Unicompartmental knee replacement combined with anterior cruciate ligament reconstruction provides comparable results to total knee replacement with no increased risk of complications.

INTRODUCTION: There is controversy about the management of unicompartmental knee osteoarthritis (OA) in young, active patients with anterior cruciate ligament (ACL) insufficiency. This study compares the subjective, radiological, and functional results of total knee replacement (TKR) vs. combined medial unicompartmental knee replacement (UKR) with ACL reconstruction. METHOD: Twelve patients suffering from medial OA and ACL deficiency with varus knee deformity and/or tibial slope <10° and absence of patellofemoral-related problems were eligible for combined UKR and ACL reconstruction (Group A). Twenty-six patients matched for age, male/female ratio and body mass index who received TKR in the same time frame were included as a control group (Group B). Oxford Knee Score (OKS), WOMAC index of osteoarthritis, Knee Osteoarthritis Outcome Score (KOOS), and routine X-rays were used for assessment. RESULTS: Ten years after surgery, the mean overall KOOS score, OKS, WOMAC index increased from preoperatively, showing a statistically significant difference (p < 0.001). In terms of KOOS, OKS, or WOMAC scores at the most recent follow-up, there was no discernible difference between the groups (p = n.s.). Three years following surgery, one female patient in group A received revision TKR due to the lateral compartment's osteoarthritis developing and the patient's pain persisting. Concerning radiographic assessment, at the most recent follow-up (average 7.9 years in group A and 8.8 years in group B), there were no radiographic indications of implant loosening or proof of pathologic radiolucent lines. CONCLUSIONS: UKR combined with ACL restoration offers clinical and radiographic outcomes comparable to TKR 10 years following surgery with no elevated risk of complications.

A four-step approach improves long-term functional outcomes in patients suffering from chronic ankle instability: a retrospective study with a follow-up of 7-16 years.

PURPOSE: The aim of the present study was to assess the long-term outcomes of the treatment of chronic ankle instability (CAI) with a four-step protocol. METHODS: Fifty-four patients with isolated anterior talo-fibular ligament (ATFL) lesion suffering from CAI who underwent surgical treatment between 2000 and 2009 were assessed. All the patients underwent a four-step protocol including synovectomy, debridement of ATFL lesion borders, capsular shrinkage, and 21-day immobilization and nonweightbearing. Median age at surgery was 31.6 years (18-48). Patients were examined preoperatively and at follow-up. Clinical assessment included the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scoring system, Karlsson-Peterson score, Tegner activity level, and objective examination comprehending range of motion (ROM) and manual laxity tests. RESULTS: AOFAS (preoperative, 64.8; postoperative, 92.4; p < 0.001) and Karlsson-Peterson score (preoperative, 62.5; postoperative, 88.8; p < 0.001) significantly improved after a median 11 years follow-up (7-16 years). Similarly median Tegner activity level significantly increased at follow-up compared to pre-operatory status (6.0 and 4.0 respectively, p < 0.001). Objective examination documented a statistically significant improvement in terms of ankle stability compared to pre-operative manual laxity tests, with negative anterior drawer test observed in 48 (88.9%) patients (p < 0.001). Sagittal ROM was full in 50 patients (92%). Nine patients had subsequent ankle sprains (15.6%), two patients required further surgery, while seven were treated conservatively. No major complications were reported. CONCLUSION: Satisfying subjective and objective clinical outcomes in selected patients with isolated ATFL lesion suffering from CAI were reported with a treatment protocol including arthroscopic synovectomy, debridement of ATFL remnants, capsular shrinkage, and immobilization. These findings are of clinical relevance because they provide a suitable minimally invasive method for the treatment of mild to moderate ankle instability. LEVEL OF EVIDENCE: Level IV.

Unicompartmental Knee Replacement Combined to Anterior Cruciate Ligament Reconstruction: Midterm Results.

