Three-dimensional-printed patient-specific instrumentation is an accurate tool to reproduce femoral bone tunnels in multiple-ligament knee injuries.

PURPOSE: Multiple-ligament knee reconstruction techniques often involve the creation of several bone tunnels for various reconstruction grafts. A critical step in this procedure is to avoid short tunnels or convergences among them. Currently, no specific template guide to reproduce these angulations has been reported in the literature, and the success of the technique still depends on the experience of the surgeon. The aim of this study is to analyze the accuracy and reliability of 3D-printed patient-specific instrumentation (PSI) for lateral and medial anatomical knee reconstructions. METHODS: Ten cadaveric knees were scanned by computed tomography (CT). Using specific computer software, anatomical femoral attachments were identified: (1) on the lateral side the lateral collateral ligament (LCL) and the popliteal tendon (PT) and (2) on the medial side the medial collateral ligament (MCL) and the posterior oblique ligament (POL). Four bone tunnels were planned for each knee, and PSI with different directions were designed as templates to reproduce the planned tunnels during surgery. Twenty 3D-printed PSI were used: ten were tailored to the medial side for reconstructing MCL and POL tunnels, and the other ten were tailored to the lateral side for reconstructing LCL and PT tunnels. Postoperative CT scans were made for each cadaveric knee. The accuracy of the use of 3D-printed PSI was assessed by superimposing post-operative CT images onto pre-operative images and analyzing the deviation of tunnels performed based on the planning, specifically the entry point and the angular deviations. RESULTS: The median entry point deviations for the tunnels were as follows: LCL tunnel, 1.88 mm (interquartile range (IQR) 2.2 mm); PT tunnel, 2.93 mm (IQR 1.17 mm); MCL tunnel, 1.93 mm (IQR 4.26 mm); and POL tunnel, 2.16 mm (IQR 2.39). The median angular deviations for the tunnels were as follows: LCL tunnel, 2.42° (IQR 6.49°); PT tunnel, 4.15° (IQR 6.68); MCL tunnel, 4.50° (IQR 6.34°); and POL tunnel, 4.69° (IQR 3.1°). No statistically significant differences were found in either the entry point or the angular deviation among the different bone tunnels. CONCLUSION: The use of 3D-printed PSI for lateral and medial anatomical knee reconstructions provides accurate and reproducible results and may be a promising tool for use in clinical practice.

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.

Conditioned pain modulation predicts persistent pain after knee replacement surgery.

INTRODUCTION: Persistent pain after total knee replacement is an underestimated outcome leading to significant health burden. Sensory testing has been explored to help surgeons in decision making and better patient selection. Patients with different chronic pain syndromes exhibit a poor descending pain inhibition that can be quantified through experimental paradigms (conditioned pain modulation). A poor preoperative descending pain inhibition response predicted persistence of pain after surgery in previous studies. METHODS: This study investigated the correlation between a preoperative inefficient endogenous analgesia and a bad postoperative pain outcome (painful prosthesis). One hundred forty-six patients were studied preoperatively by quantitative sensory testing. Conditioned pain modulation was calculated as the relative decrease in pain intensity (thermal stimulus) during heterotopic painful stimulation. RESULTS: Approximately 21.2% of patients had a bad pain outcome (painful prosthesis), 6 months after surgery. Preoperatively, 47.9% of patients exhibited an insufficient endogenous analgesia. The probability to develop persistent pain after surgery in that group was higher than that in patients with a sufficient endogenous analgesia (31.4% [20.9-43.6, 95% CI] vs 11.8% [5.5-21.3, 95% CI], respectively; P < 0.004). Correlation between conditioned pain modulation values and postoperative intensity of pain was also established. Besides, a preoperative lower quality of life (mental component) predicted a worse pain outcome, too. CONCLUSIONS: This cohort study shows that preoperative sensory testing predicts a bad pain outcome after total knee replacement. This tool could help clinicians in a better indication of patients with advanced knee osteoarthritis for replacement surgery. REGISTRATION DETAILS: ClinicalTrials.gov: NCT01811888 (prospective).

Translation and validation of the new knee society knee scoring system into Spanish: Spanish KSS translation.

