A lower starting point for the medial cut increases the posterior slope in opening-wedge high tibial osteotomy: a cadaveric study.

PURPOSE: The objective of this study was to evaluate the effects on the posterior tibial slope of different distances from the joint line to start the osteotomy and of varying the placement of the opening wedge in high tibial osteotomy. Starting the osteotomy more distally and an incorrect location for the tibial opening wedge were hypothesized to increase the posterior tibial slope. METHODS: A cadaveric study was conducted using 12 knees divided into two groups based on the distance from the joint line to the start of the osteotomy: 3 and 4 cm. The preintervention posterior tibial slope was measured radiologically. Once the osteotomy was performed, the medial cortex of the tibia was divided into anteromedial, medial, and posteromedial thirds. A 10° opening wedge was sequentially placed in each third, and the effect on the posterior tibial slope was evaluated radiographically. RESULTS: Significant changes were observed only in the 3-cm group (p = 0.02) when the wedge was placed in the anteromedial zone. In contrast, in the 4-cm group, significant differences were observed when the opening wedge was placed at both the medial (p = 0.04) and anteromedial (p = 0.012) zones. CONCLUSION: Correct control of the posterior tibial slope can be achieved by avoiding a low point when beginning the osteotomy and placing the opening wedge in the posteromedial third of the tibia when performing an opening-wedge high tibial osteotomy. LEVEL OF EVIDENCE: Controlled laboratory study.

Continuous passive motion not affect the knee motion and the surgical wound aspect after total knee arthroplasty.

BACKGROUND: This study aimed to assess whether use of continuous passive motion (CPM) could improve range of motion in patients after total knee arthroplasty (TKA), if it could affect the surgical wound aspect (SWA) and if it could influence on pain management after TKA. METHODS: We randomized 210 patients in two groups, 102 patients in the CPM group, who received a standard rehabilitation protocol together with CPM application; and 108 patients in the no-CPM group, without CPM. Variables as knee motion (flexion, extension, range of motion) and pain were measured before surgery, on the 1st, 2nd and 3rd postoperative day, and in the 2nd, 6th, 12th and 24th postoperative weeks following TKA. The SWA was determined by the "surgical wound aspect score" (SWAS) in the next 48 h after surgery. This scale analyzes swelling, erythema, hematoma, blood drainage and blisters. RESULTS: There was an improvement in the knee motion over the course of follow-up in both groups, without significant difference in flexion parameter. We found no significant differences in the total score of SWA, except for hematoma, with less severity in the CPM group. Furthermore, we found no differences in the others SWAS parameters and pain. CONCLUSIONS: The application of CPM does not provide benefit to our patients undergoing TKA in terms of either improved flexion mobility or decreased pain. No relationship was found between the use of CPM and the global score of SWA following a TKA, except for a decrease in hematoma appearance.

Central Transpatellar Tendon Portal Is Safe When Used for Anterior Cruciate Ligament Reconstruction.

Central transpatellar tendon portal (CTP) was suggested first for complex meniscal lesion and subsequently for a better femoral footprint view during reconstruction of anterior cruciate ligament (ACL). A comprehensive evaluation of possible consequences of using the CTP performing an ACL reconstruction does not exist. Our hypothesis was that the use of CTP for ACL reconstruction does not lead to a higher rate of complications or clinically evident radiological abnormalities. In total, 141 patients were prospectively evaluated, 69 underwent ACL reconstruction using a standard high medial portal as view portal, and 72 where a CTP was used. Clinical evaluation, Kujala's score, patellar height, and magnetic resonance (MR) abnormalities were evaluated up to 1-year follow-up. Clinical complications were reported in 16 cases with no statistically significant differences between the two groups. The group 2 had significantly more MR abnormalities (p = 0.048), but the differences in MR alterations do not have any clinical repercussion even in a sports-active population. No differences were found between the groups in Kujala's score, time to return to work, and sport or patellar height. The overall mean preoperative Caton-Deschamps Index decreased significantly (p = 0.034) postoperatively. Postoperative patellar height seems to slightly decrease after ACL reconstruction regardless of the kind of the portals used intraoperatively and the initial patellar height. Nevertheless, this change in patellar height does not influence the postoperative outcome. CTP used for ACL reconstruction does not lead to significative major clinical complications.

