Showing papers in "Knee Surgery, Sports Traumatology, Arthroscopy in 2003"
TL;DR: Four technical modifications of high tibial osteotomy are presented which improve its safety and reproducibility and stable osteosynthesis allows for early mobilization and avoids losses-of-correction.
Abstract: We present four technical modifications of high tibial osteotomy which improve its safety and reproducibility. (a) Open wedge correction: opening wedge osteotomy from the medial side avoids lateral muscle detachment, dissection of the peroneal nerve, proximal fibula osteotomy, and leg shortening; only one osteotomy needs to be performed and the correction can be adapted intraoperatively. (b) Biplanar osteotomy: in addition to the transverse osteotomy of the posterior tibia a second ascending osteotomy in the coronary plane underneath the tibial tuberosity is performed. This provides improved rotational stability of the osteotomy and creates an anterior buttress against sagittal tilting of the osteotomy planes. (c) Incomplete osteotomy with plastic deformation of the tibia: 10 mm of lateral bone stock is left intact. The osteotomy is opened gradually over several minutes by sequential impaction of flat chisels or by use of a special spreading tool. Manifest fractures of the lateral cortex with resulting instability are avoided. Rapid bone healing is promoted. (d) Rigid fixation: stable osteosynthesis allows for early mobilization and avoids losses-of-correction. We use a medial plate-fixator which can be applied percutanously. In 112 patients operated on using this modified technique no pseudarthosis or loss-of-correction was observed.
517 citations
TL;DR: The conclusion is that treatment with eccentric calf-muscle training produced good clinical results in patients with chronic painful mid-portion Achilles tendinosis, but not in Patients with chronic insertional Achilles tendon pain.
Abstract: Injuries involving the Achilles tendon and manifested as chronic tendon pain are common, especially among recreational athletes. In a pilot study on a small group of patients with chronic painful mid-portion Achilles tendinosis, eccentric calf-muscle training was shown to give good clinical results. The aim of this prospective study was to investigate if the previously achieved good clinical results could be reproduced in a larger group of patients, and also to investigate the effects of eccentric calf-muscle training in patients with chronic insertional Achilles tendon pain. Seventy-eight consecutive patients, having chronic painful Achilles tendinosis at the mid-portion (2–6 cm level) in a total of 101 tendons (55 unilateral and 23 bilateral), and thirty consecutive patients with chronic insertional Achilles tendon pain in 31 tendons (29 unilateral and one bilateral) were treated with eccentric calf-muscle training for 12 weeks. Most patients were recreational athletes. Evaluation of the amount of tendon pain during activity was recorded on a visual analogue scale (VAS), before and after treatment. In 90 of the 101 Achilles tendons (89%) with chronic painful mid-portion Achilles tendinosis, treatment was satisfactory and the patients were back on their pre-injury activity level after the 12-week training regimen. In these patients, the amount of pain during activity, registered on the VAS-scale (mean±SD), decreased significantly from 66.8±19.4 to 10.2±13.7. On the contrary, in only ten of the tendons (32%) with chronic insertional Achilles tendon pain was treatment satisfactory, with a significant decrease on the VAS-scale (mean±SD), from 68.3±7.0 to 13.3±13.2. Our conclusion is that treatment with eccentric calf-muscle training produced good clinical results in patients with chronic painful mid-portion Achilles tendinosis, but not in patients with chronic insertional Achilles tendon pain.
381 citations
TL;DR: Findings which support neovessels and accompanying nerves being the possible source of pain in chronic mid-portion Achilles tendinosis are demonstrated.
Abstract: Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis? : An investigation using US and colour Doppler, immunohistochemistry, and diagnostic injections
372 citations
TL;DR: The data indicate that the RD task caused an increase in peak ACL strain that is much higher than during the instrumented Lachman test, and that the strain begins to increase during the flight phase, prior to landing, and reaches a peak that corresponds to the peak ground reaction force.