PURPOSE: The aim of the study was to translate and validate the English version of the 'Knee Society Knee Scoring System' developed in 2011 (2011 KSS) into Spanish. This new KSS version considers patient satisfaction and expectations before and after knee arthroplasty. Moreover, the questionnaire allows a better characterization of a younger and more diverse population. METHODS: A cross-cultural adaptation process was carried out to obtain the Spanish version of the questionnaire. After that, patients undergoing primary knee arthroplasty answered the translated questionnaire before and 6 months after surgery. Psychometric properties including feasibility, validity, reliability, and sensitivity to change were then assessed, and the questionnaire was compared with prior KSS, as well as with SF-12 and WOMAC, all of them already validated to Spanish. RESULTS: In the cross-cultural adaptation process, alternative translations of some items in 'Patient Expectative' and 'Functional Activities' sections were suggested. One hundred and seventy-six patients answered the resulting 1.0 version. Feasibility: 'Charnley Functional Classification', 'Deduction for flexion contracture and extensor lag', the question 'Do you use these aids because of your knees?', and 'Advanced activities (total)' obtained a high number of missing items. Eighty-eight patients (50%) in the preoperative visit and 141 patients (86.5%) after surgery had at least one missing answer. Internal validity: although the analysis suggests the presence of more than one dimension, there was a dimension that explained a higher percentage of variance, which was more noticeable in the postoperative visit. Convergent validity: correlation coefficients with prior KSS, SF-12, and WOMAC confirm the questionnaire's validity. Reliability: Cronbach's alpha for the new KSS was 0.841 and 0.861 in visit 1 and 2, respectively, and higher than that for prior KSS. Sensitivity to change: statistically, significant differences were found between the mean scores between both visits. CONCLUSION: The proposed Spanish version of 2011 KSS is valid, reliable, and sensible to change in patients undergoing primary knee arthroplasty. Moreover, it has higher internal consistency (reliability) than the prior KSS. It should be emphasized its correct filling by both health professional and patients LEVEL OF EVIDENCE: II.

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.

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.

Reduction of periprosthetic Staphylococcus aureus infection by preoperative screening and decolonization of nasal carriers undergoing total knee arthroplasty.

OBJECTIVE: The aim of this study was to evaluate whether the establishment of a preoperative screening and decolonization protocol for Staphylococcus aureus carriers undergoing total knee arthroplasty (TKA) could decrease the incidence of periprosthetic joint infection (PJI) caused by this microorganism. METHODS: We conducted a retrospective study comparing a control group comprising 400 patients (134 men, and 266 women; mean age: 72.2 ± 6.8 years) who went through surgery between January 2009 and December 2013, with a second intervention group of 403 patients (125 men, and 278 women; mean age: 72.4 ± 6.9 years) in which the protocol of screening and decolonization of S. aureus nasal carriers was applied between January 2014 and December 2016. During this latter period patients were preoperatively screened and, if positive, treated with mupirocin nasal ointment and chlorhexidine soap, for 5 days prior to surgery. RESULTS: In the control group, 17 of 400 patients (4.2%) had a SSI, 8 (2%) of them caused by S. aureus and 9 (2.2%) by other microorganisms. In the intervention group 20.6% of patients had a positive S. aureus nasal swab and were treated according to the protocol. 5 of 403 patients (1.2%) in this group had a SSI, 1 (0.2%) due to S. aureus and 4 (1%) to other microorganisms. When comparing surgical-site infection (SSI) rates between the two groups, we found a statistically significant reduction in both global SSI (p = 0.009) and specifically S. aureus SSI (p = 0.02), in the intervention group. No decolonized S. aureus nasal carrier presented a SSI. DISCUSSION: In patients undergoing TKA a preoperative screening and decolonization protocol for S. aureus nasal carriers, using mupirocin nasal ointment and chlorhexidine soap, is an effective measure to reduce the rate of SSI caused by this microorganism. LEVEL OF EVIDENCE: Level III; Therapeutic Study.

Biplane opening wedge high tibial osteotomy with a distal tuberosity osteotomy, radiological and clinical analysis with minimum follow-up of 2 years.

