Surgical management of combined anterior or posterior cruciate ligament and posterolateral corner tears: for what functional results?

INTRODUCTION: Management of combined anterior or posterior cruciate ligament and posterolateral corner tears is still poorly codified. The aim of this study was to evaluate functional outcome after complete surgical treatment. MATERIALS AND METHODS: This retrospective multicenter study included 53 patients. Mean age was 29.8 yrs. (15-49). The anterior and posterior cruciate ligaments were involved in respectively 48 and 5 cases. Mean time to surgery was 25.6 months (0-184), and in 10 cases less than 21 days. Nine patients were sedentary workers and 29 non-sedentary (13 laborers). All ligament injuries were treated surgically. Mean follow-up was 49 months (12-146). Last follow-up assessment used IKDC, Lysholm and KOOS scores. RESULTS: At last follow-up, IKDC score graded 14 patients A, 25 B, 8 C and 6 D, versus 0 A, 4 B, 25 C, 22 D and 2 ungraded preoperatively. Mean subjective IKDC and Lysholm scores were respectively 72.8 (11.5-100) and 77.5 (37-100). Mean KOOS scores (pain, symptoms, daily life, sports, quality of life) were respectively 78 (3-100), 70 (25-100), 88 (47-100), 53 (0-100) and 50 (0-100). Posterolateral laxity was corrected in all but two cases. All sedentary workers and 86.7% of non-sedentary workers could return to work. The job had to be changed in 10% of cases overall, but in 25% of cases for laborers. DISCUSSION: The present results are comparable with those of the literature. The strategy of combined surgical treatment showed functional efficacy, usually associated with return to work except for some laborers. There was a non-significant trend in favor of acute-phase ligament reconstruction. LEVEL OF EVIDENCE: IV (retrospective series).

Management of combined anterior or posterior cruciate ligament and posterolateral corner injuries: a systematic review.

BACKGROUND: Combined injuries to the posterolateral corner and cruciate ligaments are uncommon. The heterogeneity of injury patterns in many studies complicates the assessment of outcomes. OBJECTIVE: To assess the prognosis and functional outcomes after surgery for combined injuries to the posterolateral corner and to the anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL). MATERIAL AND METHODS: We systematically reviewed the literature for articles reporting outcomes 1 year or more after surgery for combined injuries to the posterolateral corner and ACL (n=4) or PCL (n=9). Patients with bicruciate injuries were not studied. RESULTS: Overall, 65% of patients were IKDC A or B after surgery. The mean Lysholm score improved from 67 to 90. Mean time to surgery was 4.43 months in the group with ACL tears and 18.4 months in the group with PCL tears, and mean follow-up was 34.4 and 40.7 months in these two groups, respectively. In the groups with ACL and PCL tears, the proportions of patients classified as IKDC A or B at last follow-up were 81.6% and 81.0%, respectively, whereas 88% and 99% of patients, respectively, were IKDC grade C or D before surgery. The mean Lysholm score improved from 77 to 92 in the group with ACL tears and from 65 to 89 in the group with PCL tears. Improvements in laxity ranged from 28% to 79% in the group with PCL tears. DISCUSSION: Most of the articles selected for our review provided level III or IV evidence. Functional outcomes were satisfactory but less good than those reported after surgical reconstruction of isolated cruciate ligament tears. Full reconstruction seems the best strategy in patients with combined ACL/posterolateral corner injuries. Outcomes were also good but more variable in the group with PCL/posterolateral corner injuries. The time to surgery, which reflected the time to diagnosis, was shorter in patients with ACL than with PCL tears in addition to the posterolateral corner injury. LEVEL OF EVIDENCE: Level III (systematic literature review).

A new arthroscopic technique for lateral meniscal allograft transplantation: cadaver feasibility study.

