In vivo knee rotational stability 2 years after the ACL reconstruction using a quadriceps tendon graft with bone block and bone-patellar tendon-bone graft.

INTRODUCTION: The aim of this prospective randomised study was to evaluate clinical results and rotational stability at least 2 years after single-bundle anatomic anterior cruciate ligament reconstruction using a quadriceps tendon graft with bone block (BT) and bone-patellar tendon-bone graft (BTB). MATERIALS AND METHODS: In both groups (BT and BTB), 40 patients selected prospectively at random were evaluated. The mean follow-up after the surgery was 28 months (range 24-33 months). A navigation system was used to measure rotational stability of the knee joint. Cincinnati, Lysholm, and IKDC scores and visual analog score (VAS) were used to evaluate clinical results and the non-parametric Wilcoxon test was used for the statistical analysis. RESULTS: After the BT reconstruction, the mean internal rotation of the tibia (IR) was 9.5°. In the contralateral healthy knee joint, IR was 8.6° at average. After the BTB reconstruction, the mean IR was 9.9°. In the contralateral healthy knee joint, IR was 8.7° at average. We did not find any statistically significant difference in IR stability between BT and BTB reconstruction. In terms of clinical results, regarding the VAS, patients perceive significantly more pain after the BTB reconstruction (p < 0.05). Kneeling was reported more difficult and painful after BTB reconstruction. CONCLUSIONS: The BT reconstruction of the ACL provides similar clinical results, less pain, better flexion and the same rotational stability of the knee in comparison with the BTB reconstruction.

Topping Phenomenon with Recurrent Spinal Stenosis and Epidural Fibrosis Prevented with Oxidized Cellulose - a Case Report.

Lumbar spinal stenosis is a condition where the neural structures are compressed in the narrowed spinal canal and often situated only within a single specific segment of the spine, most frequently in the lumbar spine. A case report demonstrates a surgical solution of lumbar spinal stenosis with using oxidized cellulose as a prevention of post-operative adhesions and failed back syndrome. A female patient (68) with a significant pain of the lumbar spine lasting for a number of months due to advanced spondylosis, failing to respond to conservative treatment underwent instrumented, posterolateral fusion of affected segments. The patient re-arrived with pain due to spinal stenosis in another segments after 4 and then after 3 years. We repeatedly performed spinal fusion of the affected segments and applied an antiadhesive gel to the dural sac and the decompressed nerve roots to prevent the development of post-operative adhesions and the "failed back syndrome". Last surgical solution included mobilisation of the simultaneously constricted dural sac through laminectomy. This time we covered the sac using a haemostat made of oxidized cellulose (Traumacel FAM). After this treatment, the patient was again without significant difficulties.

Allograft alone versus allograft with bone marrow concentrate for the healing of the instrumented posterolateral lumbar fusion.

BACKGROUND CONTEXT: Spondylodesis in the operative management of lumbar spine diseases has been the subject of numerous studies over several decades. The posterolateral fusion (PLF) with pedicle screw fixation is a commonly used procedure. PURPOSE: To determine whether the addition of bone marrow concentrate (BMC) to allograft bone increases fusion rate after instrumented posterior lumbar fusion. STUDY DESIGN: The study was prospective, randomized, controlled, and blinded. METHODS: Eighty patients with degenerative disease of the lumbar spine underwent instrumented lumbar or lumbosacral PLF (22 men, 58 women; body mass index less than 35 for a good visualization of the PLF in the X-rays). In 40 cases, the PLF was done with spongious allograft chips alone (Group I, age 62.7 years in average, range 47-77 years, level of fusion 1-2). In another 40 cases, spongious allograft chips were mixed with BMC (Group II, age 58.5 years in average, range 42-80, level of fusion 1-3), including the mesenchymal stem cells (MSCs). Patients were scheduled for anteroposterior and lateral radiographs 12 and 24 months after the surgery and for computed tomography scanning 24 months after the surgery. Fusion status and the degree of mineralization of the fusion mass were evaluated separately by two radiologists blinded to patient group affiliation. The bony mass was judged as fused if there was uninterrupted bridging of well-mineralized bone between the transverse processes or sacrum, with trabeculation indicating bone maturation on least at one side of the spines. RESULTS: In Group I at 12 months, the bone graft mass was assessed in X-rays as fused in no cases (0%) and at 24 months in four cases (10%). In Group II, 6 cases (15%) achieved fusion at 12 months and 14 cases (35%) at 24 months. The statistically significant difference between both groups was proven for complete fusion at both 12 (p=.041) and 24 months (p=.011). Computed tomography scans showed that 16 cases (40%) in Group I and 32 cases (80%) in Group II had evidence of at least unilateral continuous bridging bone between neighboring vertebrae at 24 months (p<.05). CONCLUSIONS: We have confirmed the hypothesis that the autologous BMC together with the allograft is a better alternative for PLF than the allograft alone. The use of autologous MSCs in form of BMC in combination with allograft is an effective option to enhance the PLF healing.

