Surgical strategy and complication management of osteotomy around the painful degenerative varus knee: ESSKA Formal Consensus Part II.

PURPOSE: The purpose of the European consensus was to provide recommendations for the treatment of patients with a painful degenerative varus knee using a joint preservation approach. Part II focused on surgery, rehabilitation and complications after tibial or femoral correction osteotomy. METHODS: Ninety-four orthopaedic surgeons from 24 countries across Europe were involved in the consensus, which focused on osteotomies around the knee. The consensus was performed according to the European Society for Sports Traumatology, Knee Surgery and Arthroscopy consensus methodology. The steering group designed the questions and prepared the statements based on the experience of the experts and the evidence of the literature. The statements were evaluated by the ratings of the peer-review groups before a final consensus was released. RESULTS: The ideal hinge position for medial opening wedge high tibial osteotomy (MOW HTO) should be at the upper level of the proximal tibiofibular joint, and for lateral closing wedge distal femoral osteotomy (LCW DFO) just above the medial femoral condyle. Hinge protection is not mandatory. Biplanar osteotomy cuts provide more stability and quicker bony union for both MOW HTO and LCW DFO and are especially recommended for the latter. Osteotomy gap filling is not mandatory, unless structural augmentation for stability is required. Patient-specific instrumentation should be reserved for complex cases by experienced hands. Early full weight-bearing can be adopted after osteotomy, regardless of the technique. However, extra caution should be exercised in DFO patients. Osteotomy patients should return to sports within 6 months. CONCLUSION: Clear recommendations for surgical strategy, rehabilitation and complications of knee osteotomies for the painful degenerative varus knee were demonstrated. In Part 2 of the consensus, high levels of agreement were reached by experts throughout Europe, under variable working conditions. Where science is limited, the collated expertise of the collaborators aimed at providing guidance for orthopaedic surgeons developing an interest in the field and highlighting areas for potential future research. LEVEL OF EVIDENCE: Level II, consensus.

Osteotomy around the painful degenerative varus knee has broader indications than conventionally described but must follow a strict planning process: ESSKA Formal Consensus Part I.

PURPOSE: The European consensus was designed with the objective of combining science and expertise to produce recommendations that would educate and provide guidance in the treatment of the painful degenerative varus knee. Part I focused on indications and planning. METHODS: Ninety-four orthopaedic surgeons from 24 European countries were involved in the consensus, which focused on the most common indications for osteotomy around the knee. The consensus was performed according to an established ESSKA methodology. The questions and recommendations made were initially designed by the consensus steering group. And 'best possible' answers were provided based upon the scientific evidence available and the experience of the experts. The statements produced were further evaluated by ratings and peer review groups before a final consensus was reached. RESULTS: There is no reliable evidence to exclude patients based on age, gender or body weight. An individualised approach is advised; however, cessation of smoking is recommended. The same applies to lesser degrees of patellofemoral and lateral compartment arthritis, which may be accepted in certain situations. Good-quality limb alignment and knee radiographs are a mandatory requirement for planning of osteotomies, and Paley's angles and normal ranges are recommended when undertaking deformity analysis. Emphasis is placed upon the correct level at which correction of varus malalignment is performed, which may involve double-level osteotomy. This includes recognition of the importance of individual bone morphology and the maintenance of a physiologically appropriate joint line orientation. CONCLUSION: The indications of knee osteotomies for painful degenerative varus knees are broad. Part I of the consensus highlights the versatility of the procedure to address multiple scenarios with bespoke planning for each case. Deformity analysis is mandatory for defining the bone morphology, the site of the deformity and planning the correct procedure. LEVEL OF EVIDENCE: Level II, consensus.

Graft Reorientation and Lateral Extra-articular Tenodesis in Revision Surgery for Persistent Rotational Instability of a Verticalized Anterior Cruciate Ligament Graft.