INTRODUCTION: The three prerequisites for a successful meniscal allograft are fixation, graft sizing and precise positioning. The goal of this study was to demonstrate that lateral meniscal allografts can be reliably positioned using a fully arthroscopic technique. HYPOTHESIS: This surgical technique is feasible and results in good positioning of the meniscal graft. MATERIAL AND METHODS: Twelve fresh cadavers were used in the study. The meniscal graft implantation procedure was performed entirely by arthroscopy. The meniscal horns were fixed with screw-in suture anchors and the meniscal border was fixed to the capsule by arthroscopic meniscus-capsule sutures. The main outcome measure of good implant positioning was based on the distance between the implanted location of the posterior horn of the lateral meniscus (PHLM) and its original location. To accomplish this, aerial photographs of the tibial plateau were used to compare the insertion zones and to calculate the distance between them. These measurements were performed by two surgeons and then compared. RESULTS: Eleven of the 12 procedures (92%) were performed successfully. The posterior horn of the lateral meniscus was positioned an average of 4.3mm in the medial-lateral axis and 1.7 mm in the anterior-posterior axis away from its original location. Thus the position of the implanted PHLM was on average 4.6mm away from its original location. DISCUSSION: This fully arthroscopic technique is feasible. It offers the advantages associated with minimally-invasive surgery and results in good positioning of the posterior horn of the allograft. Two limitations of this study are that the size of the implant was not matched and the chosen fixation method was not subjected to biomechanical evaluation. The lack of a tibial tunnel will make it easier to combine this procedure with ACL reconstruction. In these conditions, the clinical application of this technique seems to be timely. LEVEL OF PROOF: IV - Controlled experimental study.

Anterior cruciate ligament reconstruction with fascia lata using a minimally invasive arthroscopic harvesting technique.

Anterior cruciate ligament (ACL) reconstruction using the fascia lata has undergone a number of technical modifications since the work of Hey-Groves, MacIntosh, and Jaeger. Arthroscopy has simplified this technique, notably in the positioning of the tunnels. Minimally invasive harvesting through two lateral proximal and distal approaches considerably reduces cosmetic problems. The femoral tunnel is made from the outside to the inside using a specific targeting device, and the transplant harvest site is closed using the Jaeger procedure so as not to weaken lateral knee stabilizing structures. This procedure consists in opening the lateral intermuscular septum 1cm from the femur to let it shift laterally and allow the transplant harvesting area to be closed. This technique uses a fascia lata transplant, the harvesting of which has shown few iatrogenous complications but requires rigorous adherence to certain rules.

Necrotizing fasciitis and septic shock related to the uncommon gram-negative pathogen Sphingobacterium multivorum.

We report the first case of necrotizing fasciitis due to the uncommon Gram-negative pathogen Sphingobacterium multivorum in an immunocompromised patient, who presented with septic shock. This case adds necrotizing fasciitis to the spectrum of S. multivorum-related infections and highlights the emergence of Gram-negative bacteria in severe soft tissue infections.

Does combined posterior cruciate ligament and posterolateral corner reconstruction for chronic posterior and posterolateral instability restore normal knee function?

INTRODUCTION: Posterior cruciate ligament (PCL) injuries are frequently associated with posterolateral corner (PLC) damages. These complex lesions are most often poorly tolerated clinically. Adherence to sound biomechanical principles treating these complex lesions entails obtaining a functional PCL and reconstructing sufficient posterolateral stability. HYPOTHESIS: Surgical treatment of postero-posterolateral laxity (PPLL) re-establishes sufficient anatomical integrity to provide stability and satisfactory knee function. MATERIAL AND METHODS: In this retrospective, continuous, single-operator study, 21 patients were operated for chronic PPLL with combined reconstruction of the PCL and PLC and were reviewed with a minimum 1 year follow-up. The clinical and subjective outcomes were evaluated using the IKDC score. Surgical correction of posterior laxity was quantified clinically and radiologically on dynamic posterior drawer images (posterior Telos stress test and hamstrings contraction lateral view). RESULTS: The mean subjective IKDC score was 62.8 at the last follow-up versus a preoperative score of 54.5 (NS). Preoperatively, all were classified in groups C and D. Postoperatively, 13 patients out of 21 were classified in groups A and B according to the overall clinical IKDC score. The radiological gain in laxity was 51% on the hamstring contraction films and 67% on the posterior Telos images (p<0.05). DISCUSSION: The objective of surgical treatment is to re-establish anatomical integrity to the greatest possible extent. The clinical and radiological laxity results are disappointing in terms of the objectives but are in agreement with the literature. The subjective evaluation demonstrated that this operation can provide sufficient function for standard daily activities but not sports activities. LEVEL OF EVIDENCE: Level IV retrospective study.

