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

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

Anterior Cruciate Ligament Reconstruction with Autologous Hamstring Single- versus Double-Bundle Graft: A Prospective Study with 10-Year Follow-up.

The purpose of the present study was to compare the clinical and subjective outcomes of anterior cruciate ligament (ACL) reconstruction using an autologous hamstring double bundle (DB) with a single bundle (SB) after a 10-year follow-up. A prospective comparative cohort study was performed of 47 consecutive patients with ACL rupture included between May 2006 and March 2008. Inclusion criteria were less than 2 years since the injury date, no previous surgery on the affected knee, and having closed growth plates. Patients were divided into two groups: (1) SB group (n = 25) and (2) DB group (n = 22). Patients underwent evaluation before surgery and at 1 and 10 years postoperatively. The clinical evaluation included the International Knee Documentation Committee (IKDC) Questionnaire, pivot shift test, and single hop test, as well as X-rays (anterior drawer X-rays on a Telos stress radiography). Range of motion (ROM) was assessed at 10-year follow-up. Both groups were similar in terms of baseline characteristics. Post hoc power analysis showed that among 30 and 226 patients would be needed for statistical significance, depending on the outcome. With the numbers available, no significant differences were observed in subjective IKDC, anterior stability (measured with Telos), and functional test outcomes (single hop test) between both groups at 1 and 10 years postoperatively. Regarding rotational instability (pivot-shift test), DB group was significantly superior (p = 0.002). Regarding ROM, no significant differences were observed between groups. No failure was registered in any of the groups. ACL reconstruction (ACLR) with an autologous hamstring, both with bundles and DB, shows overall better outcomes compared with the status before surgery. DB ACLR provides better rotational control of the knee, an outcome that is maintained after 10 years.

Is elective surgery during the COVID-19 pandemic safe? A multi-center prospective study in a high incidence area.

OBJECTIVE: The aim of this study was to describe the evolution of patients admitted for elective orthopaedic surgery during the immediate post-COVID-19 peak of the pandemic. METHODS: This is a multi-center, observational study conducted in 8 high complexity hospitals of Catalonia, one of the highest COVID-19 incidence areas in Spain. We included patients ≥18 years of age undergoing elective surgery (total knee or hip arthroplasty, knee or hip revision arthroplasty, shoulder or knee arthroscopy, hand or wrist surgery, forefoot surgery, or hardware removal) after the COVID-19 peak (between May 5th and June 30th, 2020). The main exclusion criterion was a positive result for SARS-CoV-2 PCR within the 7 days before the surgery. The primary outcomes were postoperative complications within 60 days (+/-30) or hospital readmission due to a COVID-19 infection. Following the recommendations of the International Consensus Group (ICM), elective surgeries were re-started when the nationwide lockdown was lifted. Before the surgery, patients were contacted by phone to rule out any exposure to confirmed COVID-19 cases, a reverse transcription-polymerase chain reaction (PCR) assay was performed in all patients 48-72 hours before hospital admission, and they were asked to maintain home confinement until the day of the surgery. RESULTS: 675 patients were included: 189 patients in the arthroplasty group (28%) and 486 in the ambulatory surgery group (72%). Mean [SD] age was 57.6 [15.3] years. The mean Charlson Comorbidity Index score was 2.21 (SD = 2.01, Min = 0, Max = 13). A total of 84 patients (12.75%) obtained an American Society of Anesthesiologists (ASA) score ≥ 3, showing no association between the ASA score and the risk of developing COVID-19 symptoms at follow-up (χ 2 (4) = 0.77, P = 0.94). The mean occupation rate of hospital beds for COVID-19 patients was 13% and the mean occupation rate of critical care beds for COVID-19 patients was 27% at the time of re-introducing elective surgeries. These were important rates to consider to decide when to reintroduce elective surgeries after lockdown. Surgical time, time of ischemia and intra-operative bleeding were not related with a higher risk of developing COVID-19 post-operatively (χ 2 (1) = 0.00, P = 0.98); (χ 2 (2) = 2.05, P = 0.36); (χ 2 (2) = 0.37, P = 0.83). Only 2 patients (0.3 %) presented with a suspected COVID-19 infection at follow-up. None of them presented with pneumonia or required confirmation by a reverse transcription PCR assay. Hospital re-admission was not needed for these patients. CONCLUSION: The risk of developing COVID-19 during the immediate post-COVID-19 peak in a region with a high incidence of COVID-19 has not been proved. These data suggest that elective orthopaedic surgeries can be resumed when assertive and strict protocols are followed.

All-Arthroscopic Nanofractured Autologous Matrix-Induced Chondrogenesis (A-NAMIC) Technique for the Treatment of Focal Chondral Lesions of the Knee.

Nanofractured autologous matrix-induced chondrogenesis (NAMIC©) is a 1-step technique that combines nanofracture needling to induce bone marrow stimulation (BMS) and the use of cell-free collagen matrix to optimize cartilage regeneration. In this Technical Note, we describe a modification of the NAMIC procedure using mosaicplasty trephines to prepare the lesion surface and to shape collagen implants in an all-arthroscopic approach (A-NAMIC). This technique is indicated for the treatment of International Cartilage Repair Society grade III to IV knee chondral lesions of ≤4 cm2. After damaged cartilage is debrided, trephines are used to create a flat, circular lesion surfaces. Subsequently, BMS is performed with nanofracture, eliciting reproducible and stop-controlled subchondral bone perforations of 9-mm depth and 1-mm width. The collagen membrane is then cut to size with the trephine, placed over the prepared defect, and secured with fibrin glue, preventing loss of regenerating cells and growth factors to the joint space. Using trephines allows the rapid and precise creation of smooth defect surfaces with known dimensions, ensuring optimal lesion coverage. Additionally, nanofracture reduces trabecular compaction and allows for a deeper access to subchondral bone in comparison with conventional microfracture, improving lesion filling and production of cartilage with higher hyaline content.

Osteogénesis imperfecta / Imperfect osteogenesis

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