A study was conducted to retrospectively evaluate the outcomes of combined medial unicompartmental knee replacement (UKR) and anterior cruciate ligament (ACL) reconstruction. The hypothesis was that this procedure would lead to satisfying results in patients affected by medial osteoarthritis and ACL insufficiency. Fourteen patients with ACL deficiency and concomitant medial compartment symptomatic osteoarthritis were treated from 2006 to 2010. Twelve of them were followed-up for an average time of 7.8 year (range: 6-10 years). Assessment included Knee Osteoarthritis Outcome score (KOOS), Oxford Knee score (OKS), American Knee Society scores (AKSS), Western Ontario and McMaster (WOMAC) index of osteoarthritis, Tegner's activity level, objective examination including instrumented laxity test with KT-1000 arthrometer, and standard X-rays. KOOS score, OKS, WOMAC index, and the AKSS improved significantly at follow-up (p < 0.001). There was no clinical evidence of instability in any of the knees as evaluated with clinical and instrumented laxity testing (p < 0.001). No pathologic radiolucent lines were observed around the components. In one patient, a total knee prosthesis was implanted due to the progression of signs of osteoarthritis in the lateral compartment 3 years after primary surgery. UKR combined with ACL reconstruction is an effective therapeutic option for the treatment of combined medial unicompartmental knee osteoarthritis and ACL deficiency and confirms subjective and objective clinical improvement up to 8 years after surgery. This study reflects level IV evidence.

Early Response to Warfarin Initiation and the Risk of Venous Thromboembolism After Total Joint Arthroplasty.

BACKGROUND: Venous thromboembolism chemoprophylaxis with warfarin is common after total joint arthroplasty. Early response to warfarin initiation has been theorized to engender a transient increase in the risk of venous thromboembolism. We hypothesized that a rapid rise in the international normalized ratio is a risk factor for venous thromboembolism after total joint arthroplasty. METHODS: This study was a retrospective analysis of Medicare patients undergoing elective total joint arthroplasty who were given nomogram-dosed warfarin for venous thromboembolism prophylaxis. Logistic regression was used to assess the relationship between the postoperative rate of change in the international normalized ratio and the occurrence of symptomatic venous thromboembolism within 30 days postoperatively. RESULTS: The study included 948 patients (715 total knee arthroplasty, 233 total hip arthroplasty), of whom 4.4% experienced symptomatic venous thromboembolism within 30 days postoperatively. The change in the international normalized ratio from postoperative day 1 to postoperative day 2 was significantly greater in the symptomatic venous thromboembolism group compared with the group that did not have venous thromboembolism (increase of 0.70 versus 0.46; P = 0.008). Regression analysis showed that a higher rate of change in the international normalized ratio was associated with increased risk of symptomatic venous thromboembolism (odds ratio, 2.59 per unit of change in the international normalized ratio; 95% confidence interval, 1.51-4.38; P = 0.001). CONCLUSION: A rapid rise in the international normalized ratio after warfarin initiation in total joint arthroplasty patients is associated with increased risk of symptomatic venous thromboembolism. This novel finding identifies a population at risk for this complication. Further study of the early effects of warfarin therapy is warranted. LEVEL OF EVIDENCE: Level III.

Medial unicondylar knee arthroplasty combined to anterior cruciate ligament reconstruction.

PURPOSE: The purpose of the present study was to retrospectively evaluate the outcomes of patients who underwent combined medial unicompartmental knee arthroplasty (UKA) and anterior cruciate ligament (ACL) reconstruction. The hypothesis was that this procedure would lead to a high success rate in patients affected by isolated medial unicompartmental osteoarthritis and concomitant ACL deficiency. METHODS: Fourteen patients with primary ACL lesion and concomitant medial compartment symptomatic osteoarthritis treated from 2006 to 2010 were followed up for an average time of 26.7 months (SD 4.2). Assessment included KOOS score, Oxford Knee score, American Knee Society scores, WOMAC index of osteoarthritis, Tegner activity level and objective examination including instrumented laxity test with KT-1000 arthrometer. Radiological assessment was done with standard simple radiographs in order to get information about any presence of loosening of the components. RESULTS: KOOS score, OKS, WOMAC index and the AKSS improved significantly after surgery (p < 0.001). Regarding AKSS, improvement was noted both in the objective score and in the functional one (p < 0.001). There was no clinical evidence of instability in any of the knees as evaluated with clinical laxity testing. No pathologic radiolucent lines were observed around the components. In one patient signs of osteoarthritis in the lateral compartment were observed 28 months after surgery. CONCLUSIONS: UKA combined with ACL reconstruction is a valid therapeutic option for the treatment of combined medial unicompartmental knee osteoarthritis and ACL deficiency in young and active patients and confirms subjective and objective clinical improvement 2 years after surgery. The use of a fixed-bearing prosthesis represents a reliable feature as it allows to overcome problems of improper ligament tensioning during the implantation of the components. LEVEL OF EVIDENCE: IV.

