Failure rate, return-to-sports and magnetic resonance imaging after meniscal repair: 119 patients with 7 years mean follow up.

BACKGROUND: One of the most important factors to consider in relation to meniscal repair is the high failure rate reported in the existing literature. AIM: To evaluate failure rates, return to sports (RTS) rate, clinical outcomes and magnetic resonance image (MRI) evaluation after meniscus suture repair for longitudinal tears at a minimum 2-year-follow-up. METHODS: We conducted a retrospective review of meniscal repairs between January 2004 and December 2018. All patients treated for longitudinal tears associated or not with an anterior cruciate ligament reconstruction (ACL-R) were included. Meniscal ramp lesions, radial and root tears, associated with multiligament injuries, tibial fracture and meniscal allograft transplants were excluded. Surgical details and failure rate, defined as symptomatic patients who underwent a revision surgery, were analyzed. As isolated bucket handle tears (BHTs) were usually associated with higher failure rates, we compared BHTs and not BHTs associated or not with an ACL-R. Since 2014, the inside-out technique using cannulas and suture needles with 2-0 Tycron began to predominate. In addition, the number of stitches per repair was increased. In view of differences in surgical technique, we compared two different cohorts: before and after 2014. We recorded the RTS according to the level achieved and the time to RTS. Lysholm and IKDC scores were recorded. Patients were studied with x-rays and MRI as standard postoperative control. RESULTS: One hundred and nineteen patients were included with a mean follow up of 7 years (SD: 4.08). Overall failure rate was 20.3% at a mean 20.1 mo. No statistically significant differences were found when comparing failure for medial and lateral meniscal repair (22.7% and 15.3%, P = 0.36), BHTs and not BHTs (26% and 17.6%, P = 0.27), isolated or associated with an ACL-R (22.9% and 18%, P = 0.47), or when comparing only BHTs associated with an ACL-R (23% and 27.7%, P = 0.9) or not. When comparing cohorts before and after 2014, we found a significant decrease in the overall failure rate from 26% to 11% (P < 0.03). Isolated lesions presented a decrease from 28% to 6.6% (P = 0.02), BHTs from 34% to 8% (P = 0.09) and those associated with an ACL-R from 25% to 10% (P = 0.09). Mean RTS time was 6.5 mo in isolated lesions and 8.64 mo when associated with an ACL-R. Overall, 56% of patients returned to the same sport activity level. Mean pre and postoperative Lysholm scores were 64 and 85 (P = 0.02), and IKDC 58 and 70 (P = 0.03). Out of 84 asymptomatic patients evaluated with MRI, 39% were classified as "not healed" and 61% as "healed". CONCLUSION: Even though the overall failure rate of our series was 20.3%, we found a statistically significant decrease from 26% to 11%, not only for isolated lesions, but also for BHT's and those associated with an ACL-R when comparing our series in two different cohorts, most probably due to improvements in surgical technique.

Clinical, imaging, arthroscopic, and histologic features of bilateral anteromedial meniscofemoral ligament: A case report.

BACKGROUND: The anteromedial meniscofemoral ligament (AMMFL) is a very rare entity, commonly unrecognized and underreported. Although it was not proved to be a cause of anterior knee pain, concerns have been raised on the relationship between the presence of this structure and medial meniscus injury secondary to its abnormal motion. Regarding histologic examination, some studies have shown meniscus-like fibrocartilage, while others have identified it as ligament-like collagenous fibrous connective tissue. CASE SUMMARY: We report the case of a 34-year-old ballerina with an AMMFL associated with a torn medial meniscus of both knees. Surgery was performed to treat the meniscal injury and two biopsies of each AMMFL were taken in different locations to define the histopathological composition. Histologic examination revealed fibrocartilaginous tissue compatible with meniscus. Follow-up evaluation one year after surgery evidenced full remission of symptoms and the patient had resumed her athletic activities. CONCLUSION: Clinical, magnetic resonance imaging, arthroscopic, and histological features have been carefully described to better characterize the AMMFL.

Revision anterior cruciate ligament reconstruction: Return to sports at a minimum 5-year follow-up.

BACKGROUND: Between 43% and 75% of patients who undergo primary anterior cruciate ligament (ACL) surgery return to sport activity. However, after a revision ACL reconstruction (ACLR) the rate of return to sports is variable. A few publications have reported returns to sports incidence between 56% to 100% after revision ACLR. AIM: To determine return to sports and functional outcomes after a single-stage revision ACLR with a 5-year minimum follow-up at a single institution. METHODS: All patients operated between 2010 and 2016 with a minimum 5 years of follow-up were included. Type of sport, intensity, frequency, expectation, time to return to sport and failure rate were recorded. Lysholm, Tegner and International Knee Documentation Committee forms were evaluated prior to the first ACLR surgery, at 6 mo after primary surgery and after revision ACLR at 5 years minimum of follow-up. Objective stability was tested with the knee arthrometer test (KT-1000 knee arthrometer, Medmetric Corp). RESULTS: A total of 41 patients who underwent revision ACLR during that period of time were contacted and available for follow-up. Median patient age at time of revision was 29 years old [interquartile range (IQR): 24.0-36.0], and 39 (95.0%) were male. The median time from revision procedure to follow-up was 70 mo (IQR: 58.0-81.0). Regarding return to sports, 16 (39.0%) were at the same level compared to preinjury period, and 25 patients (61.0%) returned at a lower level. Sixty-three percent categorized the sport as very important and 37.0% as important. One patient (2.4%) failed with a recurrent ACL torn. Mean preoperative Lysholm and subjective International Knee Documentation Committee scores were 58.8 [standard deviation (SD) 16] and 50 (SD 11), respectively. At follow-up, mean Lysholm and subjective International Knee Documentation Committee scores were 89 (SD 8) and 82 (SD 9) (P = 0.0001). Mean Tegner score prior to primary ACLR was 6.7 (SD 1.3), 5.1 (1.5 SD) prior to revision ACLR and 5.6 (1.6 SD) at follow-up (P = 0.0002). Overall, knee arthrometer test measurement showed an average of 6 mm (IQR: 4.0-6.0) side-to-side difference of displacement prior to revision ACLR and 3mm (IQR: 1.5-4.0) after revision. CONCLUSION: Almost 40.0% of patients returned to preinjury sports level and 60.0% to a lower level. These may be useful when counseling a patient regarding sports expectations after a revision ACLR.