Abstract: The mechanism of anterior cruciate ligament (ACL) injury is still unclear. To gain this insight, knowledge of the mechanical behaviour of the healthy ACL during activities that may stress the ligament must be investigated in vivo. The goal of this research was to measure ACL strain in vivo during rapid deceleration, a sport type movement that has been previously shown to precede injuries to the ACL in healthy subjects. A young male subject with no previous knee joint injuries volunteered after informed consent. The strain gauge device (DVRT) was calibrated and surgically implanted in the antero-medial band of the intact ACL. The subject was then transported to the lab for data collection. The zero strain position of the ACL was determined using the slack-taut technique. The subject hopped as quickly as possible from a distance of 1.5 m to the target, an X taped at the centre of a force plate, landing with the instrumented left leg and stopping in the landed position. The entire collection window was five seconds at 1000 Hz. A total of three rapid deceleration trials were collected and averaged over the hop cycle. The slack-taut test was then repeated to ensure proper operation of the DVRT and the reliability of the results. The results showed an average peak strain of the ACL during the instrumented Lachman test of 2.00+/-0.17%. The average peak strain of the ACL during the rapid deceleration task was 5.47+/-0.28%. The data indicate that the RD task caused an increase in peak ACL strain that is much higher than during the instrumented Lachman test, and that the strain begins to increase during the flight phase, prior to landing, and reaches a peak that corresponds to the peak ground reaction force. This technique may be used in further sport-specific movements to gain insight into movement patterns associated with ACL injury mechanisms.
247 citations
TL;DR: A significant difference was found within the ACL reconstructed group and between the reconstructed and the contralateral intact leg, suggesting ACL reconstruction may not restore tibial rotation even though anterior tibials translation has been reestablished.
Abstract: Recent in vitro research suggests that ACL reconstruction does not restore tibial rotation. This study investigated rotational knee joint stability in vivo during a combined descending and pivoting movement that applies a high rotational load to the knee joint. We studied 20 ACL reconstructed patients (bone–patellar tendon–bone graft) and 15 matched controls with a six-camera optoelectronic system performing the examined movement. In the control group the results showed no significant differences in the amount of tibial rotation between the two sides. No significant differences were also found between the contralateral intact leg of the ACL group and the healthy control. However, a significant difference was found within the ACL reconstructed group and between the reconstructed and the contralateral intact leg. Therefore ACL reconstruction may not restore tibial rotation even though anterior tibial translation has been reestablished.
226 citations
TL;DR: EMG firing patterns in lower extremity muscles in subjects with AKP while ascending and descending stairs showed changes in neuromuscular activity patterns may be a result of a compensations strategy due to AKP.
Abstract: Ascending and descending stairs is a provocative activity for anterior knee pain (AKP) patients. The gluteus medius (GM) acts on the lower extremity in the frontal plane and can affect forces at the knee. Determining activation patterns of the GM in patients with AKP can help identify efficacy of training the GM in this population. This study examined electromyographic (EMG) firing patterns in lower extremity muscles in subjects with AKP while ascending and descending stairs. Subjects in the AKP group (n=16) demonstrated general AKP for at least 2 months compared to the control group (n=12); neither group had any history of knee trauma. Subjects were instrumented with EMG electrodes on the vastus medialis oblique (VMO), vastus lateralis (VL), and GM. Retroreflective markers were placed on lower extremities to determine knee flexion angle, and frontal plane pelvis orientation at toe contact. Subjects then performed a series of five stair (height=18 cm) ascent and descent trials. Repeated measures analyses of variance were performed on EMG and kinematic variables, between the two groups and between the symptomatic and asymptomatic sides. In the AKP group the GM demonstrated delayed onset and shorter durations for stair ascent and shorter duration during descent. There were no significant differences between sides in the AKP group. Consistent with previous studies, subjects in the AKP group demonstrated no difference in the VMO onsets relative to VL onsets compared to the control group. Changes in neuromuscular activity patterns may be a result of a compensations strategy due to AKP. Training of GM and other hip muscles is warranted during rehabilitation of AKP patients.