Platelet-rich plasma in patients with tibiofemoral cartilage degeneration.

INTRODUCTION: Recently an articular cartilage repair has been given much attention in the orthopaedic field. Cartilage regeneration capacity is very limited. Optimal approach seems to be a delivery of natural growth factors. Autologous platelet-rich plasma (PRP) contains proliferative and chemoattractant growth factors. The objective of the present study was to determine if PRP can increase tibiofemoral cartilage regeneration and improve knee function. MATERIALS AND METHODS: Fifty consecutive and strictly selected patients, affected by Grade II or III chondromalatia, underwent 1 year treatment (9 injections) with autologous PRP in a liquid form with 2.0 to 2.5-fold platelets concentration. Outcome measures included the Lysholm, Tegner, IKDC, and Cincinnati scores. Magnetic resonance imaging was used to evaluate cartilage thickness and degree of degeneration. RESULTS: The study demonstrated significant improvement in Lysholm (p < 0.05), Tegner (p < 0.05), IKDC (p < 0.05), and Cincinnati (p < 0.05) scores. Results improved at 12-month follow-up. Cartilage assessment revealed no significant cartilage regeneration (p < 0.05). There were no adverse events reported. CONCLUSIONS: PRP significantly reduced pain and improved quality of live in patients with low degree of cartilage degeneration. Magnetic resonance imaging did not confirmed any significant cartilage condition improvement.

AM bundle controls the anterior-posterior and rotational stability to a greater extent than the PL bundle - a cadaver study.

BACKGROUND: The purpose of this study was to evaluate the influence of both bundles of the anterior cruciate ligament (ACL) on knee stability, anterior-posterior translation (APT) and internal (IR) and external (ER) rotation in cadaveric knees using a computer navigation system. METHODS: The APT, IR, and ER of the knees were recorded in the intact condition, the anterolateral bundle (AM) or the posterolateral bundle (PL) deficit condition and in the ACL-deficient condition. The KT-1000 arthrometer was used for APT evaluation. The measurement of rotational movements was done using a rollimeter. All tests were performed at 30°, 60° and 90° of flexion. RESULTS: At 30° of flexion: In the intact knee APT was 5.8mm, IR 12.1°, ER 10.1°. After the AM was cut, the APT increased to 9.1mm, IR to 13.9° and ER to 12.6°. After the PL was cut, the APT was 6.4mm, IR 13.1° and ER 10.6°. After the AM and PL were cut, the APT was 10.8mm, IR 15.7° and the ER was 12.9° on average. CONCLUSIONS: The AM has a greater impact on the APT than the PL in all knee joint flexion angles. The PL does not resist the rotational stability more than the AM. The rotational stability is better controlled by both bundles of ACL as compared to one bundle of the ACL. CLINICAL RELEVANCE: This study acknowledges the fact that the both bundles of the ACL are importants for AP and rotational stability of the knee joint.

Outcomes after conventional versus computer-navigated anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this prospective randomized study was to assess biomechanical, radiographic, and functional results after single-bundle anterior cruciate ligament (ACL) reconstruction by use of a navigation system. METHODS: ACL reconstruction was performed by use of the OrthoPilot navigation system (B. Braun-Aesculap, Tuttlingen, Germany) in 40 patients (group 1); and in another 40 patients, surgery was done by the standard manual targeting technique (group 2). The anterior laxity was measured with a KT-1000 arthrometer (MEDmetric, San Diego, CA). Femoral and tibial tunnel position was evaluated radiologically according to the method described by Bernard and Hertel and by Harner et al., respectively. The questionnaire-based Lysholm and International Knee Documentation Committee scales were included to compare the functional state in both groups. RESULTS: The knees in group 1 were as stable as those in group 2 during the arthrometer testing, with a lower value of dispersion. The postoperative Lysholm and International Knee Documentation Committee scores had the same value in both groups. Statistical differences existed with regard to anterior-posterior femoral tunnel placement when the navigated and standard techniques were compared; in the navigated group, more exact results were found. No significant complications were observed. CONCLUSIONS: The only difference that we found between the navigated and standard groups was in radiographic tunnel position measurement. The computer-assisted navigation technique in our study resulted in more accurate tunnel placement in the femur (but not the tibia) than the traditional arthroscopic technique. However, the performed standard radiographic measurements are of limited precision in principle. Functional scales and stability tests gave similar results in both groups. LEVEL OF EVIDENCE: Level I, therapeutic study.