Overview of the anterolateral complex of the knee.

In the last few years, much more information on the anterolateral complex of the knee has become available. It has now been demonstrated how it works in conjunction with the anterior cruciate ligament (ACL) controlling anterolateral rotatory laxity. Biomechanical studies have shown that the anterolateral complex (ALC) has a role as a secondary stabilizer to the ACL in opposing anterior tibial translation and internal tibial rotation. It is of utmost importance that surgeons comprehend the intricate anatomy of the entire anterolateral aspect of the knee. Although most studies have only focused on the anterolateral ligament (ALL), the ALC of the knee consists of a functional unit formed by the layers of the iliotibial band combined with the anterolateral joint capsule. Considerable interest has also been given to imaging evaluation using magnetic resonance and several studies have targeted the evaluation of the ALC in the setting of ACL injury. Results are inconsistent with a lack of association between magnetic resonance imaging evidence of injury and clinical findings. Isolated ACL reconstruction may not always reestablish knee rotatory stability in patients with associated ALC injury. In such cases, additional procedures, such as anterolateral reconstruction or lateral tenodesis, may be indicated. There are several techniques available for ALL reconstruction. Graft options include the iliotibial band, gracilis or semitendinosus tendon autograft, or allograft.

Good Short-Term Clinical Outcomes and Low Rates of Return to Sports after Repeat Revision ACL Reconstruction.

Repeat revision anterior cruciate ligament reconstruction (ACL-R) is a rare, demanding procedure and, as such, has not been well studied. Most of the available literature shows improved functional outcomes compared with preoperative state but inferior results when compared with primary ACL-R, particularly regarding return to preinjury level of sports. The purpose of this study was to assess functional outcomes in patients who had undergone repeat revision ACL-R. The secondary aims were to register return to sports, associated meniscal and/or chondral lesions, and evaluate radiological anatomical parameters. Nine patients between 2011 and 2017 were evaluated, who had a minimum follow-up of 2 years. Median age at repeat ACL-R was 32 years (interquartile range [IQR], 30-34 years) and the median follow-up was 27 months (IQR, 24-39 months). Data collected prior to surgery and at last follow-up included patient demographics, operative findings, physical examination findings including pivot shift and KT-1000 arthrometer measurement; Lysholm and International Knee Documentation Committee (IKDC) subjective scores; and return to sports and level using the Tegner score. Knee Injury and Osteoarthritis Outcome Score (KOOS) subjective score and radiographic anatomical parameters were recorded at last follow-up. Mean IKDC and Lysholm score improvement was 25 points (confidence interval [CI] 12-37) and 25 points (CI 11-39), respectively (p < 0.001). The median postoperative KOOS score was pain: 93 (IQR, 64-96); symptoms: 94 (IQR, 83-97); activities of daily life: 96 (IQR, 90-100); sports: 75 (IQR, 50-90); and quality of life: 50 (IQR, 43-81). Postoperative median side-to-side KT-1000 arthrometer difference was 2 mm (IQR, 1-8 mm). The median radiographic posterior tibial slope was 10 degrees (IQR, 9-10). One patient was considered a failure at 16 months postoperative. Only 44% (four out of nine) patients were able to return to their sports. None of these patients had a cartilage injury, while three out of five patients who did not return to their sports had International Cartilage Regeneration & Joint Preservation Society grade III or IV cartilage injury. Patients should be counseled on the challenging outcomes of repeat revision ACL-R. This is Level IV, therapeutic case series.

¿Es seguro el ácido tranexámico en la cirugía de reemplazo total de rodilla de pacientes con enfermedad coronaria? / Is tranexamic acid safe in total knee replacement surgery in patients with coronary artery disease?

Introducción: El ácido tranexámico reduce la pérdida sanguínea y los requerimientos de transfusiones luego de un reemplazo total de rodilla. Una de sus contraindicaciones relativas son los antecedentes de colocación de prótesis intravasculares coronarias, por un supuesto aumento de eventos tromboembólicos. materiales y métodos:Análisis retrospectivo de pacientes sometidos a un reemplazo total de rodilla primario y de revisión que recibieron ácido tranexámico y tenían antecedente de colocación de prótesis intravascular coronaria. Se los comparó con un grupo sin estas prótesis. Se analizó la presencia de cualquier cambio clínico o electrocardiográfico de oclusión coronaria aguda, eventos tromboembólicos, el requerimiento de transfusión sanguínea y el nivel de hemoglobina pre y posoperatorio. Resultados: 57 pacientes (59 cirugías, 56 reemplazos primarios y 3 revisiones) con colocación de prótesis intravascular coronaria, al menos, un año antes de la artroplastia. Un paciente tuvo síntomas de síndrome coronario agudo y cambios en el electrocardiograma. No hubo diferencias en la cantidad de eventos tromboembólicos. Solo un paciente del grupo de control recibió una transfusión de glóbulos rojos. El sangrado relativo fue menor en el grupo coronario independientemente del uso crónico de aspirina y clopidogrel antes de la cirugía (2,09 vs. 3,06 grupo de control; p = 0,01). En pacientes del alto riesgo, el ácido tranexámico no se asoció con más eventos tromboembólicos. Conclusiones: El ácido tranexámico impresionó ser seguro y efectivo en nuestro grupo de pacientes con prótesis intravasculares coronarias; sin embargo, se necesita un estudio prospectivo con más casos para confirmar estos resultados. Nivel de Evidencia: IV