189 citations
TL;DR: The conclusion of the study is that acetabular labrum tears can be a common cause of groin pain in athletes and sports clinicians managing athletes with groin pain have to be well aware of the condition.
Abstract: To the best of our knowledge, this prospective study is the first to investigate the prevalence of acetabular labrum tears in athletes presenting with groin pain. Eighteen athletes who presented to our sports clinic with groin pain, underwent clinical assessment and magnetic resonance arthrography (MRa) to detect presence or absence of acetabular labrum tears. Ethical committee approval and informed consent was obtained from each patient. In four out of these eighteen athletes (22%) the MRa demonstrated the presence of acetabular labrum tear. Three of them underwent arthroscopic debridement of their acetabular labrum tears and returned to their sporting activities within 8 months. Clicking sensation of the hip was a sensitive (100%) and specific (85%) clinical symptom to predict labral tears. The internal rotation-flexion-axial compression manoeuvre was sensitive (75%) but not specific (43%). The Thomas test was neither sensitive nor specific. The conclusion of the study is that acetabular labrum tears can be a common cause of groin pain in athletes. Sports clinicians managing athletes with groin pain have to be well aware of the condition.
186 citations
TL;DR: Evidence shows how the posterolateral and posteromedial structures are responsible for posterior knee stability near extension, and this, along with the action of the meniscofemoral ligaments, may explain why an isolated rupture of the posterior cruciate ligament does not often lead to knee instability.
Abstract: This paper reviews and updates our knowledge of the anatomy and biomechanics of the posterior cruciate ligament, and of the posterolateral, posteromedial and meniscofemoral ligaments of the knee. The posterior cruciate ligament is shown to have two functional fibre bundles that are tight at different angles of knee flexion. It is the primary restraint to tibial posterior draw at all angles of knee flexion apart from near full extension. In contrast, the posterolateral and posteromedial structures are shown to tighten as the knee extends, and to be well-aligned to resist tibial posterior draw. These structures also act as primary restraints against other tibial displacements. Tibial internal rotation is restrained by the medial and posteromedial structures, while tibial external rotation is restrained by the lateral and posterolateral structures. They are also the primary restraints against tibial abduction-adduction rotations. The meniscofemoral ligaments are shown, for the first time, to contribute significantly to resisting tibial posterior draw, and to have a strength of approximately 300 N. Taken together, this evidence shows how the posterolateral and posteromedial structures are responsible for posterior knee stability near extension, and this, along with the action of the meniscofemoral ligaments, may explain why an isolated rupture of the posterior cruciate ligament does not often lead to knee instability
173 citations
TL;DR: Knowing the anatomical variations in detail along the course of the suprascapular nerve might be important for better understanding of location and source of the entrapment syndrome, especially for individuals who are involved in violent overhead sports activities such as volleyball and baseball.
Abstract: The purpose of the study was to determine anatomical variations at the suprascapular notch for better understanding of possible predisposing factors for suprascapular nerve entrapment. We dissected 32 shoulders of 16 cadavers between the ages of 39 and 74 years. We observed abnormally oriented superior fibers of the subscapularis muscle in five shoulders of the 16 cadavers, which were covering the entire anterior surface of the suprascapular notch and significantly reducing the available space for the suprascapular nerve. We also detected anterior coracoscapular ligament in six of the 32 shoulders, and calcified superior transverse scapular ligament in four of the shoulders. In this study, we classified the variations for the superior transverse scapular ligament. In conclusion, knowing the anatomical variations in detail along the course of the suprascapular nerve might be important for better understanding of location and source of the entrapment syndrome, especially for individuals who are involved in violent overhead sports activities such as volleyball and baseball. To our knowledge, close relationship of subscapularis muscle with the suprascapular nerve as a possible risk factor for suprascapular nerve entrapment has not been mentioned previously.
159 citations
TL;DR: Treatment only focusing on sclerosing the area with neovessels showed promising short-term clinical results in this small pilot study, and the findings support further studies, preferably in a randomised manner.