Persistent rotational instability after anterior cruciate ligament reconstruction is a relatively common postoperative complication, typically associated with graft verticalization due to improper femoral tunnel placement, especially with classic transtibial femoral tunnel techniques. This article describes a technique designed to reorient a verticalized anterior cruciate ligament graft at its femoral insertion to a more anatomic position in the coronal and sagittal planes, aiming to restore knee stability without the need for a complete revision operation. Additionally, a lateral extra-articular tenodesis with fascia lata is added to reinforce rotational stability.

The Proportion of Meniscus Tears Considered Repairable, and Thus Repaired, Increased During a Single Surgeon's Practice of 20 Years.

Purpose: The purpose of this study was to evaluate practice patterns of a single surgeon with respect to meniscectomy and meniscal repair over a 20-year period at a single institution. Methods: A cross-sectional descriptive study was carried out by reviewing the surgical data from the past 20 years (2002-2021) of patients who underwent arthroscopic primary meniscal surgery. Age, sex, knee and meniscus affected, morphology of the meniscal tear, meniscal radial location, location on the axial plane, tissue quality, and associated injuries were recorded. An analysis of the evolution of the characteristics of the meniscal lesions was performed according to the presence of degenerative tissue, the repairability of the lesion, and the treatment performed. Categorical data were represented in contingency tables and compared using the χ2 test for significance of differences, which was set at P < .05. Results: In total, 1,892 cases were included. A decrease in degenerative meniscal tears was found, from 63.2 in 2002 to 2006 to 9.7% in 2017 to 2021 (P < .001), while repairable tears increased from 1.6% to 82.3% P < .001); in the same periods, arthroscopic partial meniscectomy procedures declined from 75.7% to 17.7% (P < .001) while meniscal repair increased from 0.4% to 81.3% (P < .001). All types of tears increased significantly their repairability, although longitudinal tears, root tears, and ramp lesions showed the highest possibilities for repair. Conclusions: In the present study, a drastic change in the attitude toward meniscal preservation in the past 20 years was observed, with a large increase in the proportion of tears considered repairable found in primary arthroscopic surgery (to 80% of cases) and a decrease in degenerative meniscus tears (to less than 10%). Clinical Relevance: In the past 2 decades, arthroscopic knee surgery has evolved such that more meniscus tears are deemed repairable, and fewer tears considered degenerative are indicated for arthroscopy.

Improved tibiofemoral contact restoration after transtibial reinsertion of the anterior root of the lateral meniscus compared to in situ repair: a biomechanical study.

PURPOSE: To compare biomechanical behaviour of the anterior root of the lateral meniscus (ARLM) after a transtibial repair (TTR) and after an in situ repair (ISR), discussing the reasons for the efficacy of the more advantageous technique. METHODS: Eight cadaveric human knees were tested at flexion angles from 0° to 90° in four conditions of their ARLM: intact, detached, reinserted using TTR, and reinserted using ISR. Specimens were subjected to 1000 N of compression, and the contact area (CA), mean pressure (MP), and peak pressure (PP) on the tibial cartilage were computed. For the TTR, traction force on the sutures was registered. RESULTS: ARLM detachment significantly altered contact biomechanics, mainly at shallow flexion. After ISR, differences compared to the healthy group persisted (extension, CA 22% smaller (p = 0.012); at 30°, CA 30% smaller (p = 0.012), MP 21%, and PP 32% higher (both p = 0.017); at 60°, CA 28% smaller (p = 0.012), MP 32%, and PP 49% higher (both p = 0.025). With TTR, alterations significantly decreased compared to the injured group, with no statistical differences from the intact ones observed, except for CA at extension (15% decrease, p = 0.012) and at 30° (12% decrease, p = 0.017). The suture tension after TTR, given as mean(SD), was 36.46(11.75)N, 44.32(11.71)N, 40.38(14.93)N, and 43.18(14.89)N for the four tested flexion angles. CONCLUSIONS: Alterations caused by ARLM detachment were partially restored with both ISR and TTR, with TTR showing better results on recovering CA, MP, and PP in the immediate postoperative period. The tensile force was far below the value reported to cause meniscal cut-out in porcine models.