BACKGROUND: High tibial osteotomy is an established and helpful treatment for unicompatimental osteoarthritis associated with varus deformity. However, asupratubercle high tibial osteotomy leads to a decrease in patellar height making the technique not suitable in case of concomitant patella baja. Moreover, this kind of osteotomy can change in situ forces at patellofemoral joint and the lateral patellar tilt. With the aim to widen the indication of high tibial osteotomy was proposed a biplane opening wedge high tibial osteotomy with a distal tuberosity osteotomy (B-OWHTO). This technique provide that the tibial tuberosity remains joined to the tibial metaphysis so as not to theoretically alter the patellar height. However, some Authors claim that BOWHTO could lead to an increase in tibial slope. The purpose of the present study was to assess the tibial slope, patella-femoral changes and axial correction as well as functional outcomes following a B-OWHTO. METHODS: Patients operated on with a B-OWHTO and a minimum 24 months of follow-up were included. The mechanical alignment of the lower limb, patellar height, lateral patellar tilt and posterior tibial slope were calculated preoperatively, immediately after surgery and at the 24-month follow-up. The clinical results were evaluated using the Lysholm, Kujala and Hospital for Special Surgery knee scores. The possible postoperative development of patellofemoral pain or radiologic patellofemoral alteration was also evaluated. RESULTS: Twenty-three patients were included with a mean follow-up of 33 months (range 27-41). The mechanical alignment of the lower limb shifted from a mean 9.3º ± 2.5 varus preoperatively to a mean 0.2º ± 2.2 valgus postoperatively. No changes in patellar height, lateral patellar tilt or in the posterior tibial slope were observed. The mean Lysholm and HSS scores improved from 68.3 ± 9.1 and 64.2 ± 5.2 preoperatively to 93.2 ± 2.1 and 94.1 ± 3.6 at final follow-up (p < 0.01). The mean Kujala score improved from 67.3 ± 9.8 to 86.4 ± 7.6 at final follow up (p < 0.01). No patients developed both radiological or clinical symptoms at patellofemoral joint. CONCLUSIONS: Open wedge high tibial osteotomy with a dihedral L-cut distal and posterior to the tibial tubercle accurately corrected axial malalignment without any change at patella-femoral joint or any modification to the posterior tibial slope while providing improved knee function at short-term follow-up. The radiographic as well as the clinical results support the use of this technique to treat medial compartment knee osteoarthritis and varus malalignment in young and middle-aged patients with a normal-to-low patellar height. LEVEL OF EVIDENCE: Case series with no comparison group, Level IV.

Capsulodesis Versus Bone Trough Technique in Lateral Meniscal Allograft Transplantation: Graft Extrusion and Functional Results.

PURPOSE: To compare the radiographic results (in terms of graft extrusion) and the functional results of lateral meniscus allograft transplantations (MAT) performed with a bony fixation technique or with a soft tissue fixation technique after capsulodesis. METHODS: A prospective series of 29 consecutive lateral MAT was analyzed. The inclusion criterion for MAT was lateral joint line pain due to a previous meniscectomy. Malalignment, patients who had an Ahlback grade greater than II, and patients with a body mass index over 30 were considered as the exclusion criterion to prevent confounding results. Fifteen of the grafts were fixed with a bony fixation technique (group A). The remaining 14 cases (group B) were fixed with sutures through bone tunnels after lateral capsular fixation (capsulodesis). All patients were studied with magnetic resonance imaging to determine the degree of meniscal extrusion at an average of 18 months of surgery (range, 12-48 months). Meniscal extrusion was measured on coronal magnetic resonance imaging. To standardize the results, the percentage of meniscus extruded for each group was also calculated and compared. The functional results were analyzed by means of standard knee scores (Lysholm, Tegner, and visual analog scale). RESULTS: If we consider the first 4 cases of group B as the learning curve of the new technique, we observe that group A had 8 cases (53.3%) of major extrusion, whereas group B had 1 case (7.1%) (P = .02). When comparing the degree of meniscal extrusion with the type of fixation employed, an even lower percentage of extruded menisci was found in group B (P = .01). The final follow-up Lysholm score in group A was 94.33 ± 5.96 (P < .001) and 91.43 ± 6.19 (P < .001) in group B. The median follow-up Tegner score significantly improved from 4 (range, 2-5) to 7 (range, 6-9) in group A (P < .001) and from 4 (range, 3-5) to 7 (range, 6-8) in group B (P < .001). The average visual analog scale score dropped down 5.87 and 7.29 points in groups A and B, respectively (P < .001). The Knee Injury and Osteoarthritis Outcome Score improved from 51.98 ± 2.84 to 90.88 ± 7.53 in group A (P < .001) and from 50.44 ± 2.32 to 92.01 ± 6.71 in group B (P < .001). Patient satisfaction with regard to the procedure stood at a mean of 3.6 ± 0.2 points out of a maximum of 4 in group A and 3.8 ± 0.4 in group B. There were no complications in this series. CONCLUSIONS: The capsulodesis technique in lateral MAT proved not to be statistically different at decreasing the degree of meniscal extrusion with respect to the bone-bridge fixation. If the first 4 cases using the new capsulodesis technique had not included in the results, the capsulodesis technique would have effectively presented better results relative to the degree of meniscal extrusion compared with the bone-bridge fixation technique. In addition, the functional results were similar. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Magnetic Resonance Imaging and Functional Outcomes After a Polyurethane Meniscal Scaffold Implantation: Minimum 5-Year Follow-up.