Abstract: The origin of Achilles tendon insertional pain has not been clarified. Treatment is considered difficult, though tendon, bone, and bursae, alone or in combination, may all be the source of pain. Recently, neovascularisation in the area with tendon changes was shown to correlate with pain in patients with chronic mid-portion Achilles tendinosis. In a pilot study, sclerosing the neovessels outside the tendon cured the pain in the majority of patients. In this pilot-study, ultrasonography and colour Doppler was used for the investigation of eleven patients (nine men and two women, mean age 44 years) with a long duration (mean 29 months) of chronic Achilles tendon insertional pain. All patients had distal tendon changes and a local neovascularisation inside and outside the distal tendon on the injured/painful side, but not on the noninjured/pain-free side. In nine patients there was also a thickened retrocalcaneal bursae, and in four patients also bone pathology (calcification, spur, loose fragment) in the insertion. The sclerosing agent polidocanol was injected against the local neovessels found in all patients. At follow-up (mean eight months), sclerosing of the area with neovessels had cured the pain in eight out of eleven patients, and in seven of the eight patients there was no neovascularisation. Pain during tendon-loading activity, recorded on a VAS-scale, decreased from 82 mm before treatment to 14 mm after treatment in the successfully treated patients. In conclusion, treatment only focusing on sclerosing the area with neovessels showed promising short-term clinical results in this small pilot study. The findings support further studies, preferably in a randomised manner.
129 citations
TL;DR: Navigated implantation of a UKP with the used, non-image-based system improved the accuracy of the radiological implantation without any significant inconvenience and with little change in the conventional operative technique.
Abstract: The accuracy of implantation is an accepted prognostic factor for the long-term survival of unicompartmental knee prostheses (UKP). We developed a non-image-guided navigation system for UKP implantation without any extramedullary or intramedullary guiding device. The 30 patients operated on with the navigation system (group A) were matched to 30 patients operated on with the conventional technique (group B) using age, sex, body mass index, preoperative coronal mechanical femorotibial angle, and severity of the preoperative degenerative changes. All patients had a complete radiological examination in the first 3 months after the index procedure, with anteroposterior and lateral plain knee radiographs and anteroposterior and lateral long leg radiographs. Coronal femorotibial mechanical angle and both coronal and sagittal orientations of the femoral and tibial components were measured. There were no significant differences in the mean numerical values of all measured angles except for the sagittal orientation of the tibial component, with a significant excessive posterior tibial slope in group B. There was a significant increase in the rate of prostheses implanted in the desired angular range for all criteria except the coronal mechanical femorotibial angle in group A. An optimal implantation with all optimal items was obtained by 18 cases in group A and 6 cases in group B. Navigated implantation of a UKP with the used, non-image-based system improved the accuracy of the radiological implantation without any significant inconvenience and with little change in the conventional operative technique. The only inconvenience was a 20-min longer operative time. This improvement could be related to a longer survival of such implanted prostheses.
TL;DR: Several grafts and several fixation techniques have been introduced for PCL reconstruction over the past years, and autograft and allograft tissues are recommended forPCL reconstruction, whilst synthetic grafts should be avoided.
Abstract: Several grafts and several fixation techniques have been introduced for PCL reconstruction over the past years To date, autograft and allograft tissues are recommended for PCL reconstruction, whilst synthetic grafts should be avoided Autograft tissues include the bone-patellar tendon-bone graft, the hamstrings and the quadriceps tendon Allograft tissues are increasingly being used for primary PCL reconstruction The use of allograft tissues requires a number of formal prerequisites to be fulfilled Besides the previous mentioned graft types allograft tissues include Achilles and tibialis anterior/posterior tendons To date no superior graft type has been identified Several techniques and devices have been used for fixation of a PCL replacement graft Most of these were originally developed for ACL reconstruction and then adapted to PCL reconstruction However, biomechanical requirements of the PCL differ substantially from those of the ACL To date, requirements for PCL graft fixations are not known From a systematic approach femoral graft fixation can either be achieved within the bone tunnel (nearly anatomic) with an interference screw or outside the bone tunnel on the medial femoral condyle using a staple, an endobutton or a screw Tibial graft fixation can be achieved either with an interference screw in the bone tunnel or with a staple, screw/washer or sutures tied over a bone bridge outside the bone tunnel (extra-anatomic) An alternative fixation on the tibial side is the inlay technique that reduces the acute angulation of the graft at the posterior aspect of the tibia Further research is necessary to identify the differences between the various fixation techniques
TL;DR: Clinical and patient-reported outcomes following meniscal allograft transplantation with and without combined ACL reconstruction in carefully selected patients with complaints of compartmental joint line pain and/or instability appears able to provide relief of symptoms and restore relatively high levels of function, particularly during activities of daily living.
