconstruction in patients aged over 50 years.

PURPOSE: Several studies report satisfactory clinical outcomes following ACLR in older patients, but none evaluated the effects of meniscal and cartilage lesions. The aim was to evaluate the influence of meniscal and cartilage lesions on outcomes of ACLR in patients aged over 50 years. METHODS: The authors prospectively collected records of 228 patients that underwent primary ACLR, including demographics, time from injury to surgery, whether injuries were work related, and sports level (competitive, recreational, or none). At a minimum follow-up of 6 months, knee injury and osteoarthritis outcome scores (KOOS), International Knee Documentation Committee (IKDC) score and Tegner activity level were recorded, and differential laxity was measured as the side-to-side difference in anterior tibial translation (ATT) using instrumented laximetry devices. Regression analyses were performed to determine associations between outcomes and meniscal and cartilage lesions as well as nine independent variables. RESULTS: A total of 228 patients aged 54.8 ± 4.3 years at index ACLR were assessed at a follow-up of 14.3 ± 3.8 months. KOOS subcomponents were 85 ± 13 for symptoms, 91 ± 10 for pain, 75 ± 18 for daily activities, 76 ± 18 for sport, and 88 ± 12 for quality of life (QoL). The IKDC score was A for 84 (37%) knees, B for 96 (42%) knees, C for 29 (13%) knees, and D for 8 (4%) knees. Tegner scores showed a decrease (median 0, range -4 to 4) and differential laxity also decreased (median - 4, range - 23.5 to 6.0). KOOS symptoms worsened with higher BMI (p = 0.038), for women (p = 0.007) and for knees that had medial meniscectomy (p = 0.029). KOOS pain worsened with higher BMI (p ≤ 0.001), for women (p = 0.002) and for knees with untreated (p = 0.047) or sutured (p = 0.041) medial meniscal lesions. Differential laxity increased with follow-up (p = 0.024) and in knees with lateral cartilage lesions (p = 0.031). CONCLUSION: In primary ACLR for patients aged over 50 years, female gender and medial meniscal lesions significantly compromised KOOS symptoms and pain, while lateral cartilage lesions significantly increased differential laxity. Compared to knees with an intact medial meniscus, those with sutured or untreated medial meniscal lesions had worse pain, while those in which the medial meniscus was resected had worse symptoms. These findings are clinically relevant as they could help surgeons with patient selection and adjusting expectations according to their functional demands. LEVEL OF EVIDENCE: III.

ACL reconstruction in over-50 year-olds: Comparative study between prospective series of over-50 year-old and under-40 year-old patients.

INTRODUCTION: ACL reconstruction is increasingly proposed for over-50 year-olds, although surgery had a poor reputation in this age-group, mainly due to postoperative stiffness. ACL reconstruction results were compared between two prospective series of, respectively, over-50 year-old (group 1) and under-40 year-old patients (group 2). The main study hypothesis was that ACL surgery provides the same functional results after 50 as before 40 years of age, and the secondary hypothesis was that the rate of complications does not differ. METHODS: A multicenter prospective non-randomized follow-up study included 228 over-50 year-old and 130 under-40 year-old patients in 10 public and private sector centers. Epidemiological data were collected. Clinical laxity, differential laxity, KOOS, IKDC, Tegner and ACL-RSI scores and radiologic aspect were assessed pre- and post-operatively. Early (<3 months) and late (>3 months) complications were collected. Functional scores were compared between groups at last follow-up: 14.2 months (range, 3.5-30.5 months in group 1, and 20.5 months (range, 11.4-29.4 months) in group 2. RESULTS: Analysis of epidemiological data showed some inter-group differences: female predominance in group 1 (59% versus 35%), longer trauma-to-surgery time in group 2 (23.6 versus 8.7 weeks), predominance of pivot-contact (team) sports in group 2 (49% versus 6%), and predominance of pivot sports (skiing) in group 1. Tegner scores were lower in group 1 (5.2 versus 7.6). Meniscal lesions were more frequent in group 1 (68% versus 36%), as were cartilage lesions (76% versus 10%). Initial laxity levels were identical (6.5mm in group 1 and 6.7mm in group 2). Type of surgery was identical: 86% hamstring graft in group 1 and 89% in group 2. There were more early complications (hematoma) in group 1; rates of late complications were comparable. Laxity at last follow-up was 2.2mm in both groups, and thus Lachman and pivot-shift test results were identical in terms of firm end-feel and absence of pivot shift. Quality-of-life assessment found higher KOOS scores in group 2, although ACL-RSI scores were identical. Global IKDC scores were slightly better in group 2, due to osteoarthritis in the older patients. CONCLUSION: ACL reconstruction after 50 years of age gave good results, correcting laxity as effectively as in under-40 year-olds, with identical technique and identical rates of complications. Time to return to sports and resumed level were comparable. LEVEL AND TYPE OF STUDY: III, prospective comparative non-randomized.

Percutaneous bunionette correction.

BACKGROUND: Treatment of tailor's bunion is largely conservative. For severe or refractory cases surgical intervention is necessary. The aim of this study is to evaluate a percutaneous technique for correcting such bunionette deformities. METHODS: Twenty-one procedures were performed on 20 patients using a percutaneous technique. Patients were scored using the American Orthopaedic Foot & Ankle Society (AOFAS) Lesser Toe Metatarsophalangeal-Interphalangeal Scale. RESULTS: No wound healing problems, infections, non-unions or mal-unions occurred. Functional assessments revealed very good results. Radiographic evaluation confirmed good average correction of the fourth-fifth intermetatarsal angle and metatarsophalangeal angle. CONCLUSIONS: This percutaneous technique is a reliable and effective approach for the treatment of bunionette deformity. The results obtained were comparable to those reported using traditional open techniques, but major complications due to soft tissue damage were averted. This technique can be adapted depending on the type of deformity, and does not require internal fixation.