Introduction: Tranexamic acid (TXA) reduces blood loss and need for a transfusion after total knee arthroplasty (TKA). However, patients with a history of coronary artery (CA) stent placement might be at increased risk for thromboembolic complications. Materials and methods: We performed a retrospective analysis of patients with a history of coronary stenting who had undergone primary and revision TKA and received preoperative TXA. A comparison was made with a group of patients without coronary stenting. The presence of any clinical or electrocardiographic changes of acute coronary occlusion, thromboembolic events (TEE), blood transfusion, and pre- and postoperative hemoglobin levels were analyzed. Results: 57 patients underwent 59 TKA surgeries (56 primary and 3 revisions) with a history of coronary stenting at least 1 year before arthroplasty. One patient presented symptoms of acute coronary syndrome and electrocardiogram (ECG) changes. There were no differences in the number of thromboembolic events. Only 1 patient received red blood cell transfusion in the control group. Relative bleeding was lower in the coronary group regardless of chronic use of aspirin and clopidogrel before surgery (2.09 vs 3.06 in the control group; p=0.01). In high-risk patients, TXA was not associated with higher TEEs. Conclusions: Although TXA seemed safe and effective in this database review of patients with previous placement of CAS; a larger prospective trial is warranted to confirm these results. Level of Evidence: IV

Trombosis arterial de diagnóstico tardío que simula un síndrome de Südeck luego de un reemplazo total de rodilla / Late-diagnosed arterial thrombosis mimicking Complex regional pain syndrome after total knee arthroplasty in a patient with CREST syndrome

La trombosis arterial luego de una artroplastia total de rodilla es una complicación poco frecuente; sin embargo, puede tener consecuencias devastadoras. Describimos un caso de una oclusión arterial después de una artroplastia total de rodilla en una mujer de 85 años. Inicialmente, la presentación clínica nos hizo pensar en una manifestación de la enfermedad de Raynaud (la paciente tenía antecedente de síndrome de CREST). Entre los diagnósticos diferenciales también se planteó un síndrome de dolor regional complejo, que retrasó el diagnóstico durante dos semanas. Finalmente, el diagnóstico y el tratamiento se realizaron mediante angiografía. La recuperación funcional fue completa. La baja frecuencia de esta lesión puede determinar que el diagnóstico sea un desafío para el cirujano. En este caso, la oclusión parcial de las arterias evitó complicaciones más graves. Nivel de Evidencia: IV

Arterial thrombosis after total knee replacement (TKR) is a rare complication; however, it can lead to disastrous consequences. We describe a case of an arterial occlusion after TKR in an 85-year-old female patient. Initially, the clinical presentation made us con-sider Raynaud (she had a history of CREST) and complex regional pain syndrome, which delayed the diagnosis for 2 weeks. Diagnosis and treatment were accomplished with angiography and the patient achieved a full recovery. The low frequency of this injury may make diagnosis a challenge for the surgeon. In this case, partial occlusion of the arteries avoided more serious complications. Level of evidence: IV

Osteotomia valguizante de tibia aditiva medial: analisis de dos tipos de implante / Valgus tibial osteotomy. Two surgical alternatives

La osteotomía valguizante de tibia es un procedimiento comúnmente utilizado para la corrección del deseje en varo con el objetivo de restaurar el eje neutro. Existen dos alternativas quirúrgicas: osteotomía de apertura y de cierre. Los implantes utilizados para la osteotomía de apertura ofrecen ciertas ventajas y también desventajas. El objetivo de esta nota técnica es describir y comparar dos tipos de implante diseñados para las osteotomías valguizantes de tibia proximal: la placa Puddu y la placa TomoFix™. Nivel de Evidencia: V

The valgus tibial osteotomy is a procedure commonly used for the correction of the varus displacement with the objective of restoring the neutral axis. There are two surgical alternatives, opening and closing osteotomy. The implants used for opening osteotomy offer certain advantages and disadvantages. The objective of this technical note is to describe and compare two types of implants designed for valgus osteotomies of the proximal tibia: the Puddu plate and the TomoFix™ plate. Level of Evidence: V

Osteonecrosis bilateral de rodilla tratada con descompresión y concentrado de aspirado de médula ósea / Bilateral knee osteonecrosis with decompression and bone marrow concentrate

Descripta por Ahlbäck en 1968, la osteonecrosis de rodilla es una patología con un gran potencial de morbilidad. Está dividida en tres grandes grupos: primaria/espontánea, postoperatoria y secundaria/atraumática. Esta última podría estar directamente relacionada con el consumo prolongado de corticoides. Su tratamiento constituye un desafío para el cirujano ortopedista. Va a depender del estadio de la enfermedad y del colapso articular, y se intentará siempre preservar la superficie articular nativa. Dentro de las distintas opciones terapéuticas, las terapias biológicas constituyen una herramienta potencialmente valiosa como complemento al tratamiento quirúrgico, y muestran resultados clínicos esperanzadores. Presentamos el caso de una paciente con una osteonecrosis de rodilla bilateral, secundaria al consumo crónico de corticoides, tratada con una artroscopía bilateral asociada a perforaciones subcondrales descompresivas y aplicación subcondral de concentrado de médula ósea (CMO), con evolución satisfactoria de los síntomas a los treinta meses de seguimiento en la rodilla derecha, mientras que en la rodilla izquierda presentó una evolución tórpida de los síntomas a partir de los veinticuatro meses, por lo que está en plan de reemplazo articular.