Incidence of bacterial contamination and predisposing factors during bone and tendon allograft procurement.

The aim of this study was to analyze factors contributing to bacteriological contamination of bone and tendon allograft. Between 2008 and 2011, 2,778 bone and tendon allografts obtained from 196 organ and tissue donors or tissue donors only were retrospectively analysed. Several variables were taken into account: donor type (organ and tissue donors vs. tissue donor), cause of death, time interval between death and tissue procurement, duration of the procurement procedure, type of allografts, number of team members, number of trainees members, associated surgical procedures, positivity to haemoculture, type of procurement. The overall incidence of graft contamination was 23 %. The cause of death, the procurement time, the duration of procurement, the associated surgical procedures were not associated with increased risk of contamination. Significant effect on contamination incidence was observed for the number of staff members performing the procurement. In addition, our study substantiated significantly higher contamination rate among bone allografts than from tendon grafts. According to these observations, in order to minimize the contamination rate of procured musculoskeletal allografts, we recommend appropriate donor selection, use of standard sterile techniques, immediate packaging of each allograft to reduce graft exposure. Allograft procurement should be performed by a small surgical team.

Lateral ligament reconstruction with allograft in patients with severe chronic ankle instability.

INTRODUCTION: Chronic ankle instability is a condition of perception of giving way and persistent pain usually following multiple ankle sprains. In case of severe joint laxity, surgical treatment with reconstruction of the lateral ligamental complex is recommended. The aim of this study was to evaluate the functional outcome of patients treated with lateral ligament reconstruction with allograft for severe chronic lateral ankle instability. MATERIALS AND METHODS: We performed a retrospective cohort study of ten patients who underwent allograft external non-anatomic ligamentoplasty for severe chronic lateral ankle instability between 2009 and 2011, with an average follow-up of 16.3 months (SD 8.2). Median age at surgery was 29 years (range 25-35). All patients presented both ATFL and CFL lesion. Patients were evaluated using American Orthopaedic Foot and Ankle Society score, Karlsson-Peterson score, Tegner activity level, Sefton stability scale, and objective examination comprehending range of motion, anterior drawer sign and talar tilt test. Telos stress equipment was used for pre- and post-operative radiographic laxity testing. RESULTS: Follow-up examination at an average of 16.3 months (SD 8.2) after surgery showed significant improvement of all variables compared to pre-operative values (p < 0.001). Most patients rated their outcome as good/excellent. Telos stress radiographs documented improvement in joint stability. CONCLUSIONS: Lateral ligament reconstruction with allograft represents a valid treatment option in patients with severe chronic lateral ankle instability.

Revision surgery after failed ACL reconstruction with artificial ligaments: clinical, histologic and radiographic evaluation.

Synthetic ligament for anterior cruciate ligament (ACL) reconstruction has been widely used in the past. Long-term follow-up has demonstrated the unreliability of many of these devices in ACL surgery, and problems may arise for the surgeon approaching a patient with failed artificial ligament reconstruction. The aim of this study is to investigate whether revision surgery may improve clinical and radiographic outcomes in patients with failed synthetic ACL reconstruction. Fourteen patients who were treated in the past with ACL reconstruction with synthetic grafts underwent two-stage revision surgery. Follow-up averaged 4.2 years (range 2-6 years). Mean KOOS score was 75.8 (SD 10.2); IKDC score was B in two patients, C in nine and D in three. The improvement compared to preoperative status was not statistically significant (p > 0.05). Four patients were positive to Lachman and anterior drawer tests. Mean side-to-side anterior laxity averaged 4.3 mm (SD 1.2). Biopsy specimens documented the presence of foreign body granulomatous reaction, giant foreign body cells and polyethylene wear particles. The level of osteoarthritis worsened at follow-up compared to preoperative status (p < 0.05). ACL revision surgery with autografts in patients who underwent previous failed primary synthetic ligament reconstruction does not improve clinical outcomes and does not influence the natural history of knee osteoarthritis started from artificial ligament debris.