PURPOSE: To report the magnetic resonance imaging (MRI) and clinical outcomes at a minimum 5-year follow-up in a series of patients with postmeniscectomy syndrome and treated with a polyurethane scaffold. METHODS: All consecutive patients operated on from September 2008 to February 2011 for either persistent medial or lateral joint line compartmental pain receiving a polyurethane scaffold due to a previous partial meniscus resection with a minimum 5-year follow-up were included. Functional scores (Knee Injury and Osteoarthritis Outcomes Score, International Knee Documentation Committee, Lysholm, and Tegner) were assessed preoperatively and at the last follow-up. The state of the scaffold as well as postoperative scaffold extrusion and the total remaining meniscal volume was also evaluated in MRI. RESULTS: Thirty-two patients were included. The mean follow-up was 70.8 ± 7.5 months. The functionality of the knees improved in all the scores used (P < .001) except for the Tegner score that stayed steady. Most of meniscal implants showed extrusion of 2.4 mm (95% confidence interval [CI], 1.1-3.7) were smaller and a hyperintensity signal was seen in the MRI. Three scaffolds were resorbed at the last follow-up. The meniscal volume, determined by MRI, was 1.14 cm3 (95% CI, 0.96-1.31) preoperatively and 1.61 cm3 (95% CI, 1.43-1.7) at the last follow-up. No differences were presented. CONCLUSIONS: The use of a polyurethane meniscal scaffold in patients with a symptomatic meniscus deficit had a good functional outcome at 5 years after surgery. However, the implanted scaffolds did not present normal meniscal tissue with MRI, and the implant volume was considerably less than expected. The fact that most of patients included received different concomitant procedures during scaffold implantation introduces a degree of performance bias into the results. LEVEL OF EVIDENCE: Level IV, case series.

Contamination occurs during ACL graft harvesting and manipulation, but it can be easily eradicated.

PURPOSE: Why anterior cruciate ligament (ACL) autograft soaking in a 5 mg/ml vancomycin solution decreases the rate of infection has not been well-explained. One hypothesis is that grafts can be contaminated during harvesting and vancomycin eradicates the bacteria. The purpose of the present study is to assess how the vancomycin solution acts against ACL graft contamination during graft harvesting and preparation. METHODS: The study was carried out in three university hospitals over a period of 6 months. After sample size calculation, 50 patients were included in the study. Three samples were taken from each ACL graft. Sample 1 was obtained immediately after graft harvesting. After graft manipulation and preparation, the remaining tissue was divided into two parts. The raw sample was denominated sample 2 and sample 3 consisted of the rest of the remaining tissue that had been soaked in the vancomycin solution. All the cultures were incubated at 37 °C with 5% CO2 in agar plates for 7 days (aerobically) or 14 days (anaerobically) and inspected daily for microbial growth. Any bacterial growth and the number of colony forming units were reported. RESULTS: In seven cases (14%), either sample 1 or sample 2 was positive. In five of the cases (10%), only the sample after graft preparation was positive (sample 2). In two cases (4%), sample 1 and sample 2 were positive for the same bacteria. Isolated microorganisms corresponded to coagulase-negative staphylococci (CNS) and Propionibacterium acnes. No bacterial growth was observed in sample 3 (p < 0.001). Thus, none of those seven positive cases (0%) were positive after vancomycin soaking (p < 0.001). CONCLUSION: In the series, ACL graft harvesting and manipulation leads to bacterial contamination in 14% of the cases. This contamination is fully eradicated after soaking in the vancomycin solution in this series. LEVEL OF EVIDENCE: Level II.

Lateral Capsular Fixation: An Implant-Free Technique to Prevent Meniscal Allograft Extrusion.

Although several surgical techniques have been described to perform meniscal allograft transplantation with good clinical results and although different methods of capsular stabilization can be found in the literature, there is no standard surgical technique to prevent a common complication in the most of series: the tendency to a radial displacement or extrusion of the transplanted menisci. We present a simple, reproducible, and implant-free technique to perform a lateral capsular fixation (capsulodesis) at the time of only the soft-tissue fixation technique of meniscal allograft transplantation in an effort to reduce or prevent the risk of graft extrusion. Using a minimum of two 2.4-mm tunnels drilled from the contralateral side of the tibia with the help of a regular tibial anterior cruciate ligament guide, a capsular attachment to the lateral tibial plateau is obtained.