Described by Ahlbäck in 1968, osteonecrosis of the knee is a pathology with great potential for morbidity. It is divided into three large groups: primary/spontaneous, postoperative, and secondary/atraumatic. The latter might be directly related to prolonged consumption of steroids. Its treatment is a challenge for the orthopedist. It will depend on the disease stage and articular collapse, always trying to preserve the native articular surface. Within the different therapeutic options, biological therapies are a potentially valuable tool as a complement to surgical treatment, showing encouraging clinical results. We present the case of a female patient with bilateral osteonecrosis of the knee, secondary to chronic consumption of steroids, treated with bilateral arthroscopy associated with decompressive subchondral perforations and subchondral application of bone marrow concentrate (BMC), with a satisfactory evolution of symptoms after thirty months of follow-up in the right knee. However, the left knee showed a torpid evolution of symptoms after twenty-four months of follow-up, so she is on a joint replacement plan

Reemplazo total de rodilla asistido por el robot ROSA / ROSA Robotic-assisted total knee replacement

El reemplazo total de rodilla es un procedimiento con excelentes resultados, siempre y cuando se alcancen los objetivos de alineación y balance ligamentario. El confort y el bienestar posoperatorios se logran mediante un implante adecuado para cada paciente y el correcto posicionamiento de la prótesis. El sistema robótico ROSA utiliza información recolectada antes de la cirugía y durante esta, y le otorga al cirujano las herramientas necesarias para reproducir la anatomía específica de cada paciente. De esta manera, se logran implantes personalizados basados en los reparos anatómicos de cada individuo y en una planificación a partir de datos biométricos concretos. Nivel de Evidencia: IV

Total knee replacement is a procedure with excellent outcomes as long as the objectives of alignment and ligament balance are met. Postoperative comfort and well-being are achieved through a suitable implant for each patient and the correct positioning of the prosthesis. The ROSA robotic system uses information collected before and during surgery, and provides the surgeon with the necessary tools to reproduce the specific anatomy of each patient. In this way, personalized implants are achieved based on the anatomical landmarks of each individual and planning based on specific biometric data. Level of evidence: IV

Preparación del injerto con vancomicina y su incidencia en la disminución de infección luego de la reconstrucción del LCA / Presoaking of autograft in vancomycin for primary ACL reconstruction. Incidence of infection decreased

Introducción: La artritis séptica (AS) posterior a la cirugía de reconstrucción del LCA (RLCA) es una complicación infrecuente pero potencialmente devastadora. Para disminuir el riesgo de esta complicación, en el 2019 comenzamos a utilizar el tratamiento local del injerto de LCA con vancomicina previo a su colocación. El objetivo de este estudio fue comparar la incidencia de AS postoperatoria en pacientes en los que se utilizó este protocolo con el período inmediatamente anterior, en el que no se usó. Materiales y métodos: Se efectuó un estudio de cohorte retrospectiva con inclusión de todos los pacientes a los que se les realizó una RLCA primaria. Se analizaron dos períodos consecutivos: enero de 2016 a febrero de 2019 (grupo sin tratamiento local con vancomicina) y marzo de 2019 a marzo de 2021 (grupo con protocolo con vancomicina). Se estimó la incidencia de AS postoperatoria en ambos grupos. Se registraron también los casos de infección superficial del sitio quirúrgico y los casos de rigidez postoperatoria. Resultados: se incluyeron un total de ochocientos ocho pacientes. El grupo sin vancomicina quedó conformado por quinientos cincuenta y un (68%) pacientes y el grupo con vancomicina por doscientos cincuenta y siete (32%). En total, siete de los quinientos cincuenta y un pacientes en los cuales no se utilizó vancomicina desarrollaron AS, lo que arrojó una incidencia del 1.27% (IC 95%: 0.5% - 2.5%), mientras que no se registraron casos de AS en el grupo de pacientes en los cuales se utilizó el protocolo con vancomicina (p = 0.07). Con respecto a las infecciones superficiales, se registraron cuatro casos, todas también en el grupo sin vancomicina (p = 0.17). En cuanto a los casos de rigidez postoperatoria se registraron en total catorce, doce del primer grupo (2.1%) y dos del segundo grupo (0.78%) (p = 0.156). Conclusión: El tratamiento local de los injertos con vancomicina previo a la RLCA evitó la AS postoperatoria durante el período de estudio, en comparación con el período inmediatamente anterior, en el que no se utilizó vancomicina. Nivel de Evidencia: III

Introduction: Postoperative septic arthritis (SA) after anterior cruciate ligament reconstruction (ACLR) is a rare but potentially devastating complication. To decrease this risk in 2019 we started presoaking ACL grafts with vancomycin prior to implantation. The purpose of this study was to compare the rate of postoperative SA with and without vancomycin presoaked grafts. Materials and methods: A retrospective cohort study was conducted including all patients who underwent primary ACLR. Consecutive periods were studied, inclusive of January 2016 through February 2019 (group without vancomycin) and March 2019 through March 2021 (group with vancomycin protocol). The final outcome studied was occurrence of postoperative SA in both groups. Cases of superficial wound infection and cases of postoperative arthrofibrosis were also recorded. Results: a total of 808 patients were included in the study: 551 (68%) in the group without vancomycin and 257 (32%) in the vancomycin protocol group. Seven cases of postoperative SA were noted in the first group (rate 1.27%, IC95%: 0,5% - 2,5%), while no cases of SA were noted in the vancomycin group during the study period (p = 0.07). Regarding superficial wound infection, four cases were noted, all of them in the first group (p = 0.17). A total of fourteen cases of arthrofibrosis were treated with a mobilization under anesthesia, twelve from the first group (2.1%) and two from the vancomycin group (0.78%) (p = 0.156). Conclusion: Presoaking of autografts in vancomycin for primary ACLR prevented the occurrence of postoperative SA during the study period as compared with no soaking of the grafts. Level of Evidence: III

Has platelet-rich plasma any role in partial tears of the anterior cruciate ligament? Prospective comparative study.