Abstract: The menisci provide a vital role in load transmission across the knee joint as well as contribute to knee stability, particularly in the ACL-deficient knee. Loss of the meniscus, in part or in total, significantly alters joint function and predisposes the articular cartilage to degenerative changes, which has been well documented both clinically and radiographically. This study examined clinical and patient-reported outcomes following meniscal allograft transplantation with and without combined ACL reconstruction in a select group of 31 patients with complaints of pain and/or instability (34 meniscal allografts); 11 underwent isolated meniscal transplantation and 20 meniscal transplantation combined with ACL reconstruction. Bony fixation was performed with bone plugs for medial transplants and using a bone bridge for lateral transplants. All patients completed several knee-specific and general measures of health-related quality of life and underwent a comprehensive physical examination. Flexion weightbearing PA radiographs at latest follow-up were compared to those obtained preoperatively. Mean follow-up was 2.9 years (range 2–5.5 years). The Activities of Daily Living and Sports Activities Scale scores were 86±11 and 78±16, respectively, and the average Lysholm score was 84±14. There were no significant differences in these scores based upon which meniscus (medial or lateral) was transplanted, concurrent ACL reconstruction, or the degree of chondrosis at arthroscopy. SF-36 scores indicated that patients were functioning at a level similar to the age- and sex-matched population. Twenty-two patients stated they were greatly improved, 8 were somewhat improved, 1 was without change. All but one patient reported that knee function and level of activity were normal or nearly normal. The average loss of motion compared to the noninvolved side was 3° for extension and 9° for flexion. All but one patient had a negative or 1+ Lachman's test. The remaining patient had a 2+ Lachman's test. Assessment with the KT-1000 arthrometer revealed a side-to-side difference of 2 mm (range −2 mm to 7 mm). Average hop and vertical jump indices were both 85% of the contralateral extremity. No statistically significant joint space narrowing was observed by radiography over time. Meniscal allograft transplantation with and without combined ACL reconstruction in carefully selected patients with complaints of compartmental joint line pain and/or instability appears able to provide relief of symptoms and restore relatively high levels of function, particularly during activities of daily living.
TL;DR: It is demonstrated that the ACL can be reliably reconstructed in patients over the age of 50 years with good symptomatic relief, restoration of function and return to sporting activity.
Abstract: We present medium-term results in 30 prospectively followed patients aged over 50 years at the time of ACL reconstruction (31 procedures); mean follow-up time was 46 months (range 24–95). Mean Lysholm score improved significantly from 63 pre-operatively to 93 at final review Cincinnati score from 49 to 89. In IKDC score 25 knees (81%) were considered normal or nearly normal and 6 abnormal; there were no severely abnormal results. Mean Tegner activity scores improved from pre-operatively from 3.7 to 5.2 at review. Mean side-to-side difference measured by the KT-1000 at maximal manual pressure was 2.7 mm; two knees had. a measured difference greater than 5 mm. The mean torque ratio for isokinetic flexion strength was 102% and for extension strength 94%. Poor results as determined by the three scoring systems were associated mainly with advanced articular degenerative changes (Outerbridge grade 3 or 4) seen at the time of reconstruction. Despite this all patients reported improvement in stability and overall function of the knee. Degenerative change itself was associated with increased time to surgery from injury. This study demonstrates that the ACL can be reliably reconstructed in patients over the age of 50 years with good symptomatic relief, restoration of function and return to sporting activity.