Open-Wedge Valgus High Tibial Osteotomy Technique With Inverted L-Shaped Configuration.

High tibial osteotomy (HTO) is a useful alternative in the treatment of symptomatic varus malalignment. However, among its drawbacks is the tendency to decrease patellar height and increase the posterior tibial slope. The increased tibial slope increases anterior cruciate ligament tension and may compromise its function. On the other hand, patella baja often causes anterior knee pain and, over time, may favor degeneration of the patellofemoral joint. The aim of this study is to describe a technical modification of the standard open-wedge HTO. It consists of a double inverted L-shaped cut, which includes the anterior tibial tuberosity in the proximal fragment, to avoid any alteration of patellar height and control the eventual increase of the posterior tibial slope.

Reconstruction of the Medial Patellofemoral Ligament.

Patellar instability has been shown to be associated with different major factors. However, studies have demonstrated that soft tissue reconstructions are adequate enough to reestablish patellar constraint. In recent years, the medial patellofemoral ligament has been recognized as the primary passive restraint for lateral translation of the patella. Their reconstruction has gain popularity as the procedure is quite simple and fast. Although several surgical techniques have been described for their reconstruction, no clear consensus has been reached as to which is best. We present an implant-free, medial patellofemoral ligament reconstruction technique that uses a gracilis tendon autograft, 2 bone convergent tunnels at the original patellar attachment, and looping the graft around the adductor magnus tendon that is used as a pulley for femoral fixation.

Local infiltration analgesia adds no clinical benefit in pain control to peripheral nerve blocks after total knee arthroplasty.

PURPOSE: To evaluate the effect of the local infiltration of analgesics for pain after total knee arthroplasty in patients treated with femoral and sciatic peripheral nerve blocks. The secondary objective was to detect differences in analgesic consumption as well as blood loss after local infiltration of analgesics. METHODS: Prospective randomized double-blinded study in patients who underwent a TKA for knee osteoarthritis under spinal anesthesia and treated with femoral and sciatic nerve blocks. This study compared 50 patients treated with local infiltration with ropivacaine, epinephrine, ketorolac and clonidine and 50 patients treated with a placebo with the same technique. The visual analogic score was registered postoperatively at 2, 6, 12, 24, 36, 48 and 72 h after surgery. Analgesic consumption was also registered. Both groups of patients were treated with the same surgical and rehabilitation protocols. RESULTS: A significant difference of one point was found in the visual analogic pain scores 12 h after surgery (0.6 ± 1.5 vs. 1.7 ± 2.3). There were no significant differences in the visual analogic pain scores evaluated at any other time between 2 and 72 h after surgery. No significant differences were found in the required doses of tramadol or morphine in the postoperative period. Postoperative hemoglobin and blood loss were also similar in both groups. CONCLUSION: Adding local infiltration of analgesics to peripheral nerve blocks after TKA surgery only provides minimal benefit for pain control. This benefit may be considered as non-clinically relevant. Moreover, the need for additional analgesics was the same in both groups. Therefore, the use of local infiltration of analgesics treatment in TKA surgery cannot be recommended if peripheral nerve blocks are used. LEVEL OF EVIDENCE: I.

Autograft soaking in vancomycin reduces the risk of infection after anterior cruciate ligament reconstruction.

PURPOSE: To determine whether the bathing of an anterior cruciate ligament (ACL) autograft in vancomycin reduces the rate of infection following an ACL reconstruction. METHODS: Retrospective analysis of all ACL reconstructions over an 8-year period in two University Hospitals. In the initial 4-year period, all patients were operated on under classical antibiotic intravenous prophylaxis (group 1). Over the last 4-year period, this prophylaxis was supplemented with presoaking of the autograft (group 2). Presoaking was performed with sterile gauze previously saturated with a vancomycin solution (5 mg/ml). RESULTS: There were 810 and 734 patients in group 1 and 2, respectively. Fifteen cases of knee joint infections were identified in the series (0.97 %). All of these infections occurred in group 1, representing a rate of infection of 1.85 % in comparison with 0 % in group 2 (p < 0.001). CONCLUSIONS: Autograft presoaking with vancomycin in combination with classical intravenous antibiotic prophylaxis reduced the rate of knee joint infection following an ACLR in comparison with antibiotic prophylaxis alone. This technique could be of relevance in daily clinical practice to prevent infection after ACLR. LEVEL OF EVIDENCE: Case control study, retrospective comparative study, Level III.