Anterior Cruciate Ligament Revision Surgery Associated to Lateral Collateral and Anterolateral Ligaments Reconstruction With Single Achilles Tendon Allograft and Single Femoral Tunnel.

Lateral collateral ligament (LC) injuries that go unnoticed when associated with an anterior cruciate ligament (ACL) tear can increase stress forces on the ACL graft causing its failure. Furthermore, it is a main stabilizer to varus stress and external rotation. On the other hand, the reinforcement of anterolateral structures during ACL reconstruction has regained popularity in recent years, because evidence has shown that it increases the control of rotational laxity and decreases ACL graft failures, especially in revision surgery. The present article shows a technique to perform an ACL reconstruction, associated with the reconstruction of the LCL and of the anterolateral ligament using a single Achilles tendon allograft, which is split after the fixation of the ACL graft into two fascicles.

Biomechanical consequences of anterior root detachment of the lateral meniscus and its reinsertion.

Treatment of posterior meniscal roots tears evolved after biomechanical evidence of increased pressures on the tibiofemoral cartilage produced by this lesion and the subsequent accelerated development of arthritis or osteonecrosis observed clinically. However, little is known about the consequences of the detachment of the anterior roots. This in-vitro study analyzes the biomechanical changes in the tibiofemoral joint caused by avulsion of the anterior root of the lateral meniscus. The effectiveness of surgical root re-insertion to restore the pre-injured conditions is also evaluated. Using cadaveric knees at flexion angles from 0° to 90°, results show that the lesion significantly reduces the contact area and raises the pressure on the tibiofemoral cartilage of the injured compartment at all angles. Said modifications become larger at low flexion angles, which are the most frequent positions adopted by the knee in daily and sports activities, where they result similar to total meniscectomy. In-situ repair partially restores the contact biomechanics. Consequently, careful attention should be paid to proper diagnosis and treatment of detached anterior roots since the observed altered knee contact might induce similar degenerative problems in the cartilage as with completely detached posterior roots.

Arthroscopic Superior Capsular Reconstruction with Achilles Tendon Allograft for Massive and Revision Rotator Cuff Tears.

Massive irreparable rotator cuff tears (RCT) in younger and active patients remain a significant clinical challenge to orthopaedic surgeons. Superior capsular reconstruction (SCR) has been presented as a way to restore the restraining effect of the superior joint capsule and the balanced force couples necessary for dynamic shoulder function; furthermore, it does not exclude future treatment options. The purpose of this article is to show a technical modification of the SCR in massive and revision RCT using Achilles tendon allograft as an effective static restraint to prevent superior migration of the humeral head due to its thickness and robustness, and performing a side-to-side repair on the greater tuberosity between the graft and the residual infraspinatus tendon to completely restore the superior stability of the shoulder joint.

Anterior Capsular Reconstruction With Proximal Biceps Tendon for Large to Massive Rotator Cuff Tears.

Massive rotator cuff tears (RCT) have traditionally been a challenging clinical problem for shoulder surgeons. A broad variety of treatment options have been proposed to address this problem, but outcomes have been as variable as the techniques themselves. Superior capsular reconstruction has been presented as a way to restore the restraining effect of the superior joint capsule and balanced force couples in massive tears of the superior rotator cuff. The purpose of this article is to propose a technical modification of the superior capsular reconstruction in large to massive RCT, and, especially in anterior L-shaped RCT, using the long head of the biceps tendon autograft to reinforce the weakest area of the anterior capsule, not as an augmentation of the rotator cuff, but as a static stabilizer of the humeral head, allowing the rotator cuff repair to heal without tension.

Comparison of two different ways to apply a circular plaster cast for distal radius fractures: biomechanical study.