Modification of the Hybrid Anatomic Technique for Anterior Cruciate Ligament Reconstruction in Pediatric Patients.

The incidence of anterior cruciate ligament (ACL) lesions with Tanner stage ≤4 has been increasing in children. To stabilize the knee, different surgical techniques have been developed for ACL reconstruction in the pediatric population. The use of a hybrid anatomic technique, intra-epiphyseal in the femur and transphysis in the tibia, has been recommended as the technique of choice to reconstruct the ACL in these patients. Despite the favorable results, this technique is not exempt from complications. The aim of this study was to present a simple and reproducible modification of the hybrid anatomic technique for ACL reconstruction in pediatric patients.

Evaluating for Tunnel Convergence in Anterior Cruciate Ligament Reconstruction With Modified Lemaire Tenodesis: What Is the Best Tunnel Angle to Decrease Risk?

PURPOSE: The purpose of this study was to analyze postoperative computed tomography (CT) scan evaluations of patients who had undergone a combined anterior cruciate ligament (ACL) reconstruction and modified Lemaire anterolateral tenodesis (ALT) with femoral fixation through a bony tunnel. METHODS: Postoperative CT scans of 52 patients who had undergone combined ACL and ALT were prospectively evaluated. ACL femoral tunnels were drilled through an anteromedial portal in the center of the native footprint. An ALT fixation tunnel was drilled 5 mm proximal to the lateral epicondyle, aiming at an inclination of 30° proximally and 30° anteriorly. Two independent observers evaluated the CT scans measuring any degree of collision, the shortest distance between the tunnels, and the inclination of the ALT tunnels. Measurements were carried out at both the cortical level and on a plane passing 1 cm deeper in the lateral condyle. RESULTS: At the level of the cortex, no convergence of the tunnels was identified. In 14 of 52 cases (26.9%), the shortest distance between the tunnels was less than 5 mm. Tunnel collision occurred in 8 of 52 cases (15.4%), and the bone bridge between the tunnels was less than 5 mm in 11 cases (21.1%) when the measurements were made on the deeper plane. When the inclination on the axial plane was less than 15°, a collision always (P < .001) occurs. When it was more than 20°, no collision occurred (P < .001). No correlation between convergence and the inclination of the ALT tunnel on the coronal plane was detected. CONCLUSIONS: To fix a modified Lemaire ALT through a femoral tunnel avoiding any interference with an anatomic femoral ACL tunnel, we recommend that the femoral tunnel be drilled with an inclination of at least 20° anteriorly. LEVEL OF EVIDENCE: IV, therapeutic case series.

Internal Fixation of Osteochondritis Dissecans of the Knee Leads to Good Long-Term Outcomes and High Degree of Healing without Differences between Fixation Devices.

The aim of the present study is to describe results at long-term follow-up of internal fixation of unstable Osteochondritis Dissecans (OCD) achieved with three different fixation devices in skeletally mature knees. A retrospective cohort study was performed at 5 to 19 years follow-up. Patient-reported questionnaires were collected at the final follow-up. Postoperative X-rays and MRIs were evaluated for healing of the lesion and articular degeneration. An arthroscopic second look was performed in 74.3% of the cases. Failures were reported as reintervention to address the osteochondral lesion or poor functional outcomes at the last follow-up. A total of 39 subjects with a median follow-up of 10.7 years were included. Herbert screws were used in 51.2% of the cases, bioabsorbable nails in 25.7% of the cases and cannulated screws in 23.1% of the cases. No differences were observed in terms of the clinical score (International Knee Documentation Committee (IKDC) p = 0.211; Lysholm p = 0.197), radiographic union (p = 0.102) or radiographic degeneration (p = 0.238) between the three different fixation devices. Arthroscopic second look found complete stability of the lesions in all 29 cases evaluated. The mean postoperative Lysholm score was 83 (range = 33-100) and IKDC score was 79 (range = 39-100). Radiographic union was seen in 74% of the cases. Lack of radiographic union was correlated with worst functional scores. A failure rate of 20.5% was found: four reinterventions were performed, and four patients had poor scores at last follow up. This study shows that internal fixation of condylar OCD in skeletally mature patients provides good long-term clinical results and a high degree of healing regardless of the dimensions of the lesion and type of fixation.