TL;DR: It was showed that successful treatment with eccentric training was not associated with lowered intratendinous glutamate levels, and the mean VAS score decreased from 69 before treatment to 17 after treatment.
Abstract: Microdialysis has shown intratendinous glutamate levels to be significantly higher in Achilles tendons with painful tendinosis than in normal pain-free tendons, and treatment with eccentric training has shown good clinical results with diminished tendon pain during activity. In six patients with chronic painful Achilles tendinosis we performed microdialysis for 2 h, before and after the 12-week eccentric training program. The treatment was successful in all six patients, and the mean VAS score (amount of pain during Achilles tendon loading) decreased from 69 before treatment to 17 after treatment. There was no significant difference between the intratendinous glutamate levels before and after treatment. Our results offer no obvious neurophysiological explanation but showed that successful treatment with eccentric training was not associated with lowered intratendinous glutamate levels.
TL;DR: This technique demonstrated a high reliability, low morbidity, low functional deficit and fast recovery using hamstring grafts, and men had significantly better results then women.
Abstract: This prospective study examined 50 patients who underwent ACL surgery using hamstring tendons with a modification including intra- and extra-articular reconstruction. All patients were athletes competing at a high level in various sports. Full return to sports was allowed at 4 months. IKDC score and KT-2000 were used for assessing clinical outcome at a mean of 6.4 years (5-7 years) Resumption of sport, Tegner activity score, and isokinetic test were also used. The IKDC score showed 92% of normal or nearly normal knees. Of the 50 patients 48 regained full extension, and only two had extension deficit between 0 degrees and 3 degrees. KT evaluation was less than 3 mm in 38 cases (76%), 3-5 mm in 9 (18%), and more than 5 mm in 3 (6%). In 90% of cases the patient resumed sport at the same level. The mean Tegner activity score was 8.1 (5-10). The isokinetic test showed no deficit for hamstring and quadriceps muscles. Removal of staples was necessary in eight cases (16%) due to femoral lateral bursitis. Acute reconstruction had significantly better clinical assessment of abnormal laxity and KT value. Men had significantly better results then women. This technique demonstrated a high reliability, low morbidity, low functional deficit and fast recovery using hamstring grafts.
Atos1
TL;DR: This is the first report of a combination of microfracture and a periostal flap for repair of focal full-thickness cartilage lesions at the shoulder with chondral defects localized at the humeral head by deltoidopectoral approach.
Abstract: Focal full-thickness articular cartilage lesions of the shoulder are less common than those of the lower extremity but are often symptomatic and may progress to degenerative osteoarthritis. This prospective study evaluated our clinical results for cartilage repair in five patients with chondral defects localized at the humeral head using a combination of microfracture and periostal flap, all by deltoidopectoral approach. Mean follow-up was 25.8 months (range 24–31) and consisted of a clinical examination, Constant score examination, radiography, and magnetic resonance imaging; three patients underwent a second-look arthroscopy an average of 8 months following cartilage repair. We found the Constant score significantly improved over the preoperative level, from 43.4% to 81.8%. Pain was reduced significantly to 18.6 points. Radiography and magnetic resonance imaging showed progression of the osteoarthritis in two patients. Second-look arthroscopy revealed a significantly reduced cartilage lesion. This is the first report of a combination of microfracture and a periostal flap for repair of focal full-thickness cartilage lesions at the shoulder. Short-term follow-up clinical results were satisfactory. It is essential to address the underlying pathology. Results must be reconfirmed in a long-term study.
TL;DR: It is suggested that mechanical stretching directly activates intracellular signaling pathways, which in turn induce apoptosis, which affects tendon remodeling.