Single-bundle versus double-bundle anterior cruciate ligament reconstruction: assessment with vertical jump test.

PURPOSE: The study was designed to compare the clinical results of traditional single-bundle (SB) anterior cruciate ligament (ACL) reconstruction with those of double-bundle (DB) ACL reconstruction. METHODS: This study comprised 80 patients aged 18 to 45 years with an isolated ACL lesion: 40 patients underwent SB reconstruction, and 40 patients underwent DB reconstruction. Patients were assessed preoperatively with functional assessment including the International Knee Documentation Committee 2000 knee subjective form and visual analog scale, as well as physical examination (including the pivot-shift test and instrumented knee laxity measurement). Vertical jump assessment with the Optojump system (Microgate, Bolzano, Italy) has been introduced as a method to compare functional ability between the 2 surgical techniques. The same protocol was repeated 6 months, 12 months, and 2 years after surgery. RESULTS: No statistically significant differences were noted between the groups concerning subjective evaluation, thigh girth difference, mean visual analog scale score, range of motion, and Lachman and anterior drawer tests (P = not significant). A statistically higher number of patients in the SB group showed a positive pivot-shift test and a higher side-to-side difference when measured with the KT-1000 arthrometer (MEDmetric, San Diego, CA) than in the DB group (P < .001). Better mean jumping performance results were reported in the DB group compared with the SB group (P < .001). The average performance results for the injured limb were not significantly reduced compared with those of the uninjured limb in the DB group 12 months after surgery. At 2 years, a restoration of jumping ability in the ACL-reconstructed limb was achieved in both groups regardless of the technique used. CONCLUSIONS: DB ACL reconstruction has been proven to be superior to the SB technique with regard to knee stability and vertical jump performance. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Treatment of post-traumatic osteochondral lesions of the talus: a four-step approach.

PURPOSE: The purpose of this retrospective study was to assess the treatment of post-traumatic osteochondral lesions (OCLs) of the ankle with a four-step protocol. METHODS: Thirty-eight patients with at least one MRI-documented OCL of the ankle were treated from 2004 to 2010. Median age at surgery was 39 years (range: 18-52). Mean lesion size was 1.0 cm(2) (SD: 0.2). All patients underwent a four-step surgical procedure including synovectomy, debridement and microfractures of the OCL, capsular shrinkage, and bracing and non-weightbearing for 21 days. Clinical assessment included objective examination, the AOFAS ankle and hindfoot scoring system, Karlsson-Peterson score, Tegner activity level, and Sefton articular stability scale. MRI scans were taken 18 months after surgery in all patients. RESULTS: Follow-up examination at an average of 4 years (SD: 1.1) after surgery showed significant improvement of all variables compared to pre-operative values (P < 0.05). Most patients rated their outcome as good/excellent. MRI scans taken 18 months after surgery documented completely repaired lesion in 27 ankles, slight bone marrow oedema with partially repaired defect in 9 patients, and visible defect in 2 ankles. CONCLUSION: Based on the present results, we propose a comprehensive four-step protocol as a safe and clinically effective treatment option in patients with post-traumatic OCLs of the ankle.

Single- and double-bundle anterior cruciate ligament reconstruction in patients aged over 50 years.