SPECT scan is a reliable tool for selection of patients undergoing unicompartmental knee arthroplasty.

PURPOSE: Was to determine the relationship between pre-operative SPECT and intra-operative assessments of tibio-femoral chondral changes. METHODS: One hundred cases had been selected on the following criteria: (1) marked Tc-99 m uptake on the medial compartment and (2) its normal uptake laterally. The cartilage macroscopic condition of tibio-femoral compartments were then recorded during the surgery. RESULTS: A total of 73% of Grade 0, 24% of Grade I, and 3% of Grade II chondral injuries were detected laterally; 100% of Grade IV chondral lesions were detected medially. Statistically very significant relationship was demonstrated between SPECT and the mcroscopic cartilage condition. CONCLUSIONS: SPECT bone scan provides very useful information regarding the degree of osteoarthritis in knee weight-bearing compartments for pre-operative planning.

Intraoperative navigation in hip surface arthroplasty: a radiographic comparative analysis study.

BACKGROUND: The goal of the current prospective randomised radiological study was to determine the accuracy of conventional and computer-assisted femoral component implantation in surface arthroplasty (SRA). METHODS: We analysed on standard radiographs the femoral component positions after 30 conventional instrumented (Group 1) and 30 navigated (Group 2) SRA femoral components. We evaluated: varus or valgus orientation, horizontal femoral offset and translation of the component. RESULTS: The tendency to implant the femoral component in mild valgus position (2.8 degrees in Group 1 compared to 2.1 degrees in Group 2), more distally and ventrally in the femoral neck (in Group 1) and with femoral off-set increase (4.8 mm in Group 1 compared to 3.4 mm in Group 2) was found. CONCLUSIONS: The navigation system enables a more accurate insertion of the femoral component.

Component position following total hip arthroplasty through a miniinvasive posterolateral approach.

Implant malposition and poor fixation are potential risks of compromising long-term results after total hip arthroplasty performed with a minimally invasive technique. Between September 2000 and February 2002, 120 cemented primary total hip arthroplasties were performed at the authors' institutions in patients with primary osteoarthritis of the hip and with BMI lower than 35. In 60 of these cases selected at random, a posterolateral incision no longer than 10 cm was used. The other 60 THA's were performed through a standard posterolateral approach. The inclination and anteversion of the cup and the position of the femoral stem were assessed on radiographs and statistically evaluated. In the miniinvasive group, the average inclination angle of the cup was 42.3 degrees (range: 36 to 52 degrees) and the anteversion angle 13.6 degrees (range: 6 to 29 degrees). The coronal alignment of the femoral component was within 3 degrees of neutral in 54 cases (90.0%). Following conventional implantation in the other group, the average cup inclination angle was 42.4 degrees (range: 35 to 50 degrees) and the anteversion angle 13.6 degrees (range: 8 to 24 degrees. A total of 53 stems (88.3 %) were implanted optimally. Statistical analysis found no significant difference between the two groups regarding components position. These findings suggest that using a smaller posterolateral incision as was done in this study does not introduce a potential risk of compromising long-term results.

Mosaicplasty for the treatment of femoral head defect after incorrect resorbable screw insertion.

Articular cartilage lesions and osteochondral defects remain a difficult problem for the patient and physician. A variety of procedures and treatments have been proposed to lessen symptoms and restore the articular surface. The knee joint has been the focus of the vast majority of these cartilage restoration procedures. Osteochondral defects of the proximal femur are significantly less common, and their management remains poorly defined. This article reports the case of a young man with a deep osteochondral defect of the femoral head caused by penetrated resorbable screw after internal fixation of a displaced large single fragment of the posterior acetabular rim and subsequent treatment using mosaicplasty.