BACKGROUND: Partial tears of the anterior cruciate ligament (ACL) are frequent, and there is still considerable controversy surrounding their diagnosis, natural history and treatment. AIM: To examine patient-reported outcomes, physical examination and magnetic resonance imaging (MRI) findings of partial ACL tears treated with an intraarticular injection of platelet-rich plasma (PRP) compared to a control group. METHODS: From January 2015 to November 2017, consecutive patients from a single institution with partial ACL tears treated nonoperatively were prospectively evaluated. Partial tears were defined as a positive Lachman test with a clear end-point, a negative pivot-shift and less than 3 mm of side-to-side difference using the KT1000 arthrometer. Patients in group 1 were treated with one intraarticular injection of PRP and specific physical therapy protocol. Control group consisted of patients treated only with physical therapy. Prospective analyzed data included physical examination, Tegner activity level and Lysholm and International Knee Documentation Committee scores. Baseline MRI findings and at 6 mo follow-up were reviewed. Failure was defined as those patients with clinical instability at follow-up that required a subsequent ACL reconstruction. RESULTS: A total of 40 patients where included, 21 treated with PRP injection with a mean follow-up of 25 mo [standard deviation (SD): 3.6] and 19 in the control group with a mean follow-up of 25 mo (SD: 5.68). Overall failure rate was 32.0% (n = 13). No significant differences were observed between groups regarding subjective outcomes, return to sport and failure rate. MRI findings revealed an improvement in the ACL signal in half of the patients of both groups. However, we did not find a significant relationship between MRI findings and clinical outcomes. CONCLUSION: Overall, 95.0% of patients returned to sports at a mean follow-up of 25 mo. Mean time to return to sports was 4 mo. Out of these patients, almost 30.0% in each group had a new episode of instability and required surgery at a median time of 5 mo in group 1 and 8 mo in group 2. The addition of PRP alone was not sufficient to enhance any of the outcome measures evaluated, including MRI images, clinical evaluation and failure rate.

Mucormycosis osteomyelitis after anterior cruciate ligament reconstruction: treatment and outcomes of 21 reported cases.

AIMS: Our purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R). METHODS: We present a case-series of consecutive patients treated at our institution due to a severe fungal osteomyelitis after an arthroscopic ACL-R from November 2005 to March 2015. Patients were referred to our institution from different areas of our country. We evaluated the amount of bone resection required, type of final reconstructive procedure performed, and Musculoskeletal Tumor Society (MSTS) functional score. RESULTS: A total of 21 consecutive patients were included in the study; 19 were male with median age of 28 years (IQR 25 to 32). All ACL-R were performed with hamstrings autografts with different fixation techniques. An oncological-type debridement was needed to control persistent infection symptoms. There were no recurrences of fungal infection after median of four surgical debridements (IQR 3 to 6). Five patients underwent an extensive curettage due to the presence of large cavitary lesions and were reconstructed with hemicylindrical intercalary allografts (HIAs), preserving the epiphysis. An open surgical debridement was performed resecting the affected epiphysis in 15 patients, with a median bone loss of 11 cm (IQR 11.5 to 15.6). From these 15 cases, eight patients were reconstructed with allograft prosthesis composites (APC); six with tumour-type prosthesis (TTP) and one required a femoral TTP in combination with a tibial APC. One underwent an above-the-knee amputation. The median MSTS functional score was 20 points at a median of seven years (IQR 5 to 9) of follow-up. CONCLUSION: This study suggests that mucormycosis infection after an ACL-R is a serious complication. Diagnosis is usually delayed until major bone destructive lesions are present. This may originate additional massive reconstructive surgeries with severe functional limitations for the patients.Level of evidence: IVCite this article: Bone Joint Open 2020;2(1):3-8.

Comparación de los espaciadores articulados vs. fijos en la revisión de la infección periprotésica de rodilla / Comparison between articulating vs. fixed spacers in revision for periprosthetic knee infection

Introducción: Los espaciadores de cemento con antibiótico pueden ser fijos o articulados y se logra un resultado similar con ambos para erradicar una infección. Nuestro objetivo fue comparar el rango de movilidad articular y los resultados funcionales después del reimplante. Materiales y Métodos: Estudio de cohorte retrospectiva de pacientes sometidos a una revisión de la prótesis de rodilla por infección, en dos tiempos quirúrgicos. Se analizó la funcionalidad según el Knee Society Score (KSS) al año de la cirugía y se registró el rango de movilidad a los 45 días. Se registraron el grado de defecto óseo, dolor, satisfacción, las complicaciones y la recidiva de la infección. Resultados:Se incluyeron 103 pacientes (40 con espaciador articulado, 63 con espaciador fijo). El grupo con espaciador articulado tuvo una mediana 2,5° mayor en la movilidad final (102,5; RIC 95-110 vs. 100; RIC 90-105, p 0,01). Según el KSS funcional y el KSS de rodilla, no hubo diferencias entre ambos grupos. No hubo diferencias en el grado de satisfacción, dolor y el tiempo hasta el reimplante. Las complicaciones fueron similares en ambos grupos, con una tasa de reinfección sin diferencias estadísticamente significativas. Conclusión: Los espaciadores articulados proporcionaron un beneficio en el rango de movilidad después del reimplante de la prótesis. Nivel de Evidencia: III