Does reconstruction of isolated chronic posterior cruciate ligament injuries restore normal knee function?

INTRODUCTION: Isolated posterior laxity is most often cared for with conservative functional treatment. However, when there is pain or instability, surgical treatment can legitimately be proposed. The objective of this study was to assess the results of surgical treatment for chronic isolated posterior laxity. HYPOTHESIS: Surgical treatment of direct posterior laxity re-establishes sufficient anatomical integrity to stabilize and provide good function to the knee. MATERIAL AND METHODS: This was a retrospective, continuous, single-operator study. Eleven operated patients were retained for this study, all followed up a mean 20.9 months, with a minimum follow-up of 1 year. Subjective and clinical assessments were carried out using the International Knee Documentation Score (IKDC) score. Surgical correction of posterior laxity was measured clinically and radiologically. RESULTS: The subjective IKDC score increased from 53 preoperatively to 68.5 at the last follow-up (P=0.006). For the objective IKDC score, all knees were classified C or D preoperatively; at the last follow-up, six were A or B and none D. All the knees had preoperative Clancy grade 2 or 3 laxity; after surgery, there were three. According to the IKDC laxity score, eight knees were classified A or B at the last follow-up. The radiographic workup noted a 48.6% (P=0.05) posterior laxity correction on the TELOS test. DISCUSSION: Posterior cruciate ligament reconstruction provides partial correction of posterior laxity. However, the subjective result remains insufficient, providing acceptable function for daily life activities but not sports activities. LEVEL OF EVIDENCE: Level IV, retrospective study.

Comparative study of intraoperative knee flexion with three different TKR designs.

INTRODUCTION: Substantial flexion after total knee arthroplasty (TKA) is required for certain categories of patients who wish to squat or kneel in their daily life. Many factors influence this postoperative flexion, including the prosthesis design. It is therefore valuable to in vivo analyze these factors on three knee prosthesis designs through a study of their intraoperative flexion. HYPOTHESIS: The posterior-stabilized (PS) knee prostheses provide better intraoperative flexion than the ultracongruent (UC) model. Of the currently available PS models, the high-flexion ones have better intraoperative flexion than standard models. Our main focus endpoint was the intraoperative flexion achieved, before soft-tissues closure, during TKA surgical procedure. PATIENTS AND METHODS: This was a controlled study. Seventy-two osteoarthritic knees requiring TKA were included to compare three selected prosthesis models: the SAL ultracongruent and two PS models (the standard LPS and the LPS Flex). This was a single-operator study, with patients divided into three homogenous, comparable groups, in which intraoperative measurement of flexion was performed using computer-assisted navigation. Statistical analysis allowed comparison of the three models. RESULTS: Intraoperatively, after prosthesis implantation, before soft-tissues closure, the mean flexion of the LPS-Flex was 134 degrees versus 124 degrees for the SAL (p=0.0004); the mean flexion of the standard LPS model was 130 degrees versus 124 degrees for the SAL (p=0.14); the PS Flex model showed no significant difference (p=0.26) in flexion (134 degrees) compared to the standard model (130 degrees). The SAL ultracongruent model seemed to be a factor reducing the intraoperative flexion by 8 degrees compared to the PS models (p<10(-4)). DISCUSSION: In this study, the PS designs (standard or Flex) provided better intraoperative flexion than the SAL ultracongruent design. However, the LPS Prosthesis did not demonstrate superiority over the standard LPS Prosthesis. LEVEL OF EVIDENCE: Level III, low-power prospective study.