INTRODUCTION: Although conservative treatment with circular plaster cast is the most commonly used method in distal radius fractures, the best method to apply it remains unclear. MATERIAL AND METHODS: Two frequently used configurations of circular plaster cast (with and without a splint) were selected to compare. Group C was applied only with circular bandages (three units) and group S with a splint (one unit) and over it, a circular bandage (two units). Both configurations had the same weight. Five prototypes of each group were built and mechanically tested. Three-point flexural tensile strength and maximum deflection were measured and compared. RESULTS: The previously splinted prototypes (group S) obtained higher tensile strength with the same weight (p < 0.05). DISCUSSION: No other study regarding strength and configuration of circular casts for distal radius fractures immobilization has been previously published, leading to a high variability in construction among orthopedic surgeons. Data confirms that applying a splint before circular bandage offers more mechanical resistance to the cast in flexion, with the same weight. CONCLUSION: Applying a splint before circular bandage for plaster casts used for distal radius fractures make them more resistant to usual forces.

Obesity and Meniscal Transplant Failure: A Retrospective Cohort Study.

The purpose of this study was to analyze the effect of obesity and other clinical factors on the outcome of meniscal allograft transplantation (MAT) with transosseous fixation. A retrospective cohort study was performed on patients who underwent a MAT between 2002 and 2017. All the participants had a minimum follow-up period of 24 months. The variables assessed were age at the time of the transplant, side, sex, transplanted meniscus (lateral/medial), body mass index (BMI), smoking status, and previous surgeries. Lysholm, Tegner, and International Knee Documentation Committee (IKDC) test outcomes, and patient satisfaction were recorded. Image assessment was performed using plain standing X-rays and a follow-up magnetic resonance imaging scan. Thirty-five patients fulfilled the inclusion criteria. The mean follow-up time was of 75.7 standard deviation (SD) 43.4 months. Patients with a BMI ≥ 30 underwent medial meniscal transplants (88.9 vs. 42.3%, p = 0.022, respectively) more frequently. Obese patients had a significantly lower IKDC (48.6 SD 19.9 vs. 61.7 SD 13.1, p = 0.038, power: 57.5%) and Lysholm (60.3 SD 19.2 vs. 79.4 SD 14.3, p = 0.004, power: 88.7%) scores compared with nonobese patients. The satisfaction and Tegner scores were also lower in obese patients (55.6 vs. 80.7%, p = 0.136, and 2.8 SD 1.0 vs. 4.0 SD 1.9, p = 0.104, respectively); however, these differences were not statistically significant. Obese patients had higher rates of meniscal transplant failure compared with nonobese patients (adjusted hazard ratio: 11.8 [95% confidence interval: 1.5-91.4]). No differences were observed between obese and nonobese patients regarding age, sex, side, smoking status, and follow-up time. In this study, a BMI ≥ 30 kg/m2 resulted in higher MAT failure rates. Nonobese patients had better knee functional results compared with obese individuals.

Anterior Cruciate Ligament Reconstruction Using Combined Graft of Hamstring and Fascia Lata With Extra-articular Tenodesis. A Technique in Case of Insufficient Hamstrings.

A technique for augmentation of the anterior cruciate ligament (ACL) with hamstring graft and lateral extra-articular tenodesis is presented. The patient is positioned supine with the knee flexed 90°. First, intra-articular injuries are addressed arthroscopically, and then autologous hamstring tendons are harvested and measured; the present technique is a resource for cases with a very small graft diameter (less than 8 mm), due to thin tendons or to tendon breakage, even after tripling the hamstring graft, which is prepared using a facia lata strip long enough to fit the lengths of the femoral tunnel, the anterior cruciate ligament graft, and the tibial tunnel. A single femoral tunnel is performed and only 2 interference screws are needed for fixation.

Physeal Sparing Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients Bridging the Tibial Physis With Two Divergent Tunnels.