Introduction: Cement spacers with antibiotics can be fixed or articulating, with similar results in eradicating infection. Our objective was to compare joint range of motion (ROM) and functional outcomes after reimplantation. Materials and Methods: A retrospective cohort study of patients who had undergone a knee prosthetic revision due to infection in two surgical stages. Functionality was analyzed according to the Knee Society Score (KSS) one year after surgery and ROM was recorded 45 days after surgery. Bone defect, pain, satisfaction, complications, and recurrence of infection were recorded. Results:A total of 103 patients were included. 40 with articulating spacers and 63 with fixed spacers. The articulating spacer group presents a median of 2.5 degrees greater in final mobility (102.5 IQR 95-110 vs 100 IQR 90-105, p 0.01). The KSS functional scale and KSS of the knee did not show differences between two groups. There were no differences concerning satisfaction, pain, and time until reimplantation. Complications were similar in both groups, with a reinfection rate without statistically significant differences. Conclusion: Articulating spacers have shown a benefit in ROM after prosthetic reimplantation. Level of Evidence: III

Reemplazo total de rodilla en pacientes con anquilosis. Reporte de tres casos y revisión bibliográfica / Total knee replacement in patients with ankylosis. Report of three cases and literature review

Introducción: El reemplazo total de rodilla en pacientes con anquilosis representa un desafío para el cirujano, tanto por la alta demanda técnica de la cirugía como por la elevada tasa de complicaciones comunicada. El objetivo de este artículo es presentar tres pacientes con anquilosis tratados con un reemplazo total de rodilla y una revisión bibliográfica actualizada. materiales y métodos: Se evaluaron las distintas etiologías, la movilidad preoperatoria, la técnica quirúrgica y el tipo de implante utilizado en cada caso. En el seguimiento, se evaluaron la tasa de complicaciones, el rango de movilidad y la supervivencia del implante. Por último, se realizó una revisión actualizada de la bibliografía. Resultados: Dos pacientes tenían artritis reumatoide juvenil y uno, una secuela de osteomielitis crónica de rodilla. Los pacientes no tenían movilidad articular y sufrían un severo compromiso para realizar las actividades de la vida cotidiana. En los tres pacientes, se efectuó un abordaje pararrotuliano medial seguido de una amplia liberación de partes blandas. En dos casos, se utilizaron prótesis primarias con vástagos y, en el restante, una prótesis de bisagra rotacional. El rango de movilidad alcanzado fue de 90° en promedio y los pacientes refirieron una tasa alta de satisfacción. No se registraron complicaciones. Conclusiones: El reemplazo total de rodilla en pacientes con anquilosis es una opción terapéutica por considerar, y tiene un impacto beneficioso en la calidad de vida. Por la complejidad que representa debe afrontarse como una cirugía de revisión, con una detenida planificación preoperatoria. Nivel de Evidencia: IV

Introduction: Performing a Total Knee Replacement (TKR) in patients with ankylosed knees is technically demanding and associated with considerable complications. The purpose of this study is to report three cases of patients with ankylosed knees treated with TKR and present an updated literature review. Materials and methods: We evaluated etiologies, preoperative range of motion, surgical technique and type of implant utilized in each case. Complications and postoperative range of motion were also analyzed. Radiographs were used to evaluate loosening or osteolysis. Lastly, we performed an updated literature review. Results: The etiologies were juvenile rheumatoid arthritis in two cases and chronic osteomyelitis in one. The patients did not have range of motion at all and the ability to perform daily life activities was severely affected. A medial parapatellar approach was used in all cases followed by an extensive soft tissue release. A primary posterior-stabilized design was used in two cases and a rotating-hinge in one case. The mean postoperative range of motion was 90° and all three patients reported a high satisfaction rate. No complications were reported. Conclusions: TKR in patients with ankylosed knees has substantially improved the clinical outcome and the arc of movement. Due to its complexity, it must be approached as a revision surgery, with careful preoperative planning. Level of Evidence: IV

Artroscopia bilateral de rodilla en un solo tiempo quirúrgico, ¿es una opción segura? / Is single-stage bilateral knee arthroscopy a safe option?

Introducción: La artroscopia bilateral de rodilla en un solo tiempo quirúrgico permite cursar un solo posoperatorio y una única rehabilitación. El objetivo de este estudio fue evaluar los resultados clínico-funcionales y el tiempo hasta el retorno laboral y deportivo en una serie de pacientes sometidos a una artroscopia bilateral en un solo tiempo quirúrgico. materiales y métodos: Se evaluó a una serie retrospectiva de pacientes desde abril de 2016 hasta abril de 2019, que fueron sometidos a una artroscopia bi-lateral de rodilla en un solo tiempo quirúrgico. Se analizaron los resultados clínico-funcionales a corto y mediano plazo, y el tiempo para el retorno laboral y deportivo. Resultados: La edad promedio fue de 41 años (rango 18-63). El seguimiento promedio fue de 18 meses (rango 6-37). Los tiempos de anestesia y quirúrgico promedio fueron 105 min (rango 60-170) y 85 min (rango 50-150), respectivamente. El tiempo promedio para el retorno laboral fue de 2 meses (rango 1-5). Todos los pacientes recuperaron el rango completo de movilidad articular. Conclusiones: Si bien se han obtenido buenos resultados clínicos con la artroscopia bilateral de rodilla en un solo tiempo, en pacientes seleccionados, no se pueden establecer comparaciones ni conclusiones relevantes debido a la baja casuística y a la gran diversidad de las cirugías realizadas. La principal ventaja radicaría en evitar procedimientos en dos tiempos quirúrgicos, lo que implicaría dos operaciones, dos anestesias y dos programas de rehabilitación diferentes. Nivel de Evidencia: IV