PURPOSE: The purpose of our study was to retrospectively evaluate the outcomes after anterior cruciate ligament (ACL) reconstruction with hamstring in patients aged 50 years or older. In addition, we present, for the first time, the outcomes of a subgroup of middle-aged patients treated with double-bundle (DB) reconstruction. METHODS: Fifty patients aged 50 years or older underwent primary ACL reconstruction with hamstring. Inclusion criteria were primary ACL reconstruction in active patients. Exclusion criteria were multiligamentous injuries and a contralateral ACL-deficient knee. The mean age at surgery was 54.4 years (range, 50 to 65 years). The mean period from the initial injury to surgery was 32.6 months (range, 3 to 125 months). Of the patients, 36 underwent single-bundle (SB) ACL reconstruction and 14 underwent DB reconstruction. Patients were assessed preoperatively with physical examination (including range of motion, pivot-shift test, and instrumented knee laxity measurement), the Lysholm score, the International Knee Documentation Committee scoring system, and the Tegner activity scale. Standard radiographs were taken, and degenerative changes were graded according to the Ahlbäck radiologic classification of arthritis. RESULTS: Patients were evaluated at a mean of 4.4 years (range, 2 to 7 years) after surgery. A significant improvement in knee function and symptoms was reported in most patients, with increased Lysholm, International Knee Documentation Committee, and Tegner scores (P < .001). The outcomes of clinical assessment and instrumented laxity testing were clearly improved when compared with preoperative status (P < .001). The level of osteoarthritis did not statistically increase at follow-up. No statistically significant difference could be observed between the SB and DB groups (P = not significant). CONCLUSIONS: Operative treatment showed favorable outcomes in most of the ACL-reconstructed patients with regard to knee stability, osteoarthritis progression, and patient satisfaction in a cohort of subjects aged 50 years or older. Our subgroup of patients undergoing DB ACL reconstruction reported average satisfactory outcomes, which did not significantly differ from the SB group. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic four-step treatment for chronic ankle instability.

BACKGROUND: Chronic lateral ankle instability is a condition of perception of giving way and persistent pain usually following multiple ankle sprains. Open reconstructive procedures carry the disadvantages of subtalar joint stiffness and potential morbidity at the harvesting site. Recently, arthroscopic treatment of chronic lateral ankle instability has been proposed in order to minimize invasiveness, reduce operating time, and allow a faster rehabilitation period. The purpose of our paper was to assess the outcomes in terms of postoperative recovery and return to sport following arthroscopic reconstruction of lateral ankle instability. METHODS: Ninety patients with chronic lateral ankle instability were treated at our Department from 2004 to 2009. Mean age was 32.4 (range, 17 to 56) years. All patients underwent a four-step operative procedure, including: synovectomy, debridement of ATFL lesion borders, capsular shrinkage, and 21-day immobilization and nonweightbearing. RESULTS: Followup examination at an average of 4~years after surgery showed significant improvement of mean AOFAS scale (preoperative, 63.5; postoperative, 92.3; p < 0.001) and average Karlsson score (preoperative, 61.8; postoperative, 88.4; p < 0.001). Mean Tegner rating changed from 3.6 preoperatively to 4.9 at followup (p < 0.001). Articular stability as assessed by Sefton scale significantly improved from a preoperative value of 4.0 to 1.8 (p < 0.001). Most patients (96.6%) rated the success of their surgery as good to excellent. CONCLUSION: Based on our results, we propose arthroscopic treatment as a suitable option for moderate chronic ankle joint laxity in patients with a complete ATFL lesion.

Repair of osteochondral lesions in the knee by chondrocyte implantation using the MACI® technique.

PURPOSE: Matrix-associated autologous chondrocyte implantation (MACI(®)) is an innovative therapeutic option for the treatment of chondral and osteochondral lesions of the knee. METHODS: Fifty-three patients (54 knees) with MRI-documented osteochondral lesions were treated with MACI(®). A clinical assessment was performed using VAS score, Lysholm score, and Tegner activity level after an average follow-up of 27 months (SD: 2.3). MRI scans were performed 12 and 24 months after surgery. Seventeen patients were reevaluated after an average time of 59 months (SD: 6.7) after surgery. RESULTS: Two years after transplantation, Lysholm score increased from a preoperative mean value of 70 (SD: 13.4) to 95 (SD: 6.4); the average VAS score decreased from a preoperative value of 5.2 (SD: 2.9) to 1.9 (SD: 2.1). The difference with respect to Tegner activity level did not prove to be significant. At 1 year, MRI scans documented a completely repaired defect with slight subchondral bone abnormality in 38 cases (70%). Satisfying outcomes were confirmed on 17 patients who were reevaluated 5 years after surgery. At 60 months, MRI scans showed complete integration with the surrounding native cartilage without any sign of detachment or bone marrow edema in 15 cases (88%). CONCLUSION: The MACI(®) technique is a safe and clinically effective procedure, which has been proven to be valuable in treating osteochondral defects even over the long term. LEVEL OF EVIDENCE: Therapeutic study, Level III-2 (retrospective cohort study).