A technique for anterior cruciate ligament (ACL) reconstruction in patients with open physis is presented. The patient is positioned supine with the knee flexed 90°. After intraarticular injuries are addressed, an autologous hamstring graft is harvested and prepared using a suspension device attached in its expansion device. All-epiphyseal femoral and tibial tunnels of the same diameter of the graft are created; both of them are drilled in an outside-in direction, sparing the physis under radioscopic control. A second divergent tibial tunnel of the same diameter of the graft, distal to the physis, is created in an outside-in, mediolateral, and craniocaudal direction, leaving a 1-cm bone bridge between the 2 tibial tunnels. The graft is passed through the all-epiphyseal tunnels, from femoral to tibial, and pulled until the suspension device leans on the lateral femoral cortex. The graft is passed through the second divergent tibial tunnel and fixed in it with an interference screw to move the pressure away from the physis.

Assessment of fixation for anterior cruciate ligament reconstruction using oversized suspensory devices on full-length femoral tunnels.

BACKGROUND: In ACL repair, full-length single-diameter tunnels facilitate anatomic femoral fixation with suspensory devices, especially with outside-in techniques, and are required after accidental cortical perforation. With tunnel diameters over 6 mm, fixation resistance using regular suspensory devices may not suffice. Oversized cortical footprint devices could be a solution to guarantee fixation performance in larger tunnel diameters. This study aims to assess the biomechanical properties of ACL femoral fixation provided by two enlarged suspensory devices of similar characteristics, a fixed loop (G-Lok™ with G-Lok-XL™) and an adjustable loop (ProCinch™ with G-Lok-XL™), resting on a full-length 9 mm diameter tunnel compared to the widely accepted regular fixed-loop device (G-Lok™) on a socket tunnel. METHODS: Twenty-seven fresh frozen porcine femurs and flexor digitorum profundus tendons were randomly assigned to a study group depending on the fixation method used (N = 9). Graft-femur constructs were subjected to a traction cyclic test (5000 cycles, [50-250]N load, 1 Hz) followed by a load-to-failure test (v = 1 mm/s). Residual displacement during the cyclic test and stiffness, displacements at physiological loads, ultimate load and corresponding displacement during the load-to-failure test were determined. FINDINGS: No significant differences could be established for any parameter measured in the comparison between the control with the socket tunnel and the oversized fixations with full-length tunnels. INTERPRETATION: ACL femoral fixation achieved in full-length single diameter tunnels by using an enlarged suspension device, both with a fixed or an adjustable loop, provide similar biomechanical properties to the gold-standard fixed-loop device in a socket tunnel. Therefore, its clinical use may be safe.

The Finochietto Sign as a Pathognomonic Finding of Ramp Lesion of the Medial Meniscus.

Ramp lesions are considered hidden injuries of the medial meniscus and are very difficult to diagnose. The Finochietto jump sign is a very specific finding that could be considered pathognomonic regarding ramp lesions. This sign consists of a sudden jerk that appears when the free edge of the posterior horn of the medial meniscus is dislocated anteriorly due to the medial condyle interposition when an anterior drawer test is performed on a knee with a ramp lesion, especially when it is associated with an anterior cruciate ligament tear. In this technical note, the Finochietto sign is described clinically, is correlated with its exploration under anesthesia, and is described for the first time under arthroscopic examination in the case of a ramp lesion, in which this finding can help to the diagnosis when present, especially when associated with anterior cruciate ligament tears.

Initial Biomechanical Properties of Transtibial Meniscal Root Repair are Improved By Using a Knotless Anchor as a Post-Insertion Tensioning Device.

The importance of meniscal root integrity to preserve contact load distribution and stability at the knee joint is recognised. Transosseous suture technique is commonly used to repair meniscal root tears. However, clinical results are not completely satisfactory. Specifically, concern exists about the development of substantial displacements at the repaired root. This study aims to assess if the use of a post-insertion tensioning knotless-anchor at the distal exit of the tibial tunnel improves time-zero biomechanical properties of the transtibial repair compared to knotting sutures over a cortical button. Twenty porcine tibia with detached posterior medial meniscal roots were randomized into two groups depending on the method to fix the sutures after root repair: knotless-anchor (KA) or suture-button (SB). Specimens underwent cyclic and load-to-failure testing. Group KA showed significantly smaller residual root displacements after low-level repetitive loads. At the load-to-failure test, Group KA exhibited significantly lower displacements at representative subcritical loads and higher resistance to development of clinically relevant displacements. The authors conclude that use of a knotless suture anchor attached at the distal outlet of the bone tunnel may be an effective solution to reduce root displacements in transtibial meniscal root repairs, a matter reported to alter biomechanics of joint contact.