Introduction: Single-stage bilateral arthroscopic surgery allows the patient to undergo a single postoperative and rehabilitation period. The aim of this article was to evaluate the functional-clinical outcomes and time to return to work and sports in a series of patients who had undergone single-stage bilateral arthroscopy. Materials and Methods: We evaluated a retrospective series of patients who had undergone single-stage bilateral knee arthroscopy from April 2016 to April 2019. Short- and medium-term clinical-functional outcomes, and time to return to work and sports were analyzed. Results: The average age of the patients was 41 years (range 18 - 63), with an average follow-up of 18 months (6-37). The average anesthesia time was 105 minutes (range 60 - 170) and the average surgical time was 85 minutes (50 to 150). The average time to return to work was 2 months (range 1-5). Joint range of motion was fully recovered in all patients. Conclusion: Although single-stage bilateral arthroscopy has shown good clinical outcomes in selected patients, no relevant comparisons or conclusions can be established due to the low casuistry and the great diversity of the surgeries performed. The main advantage would be in avoiding procedures in two surgical stages, which would imply two operations, twice the anesthesia and two different rehabilitation programs. Level of Evidence: IV

Revisión de ligamento cruzado anterior aislado o asociado a plástica extraarticular lateral. Estudio comparativo de treinta y seis casos / ACL revision with and without a lateral extra-articular reconstruction. Comparative study of thirty-six cases

Introducción: El objetivo primario de nuestro trabajo es analizar los resultados funcionales y retorno deportivo de una serie de pacientes operados de revisión de LCA aislado y aquellos en quien se asoció una plástica extraarticular lateral (PEAL). Como objetivo secundario analizamos la tasa de re-ruptura en ambos grupos. Materiales y métodos: cohorte retrospectiva con recolección de datos prospectivo. Se evaluaron pacientes consecutivos operados de revisión de LCA aislado entre 2014 y 2015 (Grupo 1), y en quienes se asoció una plástica extraarticular lateral (PEAL) entre 2015 y 2016 (Grupo 2). Fueron estudiados a través de un examen clínico, escalas subjetivas de Lysholm, IKDC, evaluación artrométrica con KT-1000, retorno deportivo y una resonancia magnética (RM) al año. Analizamos la tasa de re-ruptura.Resultados: treinta y seis pacientes, dieciocho en cada grupo con un seguimiento promedio de cincuenta y tres meses (rango 37-73). Para la PEAL se realizó una tenodesis extraarticular lateral con fascia lata en trece casos y una reconstrucción con aloinjerto en cinco casos. La mediana de edad fue de 30.5 (RIC 27-36 años) en el Grupo 1 y 26.5 (RIC 24-33 años) en el Grupo 2. La mediana de la escala de Lysholm pre y postoperatoria fue 65 (RIC 61-72) y 91 (RIC 87-98) en el Grupo 1, y 72 (RIC 53-75) y 90 (RIC 79-95) en el Grupo 2 (p 0.1). La mediana de la escala de IKDC pre y postoperatoria fue 55 (RIC 45-65) y 80 (RIC 75-94) en el Grupo 1, y 56 (RIC 48-67) y 76 (RIC 68-84) en el Grupo 2 (p 0.11). Dieciséis (89%) pacientes en cada grupo retornaron al deporte. La tasa de re-ruptura fue 17% (n = 3) para el Grupo 1 y 5.5% (n = 1) para el Grupo 2 (p >0.6) en un promedio de veinticuatro meses. Conclusión: los resultados clínicos y de retorno al deporte han demostrado ser satisfactorios ambos grupos. Si bien la tasa de re-ruptura fue tres veces menor en el Grupo 2, esta diferencia no fue significativa. Se requiere mayor número de pacientes y tiempo para establecer una conclusión.Tipo de estudio: Cohorte retrospectiva. Nivel de evidencia: III

Introduction: The aim of this study is to compare the clinical outcomes and return to sports of a consecutive series of patients treated for revision ACL with and without a lateral extra-articular reconstruction. The secondary objective was to analyze the failure rate in both groups.Materials and methods: we retrospectively evaluated a series of patients treated for isolated revision ACL between 2014 and 2015 (Group 1) and revision ACL associated with a lateral extra-articular plasty from 2015 to 2016 (Group 2). All patients were evaluated with clinical examination, subjective scales of Lysholm and IKDC, return to sports, arthrometric KT-1000 evaluation, magnetic resonance (MR) at one-year follow-up and failure rate.Results: thirty-six patients were evaluated, eighteen in each Group with a mean follow-up of fifty-three months (range 37-73). For the LEAP, in thirteen cases we performed a lateral tenodesis with ilio-tibial band and in five cases a reconstruction using allograft. The median age was 30.5 (IQR 27-36 years) for Group 1 and 26.5 (IQR 24-33 years) for Group 2. The median pre and postoperative Lysholm score was 65 (IQR 61-72) and 91 (IQR 87-98) in Group 1, and 72 (IQR 53-75) and 90 (IQR 79-95) in Group 2 (p 0.1). The median pre and postoperative IKDC score was 55 (IQR 45-65) and 80 (IQR 74-94) in Group 1, and 56 (IQR 48-67) and 76 (IQR 68-84) in Group 2 (p 0.11). Sixteen (89%) patients return to sports in each Group. The failure rate was 17% (n = 3) for Group 1 and 5.5% (n = 1) for Group 2 (p >0.6) at a mean of twenty-four months.Conclusion: clinical outcomes and return to sports were similar for both groups. Even though the failure rate was three times less in Group 2, this difference was not statistically significant. Greater number of patients and more follow-up is necessary to establish any conclusion.Type of study: Retrospective cohort . Level of evidence: III

Fijación artroscópica de la fractura por avulsión de espina tibial: resultados con cinco años de seguimiento / Arthroscopic fixation of the tibial spine fracture-avulsion. fifth-years follow-up results