Selective bundle reconstruction in partial ACL tears leads to excellent long-term functional outcomes and a low percentage of failures.

BACKGROUND: The optimal treatment of partial anterior cruciate ligament (ACL) tears continues to be debatable. Short-term results of selective bundle reconstruction have already been widely shown. The purpose of this study was to assess functional outcomes, subjective satisfaction and the failure rate of selective bundle reconstructions for partial ACL tears over a five to nine year follow-up period. METHODS: Patients who underwent ACL selective bundle reconstruction between October 2008 and October 2012 were studied. Functional assessment was performed with the objective International Knee Documentation Committee (IKDC) ligament evaluation form, the Lysholm knee scale and the Tegner activity level scale. Cumulative failure and level of satisfaction have also been investigated. RESULTS: Seventy-six patients were included. The average follow-up period was 85 months (range 65-110). Thirty-four had AMB tear and 42 had PLB tears. An overall statistically significant improvement (p < 0.001) was obtained in terms of the subjective IKDC and the Lysholm questionnaire between preoperative and last follow-up. The same or no more than one level lower Tegner score was restored in 97.3% of the cases. Cumulative failure was observed in two patients (2.6%). Dissatisfied patient percentage was 15% (4/76). CONCLUSIONS: Selective bundle reconstruction in partial ACL tears leads to excellent long-term functional outcomes, a low percentage of failures and a high degree of subjective satisfaction in patients. LEVEL OF EVIDENCE: Therapeutic case series; level 4.

Femoral Tunnel Drilling Angles for Posteromedial Corner Reconstructions of the Knee.

PURPOSE: To determine the best angle to drill the femoral tunnels of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) with concomitant posterior cruciate ligament (PCL) reconstruction to avoid either short tunnels or tunnel collisions. METHODS: Eight cadaveric knees were studied. Double-bundle PCL femoral tunnels were arthroscopically drilled. Drilling of the sMCL and POL tunnels was performed in 4 different combinations of 0° and 30° axial (anteriorly directed) and coronal (proximally directed) angulations. Specimens were scanned with computed tomography to document the relations of the sMCL and POL tunnels to the intercondylar notch and PCL tunnels. A minimum tunnel length of 25 mm was required. RESULTS: When the sMCL femoral tunnel was drilled at 0° axial and 30° coronal (proximally directed) angulations or 30° axial (anteriorly directed) and 0° coronal angulations, the risk of tunnel collision with the PCL tunnels increased in comparison with the remaining evaluated angulations (P < .001). No POL tunnels collided with either PCL tunnel bundle with the exception of tunnels drilled at 0° axial and 30° coronal (proximally directed) angulations, which did so in 3 of 8 cases (P < .001). The minimum required tunnel length was obtained in all the sMCL and POL tunnels (P < .001 and P = .02, respectively). However, some of those angled at 0° on the axial plane violated the intercondylar notch. CONCLUSIONS: When one is performing posteromedial reconstructions with concomitant PCL procedures, the sMCL and POL femoral tunnels should be drilled anteriorly and proximally at both 30° axial and 30° coronal angulations. The POL femoral tunnel may also be angled 0° in the coronal plane. Tunnels at 0° axial angulations showed a shorter distance to the intercondylar notch and a higher risk of collision with the PCL tunnels. CLINICAL RELEVANCE: Specific drilling angles are necessary to avoid short tunnels or collisions between the drilled tunnels when sMCL and POL femoral tunnels are placed with concomitant PCL reconstruction.

Partial meniscus substitution with a polyurethane scaffold does not improve outcome after an open-wedge high tibial osteotomy.