Non anatomic reinsertion after amputation of the anterior horn of the lateral meniscus.

Anatomical reinsertion is the optimal treatment for meniscal root injuries. However, in chronic settings, tissue fraying of the meniscal root may impede it. This study describes a salvage technical procedure performed in 3 cases of chronic anterior root avulsion of the lateral meniscus with profuse tissue degeneration in which remnant debridement resulted in amputation of the root. Reinsertion of the meniscus at the remaining healthy tissue was performed using an all-inside anchoring technique.

One-Third of Meniscal Tears Are Repairable: An Epidemiological Study Evaluating Meniscal Tear Patterns in Stable and Unstable Knees.

PURPOSE: To analyze, in a long series of patients with knee injuries, the meniscal tear patterns in both stable and unstable knees to ascertain the exact proportion of such injuries that could have been repaired. METHODS: A descriptive cross-sectional study was undertaken by reviewing the clinical reports of arthroscopic knee operations carried out in 1 hospital. A total of 2,066 consecutive patients were included in the study. An analysis of clinical and anatomical data of knee lesions, including the shape of the meniscal tears and the surrounding injuries, was performed. RESULTS: Out of all meniscal tears, 34.9% were found to be repairable, a figure that rose to 55.6% in those tears accompanied by anterior cruciate ligament injuries; 37% of meniscal tears in male patients were repairable, and 28% in their female counterparts; 38.2% of medial meniscal tears were repairable and 30.6% in their lateral counterparts. The most frequently encountered injury was the complex tear (46.9%). CONCLUSIONS: Our study concludes that, according to current standard indications, 34.9% of all meniscal injuries offer the potential for repair. Where the injury is also accompanied by anterior cruciate ligament damage, the proportion of repairable tears rises to 55.6%. This information should increase the interest for meniscal preservation in the future. LEVEL OF EVIDENCE: Level IV, case series.

Synchronized Pedaling with Martial Arts Improves Quality of Life of Women with Breast Cancer.

Physical exercise improves the physical condition of women who have been undergone surgery for breast cancer. This study evaluated the effect of a new martial arts program that combined aerobic endurance and muscle strength exercises on improving upper limb function and aerobic performance of women who have undergone breast cancer surgery. Fifty-three women who had previously undergone breast cancer surgery with axillary lymph node dissection, radiotherapy and/or chemotherapy participated in the twelve-week program. Participants were randomly assigned to two groups; a study group (28 participants) in which participants carried out a synchronized pedaling with martial arts routine of 2 sessions per week, and a control group (22 participants) who received usual care. Study group participants demonstrated a significant increase in right hand and quadriceps strength, maximum oxygen consumption, max power-to-weight ratio, muscle mass percentage and a decrease in fat mass percentage (p≤0.05). A controlled training system like synchronized pedaling with martial arts, which combines aerobic and strength exercises, appears suitable for improving the muscle strength and aerobic capacity of these breast cancer participants.

Associated Anterior Cruciate Ligament and Fibular Collateral Ligament Reconstruction With Single Femoral Tunnel and Asymmetric Hamstring Tendon Graft.

A technique for associated anterior cruciate ligament and fibular collateral ligament reconstruction is shown, using a single hamstring tendon graft, which is prepared asymmetrically, leaving one-third of the length with a single diameter and two-thirds with a double diameter. A single femoral tunnel is created, using an interference screw for fixation and isolation of the grafts. A suspension device is used for tibial fixation, allowing for length adjustment according to the graft's length. The objective of this Technical Note is to provide the orthopaedic surgeon with a resource for anterior cruciate ligament and fibular collateral ligament reconstruction even with short grafts, saving bone stock and avoiding the need for allografts.