Managing septic arthritis after knee ligament reconstruction.

PURPOSE: Joint infection after anterior cruciate ligament (ACL) reconstruction is uncommon but has potentially serious consequences for the graft and articular cartilage. Most recently published series are in agreement that an urgent arthroscopic washout and antibiotic treatment are mandatory to preserve both graft and cartilage. However, several questions have not as yet been touched upon. METHODS: We performed a literature review to assess the most interesting series published about this issue. RESULTS: In this review, a management protocol is first presented that discusses the different diagnostic parameters to consider and surgical and antibiotic treatment suggested according to the literature. Outcomes published in different series are also discussed.

No differences in functional results and quality of life after single-radius or multiradius TKA.

PURPOSE: The main objective of this study was to compare the functional results and the impact on quality of life after a single-radius or a multiradius TKA implantation. The secondary objectives were to compare range of motion, satisfaction and the ability to perform daily life activities with both types of implant. It was hypothesized that the single-radius TKA would lead to better functional results and better quality of life than the multiradius TKA. METHODS: This is a prospective non-randomized study that included 250 cases of a single-radius TKA and 224 of a multiradius posterior-stabilized TKA implanted with the same surgical and rehabilitation protocol. RESULTS: In the 1- and 5-year follow-up, we found similar knee KSS scores (89.7 ± 12.1 in the multiradius group and 90.3 ± 11.7 in the single-radius group) and functional KSS scores (78.6 ± 21.4 in the multiradius group and 75.8 ± 20.9 in the single-radius group). The pain and the Physical SF-36 scores were also similar. Range of motion (112° ± 12° in the multiradius group and 112 ± 12° in the single-radius group), patients' satisfaction and the ability to perform daily life activities were also similar in both groups. CONCLUSION: The use of a single-radius or a multiradius posterior-stabilized knee prosthesis can improve the function of the knee and the patients' quality of life in a similar way at the short-term and midterm follow-up. Moreover, range of motion, patient satisfaction and the ability to perform daily life activities are similar with both types of prosthesis. As both types of prosthesis can improve the function and quality of life of the patients in a similar way, the sagittal radius of the femoral component should not be considered the main factor when choosing the model of TKA. LEVEL OF EVIDENCE: Therapeutic study: Prospective comparative study, Level II.

An Evaluation of the Association Between Radiographic Intercondylar Notch Narrowing and Anterior Cruciate Ligament Injury in Men: The Notch Angle Is a Better Parameter Than Notch Width.

PURPOSE: To evaluate the association of anterior cruciate ligament (ACL) injuries with the intercondylar notch angle and notch width in male patients. The secondary purpose was to evaluate the association of these injuries with other novel morphologic parameters. METHODS: Male patients undergoing primary ACL reconstruction between 2010 and 2013 for injury through noncontact mechanisms with preoperative magnetic resonance imaging were compared with an age-matched control group of male patients (patients who underwent knee operations other than ACL reconstruction) regarding the following magnetic resonance imaging-assessed parameters: intercondylar notch angle, width, and depth; condylar width; medial/lateral condylar widths; medial/lateral posterior tibial plateau slopes; anterior sagittal tibial slope (corresponding to the level of the tibial ACL footprint); coronal tibial slope; and angle between the Blumensaat line and anterior tibial slope. RESULTS: In both the coronal and axial planes, patients with ACL injury had a significantly lower intercondylar notch angle (P < .001 and P = .008, respectively) than the control group, but there were no significant between-group differences for intercondylar notch width (P = .9 and P = .97, respectively). In the sagittal plane, patients with ACL injury had significantly higher medial (P < .001) and lateral (P = .02) posterior tibial slopes, a significantly lower anterior tibial slope (P = .01), and a significantly higher angle between the Blumensaat line and anterior tibial slope (P = .02) than the control group. CONCLUSIONS: Narrowing of the intercondylar notch may be associated with ACL injury in male patients. However, the intercondylar notch angle may be a better parameter to evaluate notch narrowing and its potential association with ACL injuries compared with the notch width. The association between the angle formed by the Blumensaat line and anterior tibial slope and ACL injuries in male patients needs more investigation. This study further suggests that increased posterior tibial slope may be associated with ACL injury in male patients. LEVEL OF EVIDENCE: Level III, case-control study.