PURPOSE: The aim of the study was to determine whether medial meniscal substitution with a polyurethane scaffold (Actifit(®)) improves the outcome of medial meniscal-deficient varus knees undergoing open-wedge high tibial osteotomy. METHODS: Sixty patients with symptomatic varus knees those who underwent open-wedge high tibial osteotomies were prospectively studied. In 30 patients, the medial meniscus was left with a defect larger than 25 mm (Group M). An Actifit(®) device was implanted (Group A) in the remaining 30 patients. Patients were functionally evaluated with WOMET, IKDC and VAS. Patient satisfaction was graded from 0 (not satisfied) to 4 (very satisfied). RESULTS: Both groups were comparable preoperatively. They had similar follow-up periods (31.2 months; range 24-47.5; n.s.). WOMET improved a mean of 53.4 ± 8.4 and 42.4 ± 17.2 points in Groups M and A, respectively (p = 0.002). IKDC improved a mean of 56.7 ± 12 and 50.3 ± 15.6 points in Groups M and A, respectively (n.s.). VAS dropped 5.9 ± 2.1 and 4.7 ± 2.8 points in Groups M and A, respectively (p = 0.006). Patient satisfaction averaged 3.3 ± 0.8 and 3.3 ± 1 in Groups M and A, respectively (n.s.). CONCLUSIONS: Patients with symptomatic varus knees were treated with open-wedge high tibial osteotomies, and a meniscectomy was improved more at short-term follow-up in most of the evaluated functional scores than those patients with concomitant implantation of a medial Actifit(®) implant. However, there was no difference in terms of patient satisfaction with the procedure. Based on the short-term functional results of this study, no data were provided to support medial meniscal substitution with a polyurethane scaffold when an open-wedge high tibial osteotomy is being performed. LEVEL OF EVIDENCE: Prospective comparative study, Level II.

How to improve the prediction of quadrupled semitendinosus and gracilis autograft sizes with magnetic resonance imaging and ultrasonography.

BACKGROUND: Hamstring tendon grafts may have an unacceptable size for use in anterior cruciate ligament (ACL) reconstruction. Magnetic resonance imaging (MRI) has been proposed to predict the diameters of hamstring tendon grafts. HYPOTHESIS: Preoperative ultrasonography (US) might reliably anticipate intraoperative 4-strand semitendinosus and gracilis tendon (4ST-GT) graft sizes similarly to MRI. An MRI evaluation of the hamstring tendons with a higher magnification may improve the accuracy of the method. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 33 patients undergoing ACL reconstruction with a 4ST-GT graft and MRI performed at our institution were included. The cross-sectional area (CSA) of each semitendinosus tendon (ST) and gracilis tendon (GT) was calculated preoperatively with US and with MRI under 2× and 4× magnification. Intraoperative measurement of the final diameter of the 4ST-GT using a closed-hole sizing block with 0.5-mm increments was made. Pearson correlation coefficients were calculated to determine the relationship between the final intraoperative graft diameter of the 4ST-GT and the CSA of the ST and GT measured with US and MRI with 2× and 4× magnification. Simple linear regression was also calculated to attempt to predict the graft diameter based on given measurements. RESULTS: There were statistically significant correlations between the measured CSA with US and both MRI magnifications with the 4ST-GT diameter. However, MRI under 4× magnification showed a much higer correlation (0.86) than MRI under 2× magnification (0.54) or US (0.51). Final graft diameters ≥8 mm were observed in 80.8% of patients with a CSA >14 mm(2), in 76.9% of patients with a CSA >25 mm2, and in 96.2% of patients with a CSA >17 mm2 measured with US, 2× magnification of MRI, and 4× magnification of MRI, respectively. CONCLUSION: Preoperative calculation of the CSA of the hamstring tendons with MRI and US can help to reliably estimate 4ST-GT grafts. In terms of correlation of the CSA with graft diameter, US was comparable to 2× MRI, but 4× MRI showed a much greater accuracy. Threshold values of the CSA of the ST and GT of 25 mm2, 17 mm2, and 14 mm2 with the 2× MRI, 4× MRI, and US methods, respectively, are needed to reliably predict a 4ST-GT graft with a minimum diameter of 8 mm.

Myxoid tumor associated to migration of a suspensory fixation device of a reconstructed anterior cruciate ligament: a case report.

A 16-year-old male who had undergone 6 months before an anterior cruciate ligament (ACL) reconstruction with an autologous hamstring graft fixed with a suspensory fixation device (XoButton device; ConMed Linvatec, Largo, FL), complained of a slightly painful mass in the distal posterolateral aspect of the thigh. The knee was otherwise stable. A 79 × 60 × 17 mm multilobulated tumor surrounding the implant device was observed in magnetic resonance images. The revision arthroscopy showed an intact ACL graft. The tumor was excised through a longitudinal posterolateral approach. It had a myxoid appearance. The undamaged implant was also removed. Two months after surgery, the patient was already asymptomatic. Although most fixation device problems occur in the perioperative period due to an inadequate technique which may lead to graft instability, this case reminds clinicians of the possibility of later developing clinically relevant complications with suspensory fixation devices.