Abstract: Accelerated rehabilitation after tendon, ligament and bone injuries is widely accepted to avoid adverse effects of immobilization. However, progressive rehabilitation may also lead to an excessive inflammatory soft tissue response and often leads to structural and functional problems such as excessive scarring. The equivalent at the molecular/cellular level is in part the regulation of the sensitive homeostasis between proliferation and apoptosis. However, little attention has been paid to this aspect of tendon pathogenesis. This study investigated the response profile of human tendon fibroblasts in terms of apoptosis and anticipated alteration of Jun N-terminal kinase (JNK) activation to cyclic mechanical stretching. Human tendon fibroblasts of six patients were stretched for 15 or 60 min with 1 Hz and an elongation of 5%. Activation of stress-activated protein kinase (SAPK)/JNK was measured by western blot analysis. Apoptotic cells were determined in the stretched cells and in controls by annexin-V staining and detection by flow cytometry. Additionally DNA laddering was determined by ligation-mediated (LM) polymerase chain reaction (PCR). Application of 15 and 60 min stretch increased activation of SAPK/JNK at a maximum after 60 min. However, JNK activation after the longer stretch period 50% less than after the shorter stretch period (15 min). The apoptosis rate was correspondingly increased after short stretch application but not after longer stretch. This might be caused by an inactivation of the activated JNKs by cell protection mechanisms. The findings suggest that mechanical stretching directly activates intracellular signaling pathways, which in turn induce apoptosis. The longer stretch period resulted in a decreased apoptotic rate due to development of stress tolerance. This might be caused by heat-shock protein mediated suppression of JNK activation. This novel observation is an important issue, as defined mechanical stretching, depending on its duration, modulates apoptosis and thus affects tendon remodeling.
TL;DR: Tibialis anterior allograft use provides an effective ACL reconstruction alternative, particularly for older individuals who want to continue recreational sports and all subjects continued to participate at their pre-injury perceived activity level.
Abstract: The outcomes of 18 patients (11 females, 7 males; age, 40.4+/-11 years) at 2 years after ACL reconstruction with cryopreserved tibialis anterior allografts using a double bundle technique are presented. Most subjects (72%) described themselves as being moderately active before surgery. After providing written informed consent, subjects completed the 2000 IKDC Knee Form, underwent arthrometric knee measurements, and performed one-leg hop and isokinetic quadriceps and hamstring torque tests (60 degrees /s). Ninety-four percent (17/18) of the subjects had normal or near-normal grades for manual knee ligament tests. Knee arthrometry measurements revealed a mean 1.1-mm involved side increase at 134 N (8.9+/-2 mm vs 7.8+/-3 mm) and a 2-mm involved side increase during manual maximum testing (11.3+/-2 mm vs 9.3+/-3 mm). Group means revealed active knee flexion (136+/-8 degrees vs 139+/-6 degrees ) and knee hyper-extension (3+/-2 degrees vs 5+/-2 degrees ), which were slightly reduced at the involved knee. One-leg hop testing revealed a 15% mean deficit at the involved side (0.81+/-0.3 m vs 0.95+/-0.3 m). Isokinetic testing revealed an 11% mean deficit at the involved side (143.4+/-60 Nm vs 161.8+/-54 Nm) for the quadriceps and 7% greater strength at the involved side (105.9+/-35 Nm vs 98.8+/-35 Nm) for the hamstrings. Side-to-side comparisons revealed that many patients displayed less than normal quadriceps femoris torque (72%, 13/18), hamstring torque (28%, 5/18) and hop test (28%, 5/18) performance. Moderate positive correlations existed between involved side quadriceps ( r=0.80) and hamstring ( r=0.83) torque/bodyweight and hop test performance. Scores were 77.6+/-21 (range 28.7-100) and 78.1+/-16 (range 41.7-100) for the 2000 IKDC Subjective Knee Evaluation and Health Assessment forms. Most subjects (83%, 15/18) rated their current function at >or=91% of pre-injury levels and all subjects continued to participate at their pre-injury perceived activity level. At 2 years after ACL reconstruction with tibialis anterior allografts, this subject group displayed satisfactory functional outcomes. Tibialis anterior allograft use provides an effective ACL reconstruction alternative, particularly for older individuals who want to continue recreational sports.