Introducción: Las fracturas por avulsión del ligamento cruzado anterior (LCA) en adultos son inusuales y en general se deben a traumatismos de alta energía. Nuestro objetivo fue evaluar clínica y funcionalmente una serie de pacientes adultos con avulsión de espina tibial. Materiales y métodos: analizamos doce pacientes operados por avulsión de espina tibial entre diciembre de 2009 y diciembre de 2019 tratados con reducción y fijación artroscópica mediante suturas pull-out o tornillos canulados. Evaluamos el rango de movilidad articular (RMA) y la estabilidad postoperatoria con pruebas de Lachman, pivot shift y KT-1000, así como el retorno al deporte y resultados funcionales con las escalas de Lysholm e IKDC. Examinamos consolidación radiográfica y complicaciones postquirúrgicas. Resultados: ocho pacientes fueron incluidos. Cuatro tratados con tornillos canulados (grupo 1) y cuatro con suturas pull-out (grupo 2) con edad promedio de veintinueve años y seguimiento promedio de setenta y ocho y cuarenta y dos meses (grupos 1 y 2, respectivamente). Todos recuperaron el RMA, presentaron Lachman y pivot shift negativos y KT-1000 <3 mm. Tres de cinco pacientes retomaron deportes de pívot. Todos los pacientes presentaron consolidación radiográfica. No se registraron complicaciones postoperatorias.Conclusión: ambas técnicas quirúrgicas fueron efectivas para restablecer la estabilidad articular, lograr buenos resultados funcionales a corto y mediano plazo y alcanzar la consolidación radiográfica en los primeros tres meses postoperatorios

Introduction: Avulsion fractures of the anterior cruciate ligament (ACL) are rare in adults and generally due to high-energy trauma. The objective of this paper was to evaluate clinically and functionally a series of adult patients with anterior tibial eminence fractures treated with reduction and arthroscopic fixation using "pull-out" sutures or cannulated screws.Materials and methods: twelve patients operated on anterior tibial eminence fractures between December of 2009 and December of 2019 were analyzed in whom arthroscopic treatment was performed with "pull-out" sutures or cannulated screws. We evaluated the joint range of motion (ROM) and postoperative stability with Lachman, Pivot-Shift, and KT-1000 tests. Return to sport and functional results were evaluated with the Lysholm and IKDC scales. We analyzed radiographic consolidation and postsurgical complications. Results: eight patients were included. Four of them were treated with cannulated screws (group 1) and four with pull-out sutures (group 2) with a mean age of twenty-nine years and a mean follow-up of seventy-eight and forty-two months (groups 1 and 2, respectively). All of them recovered the ROM, presented negative Lachman and Pivot-Shift, and KT-1000 <3 mm at last follow-up. Three out of five patients returned to pivoting sports. The Lysholm average was 98.75 (group 1) and 91.25 (group 2). The IKDC average was 85.25 (group 1) and 74.67 (group 2). All patients presented radiographic consolidation. No postoperative complications were recorded.Conclusion: both surgical techniques were effective in restoring joint stability, achieving good functional results in the short and medium-term, and achieving radiographic consolidation in the first three postoperative months

Influencia de las características clínicas y el hemograma basal del paciente en la composición final del plasma rico en plaquetas / Clinical characteristics of basal blood count with the final composition of platelet-rich plasma

Introducción: El objetivo del siguiente estudio fue evaluar la influencia de la edad, el sexo, el índice de masa corporal y el hemograma previo de los pacientes en la composición final del PRP. Materiales y métodos: Se realizó un análisis multivariado en trescientos pacientes para determinar la relación entre las mencionadas variables. Resultados: el número de plaquetas finales mostró una relación directa con las plaquetas basales (F (9.187) = 2.067, p = 0.034). Cuando las plaquetas basales aumentaron en una unidad, las plaquetas finales aumentan en promedio con un intervalo de valores de 0.236 a 4.618 (IC 95%, p = 0.00752). Discusión: el valor esperado medio de leucocitos para el protocolo "bajo" es de 1597 y para el nivel "rico" es de 9253, con un IC 95% se espera que el protocolo "rico" aumente en promedio la cantidad de leucocitos finales entre 280 y 785 % con respecto al protocolo "bajo" (p <0.001). Ninguna de las otras variables estudiadas tuvo una influencia significativa en la composición final del PRP. Conclusión: la cantidad de plaquetas en el hemograma basal afectó significativamente la concentración final de plaquetas en el PRP. Además, el protocolo de preparación afectó la concentración final de leucocitos, la que fue significativamente mayor en el protocolo de PRP rico en leucocitos que en el protocolo pobre en leucocitos. El sexo, el IMC y el HTO previo no influyeron significativamente en las concentraciones finales de plaquetas ni de leucocitos del PRP final. Nivel de Evidencia: IV

Introduction: The purpose of this study study was to evaluate the influence of age, sex, body mass index and previous blood count of patients on the final composition of the PRP. Material and methods: a multivariate analysis was performed in three hundred patients to determine the relationship between sex, age, body mass index (BMI) and the characteristics of the baseline blood count with the final composition of the PRP. Results: the number of final platelets showed a direct relationship with the basal platelets (F (9.187) = 2.067, p = 0.034). When the basal platelets increased by one unit, the final platelets increased on average with a range of values from 0.236 to 4.618 (95% CI, p = 0.00752).Discussion: the mean expected value of leukocytes for the "low" protocol is 1597 and for the "rich" level it was 9253, with a 95% CI the "rich" protocol is expected to increase on average the amount of final leukocytes between 280 and 785 % with respect to the "low" protocol (p <0.001). None of the other variables studied had a significant influence on the final composition of the PRP. Conclusion: the amount of platelets in the basal blood count significantly affected the final concentration of platelets in the PRP. Likewise, the preparation protocol affected the final leukocyte concentration, being the same significantly higher in the leukocyte-rich PRP protocol than in the leukocyte-poor protocol. Sex, BMI and previous HTO did not significantly influence the final platelet or leukocyte concentrations of the final PRP. Level of Evidence: IV