Femoral tunnel drilling angles for the posterolateral corner in multiligamentary knee reconstructions: computed tomography evaluation in a cadaveric model.

PURPOSE: The goal of this study was to determine the best angle at which to drill the femoral tunnels of the popliteus tendon (PT) and fibular collateral ligament (FCL) in combined reconstructive procedures so as to avoid either short tunnels or tunnel collisions with the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) femoral tunnels. METHODS: Eight cadaveric knees were studied. ACL/PCL femoral tunnels were arthroscopically drilled. PT and FCL tunnels were drilled at 0° and 30° axial and coronal angulations. They were scanned by computed tomography to document relations of the PT and FCL tunnels to the intercondylar notch and ACL/PCL tunnels. A minimum tunnel length of 25 mm was required. RESULTS: Drilling the PT tunnel at 0° axial angulation was associated with an increased risk of tunnel collision with the ACL (P < .001). Interference with the PCL tunnel can be avoided only if the K-wire guiding the PT tunnel is drilled with 30° coronal angulations (P < .001). The minimum tunnel length of the PT could be obtained only with both axial and coronal angulations of 30° (P = .003). Sufficient tunnel lengths of the FCL were obtained at all angulations evaluated (P = .036). However, only the tunnels drilled at 30° axial and 0° coronal angulations did not collapse with the ACL tunnels (P < .001). No intersections between FCL and PT tunnels were observed. CONCLUSIONS: When posterolateral reconstructions are performed in combination with concomitant anterior and posterior cruciate procedures, PT tunnels should be drilled at 30° axial and 30° coronal angulations. FCL tunnels should be drilled at 30° axial and 0° coronal angulations. These angulations should minimize such potential complications as short tunnels or collisions with the ACL/PCL tunnels. CLINICAL RELEVANCE: Specific drilling angles are necessary to avoid short tunnels or collisions between the drilled tunnels when FCL and PT femoral tunnels are performed in multiligament knee reconstructions.

Suture-only fixation technique leads to a higher degree of extrusion than bony fixation in meniscal allograft transplantation.

BACKGROUND: Most of the published series of transplanted menisci have consistently shown some degree of allograft extrusion. The speculation is that this meniscal extrusion may be caused by the soft tissue technique used to fix the allograft. HYPOTHESIS: The percentage of extruded meniscal graft would be higher if the allograft were only fixed with sutures rather than with associated bony fixation. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: We performed a prospective series of 88 meniscal allograft transplantations. Thirty-three of the grafts were fixed with the suture-only technique (group A). The remaining 55 cases were performed with the bone plug method (group B). All patients were studied with magnetic resonance imaging (MRI) at a minimum 3 years' follow-up to determine the degree of meniscal extrusion. The time between surgery and MRI evaluation was 40 months (range, 36-48 months) in both groups. Meniscal extrusion was measured on coronal MRI. The percentage of the meniscal body width that was extruded was calculated. The average percentage of extrusion for each group was compared. The Lysholm score was analyzed in relation to the fixation method and degree of meniscal extrusion. Tears of the allograft that required surgical intervention were also reported. RESULTS: The average percentage of meniscal tissue extruded in group A was 36.3% ± 13.7% without differences between the medial (35.9% ± 18.1%) and lateral (38.3% ± 14.4%) compartments (P = .84). Group B had a mean 28.13% ± 12.2% of the meniscal body extruded without differences between the medial (25.8% ± 16.2%) and lateral (30.14% ± 13.5%) compartments. A higher percentage of extruded meniscal tissue was found in group A than in group B (P < .001). No association between the degree of meniscal extrusion and the functional score was observed (P = .4). Graft tears were observed in 21.4% of the cases in group A and in 7.3% of the cases in group B (P = .09). CONCLUSION: A meniscal allograft fixed with the suture-only technique showed a significantly higher degree of extruded meniscal body than that fixed with the bony fixation method, with no influence on the functional outcome. There was also a considerably higher rate of graft tears observed in those menisci fixed only with sutures, although this difference was not statistically significant with the numbers available.