Percutaneous double metatarsal osteotomy for correction of severe hallux valgus deformity.

Double osteotomy of the first metatarsal is an option in treatment of severe hallux valgus deformity. Good short-term results have been reported with percutaneous surgery in hallux valgus with moderate deformity. We report short-term results with percutaneous double osteotomy of the first metatarsal in severe deformities. This is a prospective study of 6 patients with severe hallux valgus deformity who were treated with percutaneous double osteotomy of the first metatarsal (proximal closing wedge and distal chevron osteotomy) in 2008. They were assessed preoperatively and one year and two years after surgery, with clinical and radiological AOFAS MTP-IP score. All patients were satisfied. The AOFAS score improved from 34 to 84. The postoperative radiological assessment showed significant improvement, compared with preoperative values of the intermetatarsal and hallux valgus angles. No complications were encountered. Post-operative stiffness of the first MT joint was observed but resolved after physiotherapy. This preliminary study showed that correction of severe hallux valgus deformity by percutaneous double osteotomy can achieve good clinical and radiological results. A larger number of cases with a longer follow-up is needed to firmly demonstrate the advantages of this technique compared with classical open surgical techniques in the treatment of severe hallux valgus deformities.

Percutaneous hallux valgus surgery: a prospective multicenter study of 189 cases.

Distal first metatarsal osteotomies have been indicated for the correction of mild-to-moderate hallux valgus deformity. The aim of this study was to assess the clinical and radiographic results of the distal Reverdin-Isham first metatarsal osteotomy with use of a percutaneous procedure after a minimum 1-year followup. One hundred eighty-nine feet in 168 consecutive subjects were included in the present prospective multicenter study. A radiographic and clinical assessment using the American Orthopaedic Foot and Ankle Society's (AOFAS) hallux-metatarsophalangeal-interphalangeal scale was performed for all the subjects with a minimum 1-year follow-up. One hundred fifty six subjects (87%) were satisfied or very satisfied with the outcome of the procedure. The median postoperative AOFAS score was 93 points. Subjects averaged a loss 17% of first metatarsophalangeal joint motion. The median hallux valgus angle and intermetatarsal angle improved from 28 degrees and 13 degrees preoperatively, to 14 degrees and 10 degrees postoperatively, respectively. Percutaneous correction of mild-to-moderate hallux valgus deformity with the Reverdin-Isham osteotomy of the first metatarsal enables us to achieve clinical and radiographic results comparable to other percutaneous or open distal metatarsal osteotomies after 1-year follow-up.

Endoscopic calcaneoplasty combined with Achilles tendon repair.

Endoscopic calcaneoplasty is a minimally invasive technique for resection of inflamed retrocalcaneal bursa as well as the posterosuperior part of the calcaneus. A relative contra-indication for this technique is a tear of the Achilles tendon. In this report, we describe the treatment of a patient with Haglund's deformity associated with a tear of the Achilles tendon. Both the lesions are treated endoscopically. The technique is described and the pitfalls are discussed.

Two-bundle, four-tunnel anterior cruciate ligament reconstruction.

We reviewed 33 patients who underwent anterior cruciate ligament (ACL) reconstruction using a two-bundle, four-tunnel technique. The posterolateral bundle (PLB) and anteromedial bundle (AMB) were individually reconstructed with gracilis and semitendinosus tendon auto-grafts, respectively, using separate tibial and femoral tunnels. At final follow-up (24 months post surgery, range 18-31) the International Knee Documentation Committee's (IKDC) objective final evaluation scores were 69 A, 19 B, 12% C. The mean global subjective IKDC score was 86+/-12 points. Ninety-four percent of the patients had returned to sport after an average of 9 months following surgery and 75% returned to their preinjury sporting level. One patient had suffered a graft rupture as a result of a further sports injury. Eighty-four percent of the patients had a negative pivot shift (IKDC A), 9% a glide (IKDC B), and 6% a "clunk" (IKDC C). The mean postoperative side-to-side laxity, measured with KT1000 arthrometry at manual maximum, was 0.9 mm (SD 1.9). Eighty-one percent of the patients had less than 3 mm difference, with only one patient having greater than 5 mm. Our early experience with this new technique appears to demonstrate satisfactory results that are at least equivalent to other techniques and show an apparent trend towards improved control of anterior laxity.

Anterior cruciate ligament reconstruction using four-strand semitendinosus and gracilis tendon grafts and metal interference screw fixation.

PURPOSE: The purpose of this study was to determine the outcome of 200 anterior cruciate ligament (ACL) reconstructions using hamstring tendons. TYPE OF STUDY: This is a case series reporting on 200 endoscopic procedures for reconstruction of the ACL. METHODS: This study included patients over 18 years old with a healthy controlateral knee, intact posterior cruciate ligament, and without any peripheral surgical procedure or cartilage injury. Patients having undergone prior ligament reconstruction were excluded from the study. The minimum follow-up was 1 year. Clinical review allowed for documentation of International Knee Documentation Committee (IKDC), KT-1000 arthrometer laxity measurement, and isokinetic dynamometric analysis. RESULTS: Quadriceps and hamstring muscle strength loss was less than 17%. At review, overall IKDC evaluation found that 50% of patients graded A, 44% graded B, and 6% were C or D. The differential anterior laxity was graded A for 157 patients with a median of 1 mm. Of the 113 high-performance athletes, 98 (86%) had resumed a preinjury level of sporting activity. CONCLUSIONS: Endoscopic reconstruction using 4-strand hamstring autograft may be considered safe, reliable, and reproducible. Preliminary outcome is fulfilling and this technique corresponds completely to therapeutic fields regarding ACL reconstructions.