Management of anterior cruciate ligament rupture in patients aged 40 years and older.

The aim of anterior cruciate ligament (ACL) reconstruction is essentially to restore functional stability of the knee and to allow patients to return to their desired work and activities. While in the young and active population, surgery is often the best therapeutic option after an ACL tear, ACL reconstruction in middle-aged people is rather more controversial due to concerns about a higher complication rate. The purpose of our article is to establish, through a systematic review of the literature, useful decision-making criteria for the management of anterior cruciate ligament rupture in patients aged 40 years and older, guiding surgeons to the most appropriate therapeutic approach. Various reports have shown excellent results of ACL reconstruction in patients over the age of 40 in terms of subjective satisfaction, return to previous activity level, and reduced complication and failure rates. Some even document excellent outcomes in subjects of 50 years and older. Although there are limited high-level studies, data reported in the literature suggest that ACL reconstruction can be successful in appropriately selected, motivated older patients with symptomatic knee instability who want to return to participating in highly demanding sport and recreational activities. Deciding factors are based on occupation, sex, activity level of the subject, amount of time spent performing such highly demanding activities, and presence of associated knee lesions. Physiological age and activity level are more important than chronological age as deciding factors when considering ACL reconstruction.

Anterior cruciate ligament reconstruction with synthetic grafts. A review of literature.

Anterior cruciate ligament (ACL) rupture, one of the most common knee injuries in sports, results in anteroposterior laxity, which often leads to an unstable knee. Traditional ACL reconstruction is performed with autograft; disadvantages of this technique are donor site morbidity and a long rehabilitation period. In the 1980s, artificial ligaments became an attractive alternative to biological grafts. The initial enthusiasm surrounding their introduction stemmed from their lack of donor morbidity, their abundant supply and significant strength, immediate loading and reduced postoperative rehabilitation. Synthetic grafts made of different materials such as carbon fibers, polypropylene, Dacron and polyester have been utilised either as a prosthesis or as an augmentation for a biological ACL graft substitute. Nevertheless, every material presented serious drawbacks: cross-infections, immunological responses, breakage, debris dispersion leading to synovitis, chronic effusions, recurrent instability and knee osteoarthritis. Recently, a resurgence of interest in the use of synthetic prostheses has occurred and studies regarding new artificial grafts have been reported. Although many experimental studies have been made and much effort has been put forth, currently no ideal prosthesis mimicking natural human tissue has been found.

Synthetic grafts for anterior cruciate ligament rupture: 19-year outcome study.

Artificial ligaments for ACL replacement have been widely used in the 1980s and early 1990s in orthopaedic surgery. Synthetic devices have been utilized either as a prosthetic material or as an augmentation for a biological ACL graft substitute. The initial enthusiasm surrounding the introduction of synthetic graft materials stemmed from their lack of donor morbidity, their abundant supply and significant strength of these devices. The disadvantages in long-term follow-up were found to be cross-infections, immunological responses, tunnels osteolysis, femural and tibial fractures, foreign-body synovitis and knee osteoarthritis. A total of 126 patients were treated with artificial ACL substitution with polyethylene terephthalate (PET) synthetic ligaments in our Institute between 1986 and 1990. Of the original group, 51 sportsmen aged 15 to 40 were followed-up at a mean of 19years (range 17.5 to 20.6years) after surgery. Assessment was made with KOOS and IKDC score, Tegner activity scale, clinical examination, KT-1000 arthrometer, and X-ray evaluation. Of the 51 patients followed-up, 27.5% were found to have ruptured their PET ligaments and 100% presented degenerative osteoarthritis at the X-ray evaluation according to Ahlbäck radiological classification of arthritis. The objective evaluation showed functional impairment in 29.4% with an average reduction of 3 points in the Tegner activity scale. The osteoarthritis observed in all patients prompted us to avoid the diffusion of this surgical technique. Although in theory well-conceived, studies have yet to substantiate the function of these augmentation devices or to show clinical better results than those achieved with isolated autograft or allograft ACL substitutes.