TL;DR: The measured gait alterations cannot be explained solely by often used biomechanical indicators such as laxity and strength, and may be a result of the surgical procedure with subsequent modified motor programming.
Abstract: Gait alterations after ACL reconstruction have been reported in the literature. The current study examined a group of 14 patients who all had an ACL reconstruction with a patellar tendon autograft. Kinetic and kinematic data were obtained from the knee during walking. The flexion-extension deficit (FED) calculated from the angular difference between maximal flexion and maximal extension during the stance phase in the ACL-reconstructed and the normal knee was measured. We investigated whether these alterations in gait are related to quadriceps strength and residual laxity of the knee. It may be that patients modify their gait patterns to protect the knee from excessive anterior translation of the tibia by reducing the amount of extension during stance. On the other hand, persistent quadriceps weakness may also cause changes in gait patterns as the quadriceps is functioning as an important dynamic stabilizer of the knee during stance. Results showed that patients had a significantly higher FED value (4.9±4.0) than a healthy control group in a previous study (1.3±0.9). This is caused mainly by an extension deficit during midstance. External extension moments of the knee (TZMAX were significantly lower in the current patients group than in a healthy control group (TZMAX −0.27±0.19 Nm/kg in patients vs. −0.08±0.06 Nm/kg in controls). There were no significant correlations between quadriceps strength and gait analysis parameters. Furthermore no correlation was found between the amount of laxity of the knee and gait. The relevance of this study lies in the fact that apparently the measured gait alterations cannot be explained solely by often used biomechanical indicators such as laxity and strength. The measured gait alterations may be a result of the surgical procedure with subsequent modified motor programming.
TL;DR: This study compared the mechanical behavior of two fixation procedures: a widely used interference screw (IFS) fixation and a press-fit fixation that is hardware free and provides the basis for future studies involving the time course of healing of these two procedures using the goat model.
Abstract: Hardware used for fixation of ACL autografts in bone tunnels frequently complicates revision surgery, requiring two-stage procedures when a bone–patellar tendon–bone (B-PT-B) autograft is used for ACL reconstruction. Therefore alternative procedures that eliminate hardware have been advocated. This study compared the mechanical behavior of two fixation procedures: a widely used interference screw (IFS) fixation and a press-fit fixation that is hardware free. Twenty hind limbs from skeletally mature Saanen breed goats were used in this study, ten each in IFS and press-fit groups. After ACL reconstruction the specimens were dissected, leaving a femur–ACL graft–tibia complex (FATC) for uniaxial tensile testing. The tests included a series of three cyclic creep tests (C1–C3) for the evaluation of residual elongation followed by a tensile load to failure test to obtain linear stiffness and ultimate load of the FATCs. Four of ten specimens failed during the cyclic creep test for the press-fit group, compared to one for the IFS group. For the remaining specimens residual elongation following three cyclic creep tests (C1–C3) was 1.7±0.5 mm in the press-fit group compared to 1.3±0.6 mm in the IFS group, and there was no statistical significant difference between the two fixations. In the load to failure test there was also no statistical significant difference in linear stiffness between the two fixations. However, the ultimate load for the press-fit group (215±75 N) was significantly lower than that for the IFS group (328±103 N). These results provide the basis for future studies involving the time course of healing of these two procedures using the goat model.
TL;DR: Weight-bearing knee kinematics in patients who received two types of anterior cruciate ligament reconstruction were studied using a fluoroscopy-based three-dimensional measurement technique, and both the normal and the reconstructed knees exhibited posterior condylar translation and internal tibial rotation with knee flexion, consistent with previous reports of normal kinematic.
Abstract: Weight-bearing knee kinematics in patients who received two types of anterior cruciate ligament reconstruction were studied using a fluoroscopy-based three-dimensional measurement technique. Eleven patients with more than 1-year follow-up and good or excellent results participated in this study. Six subjects received anterior cruciate ligament reconstruction using a multiply folded semitendinosus and gracilis tendon graft, and five received combined intra- and extra-articular anterior cruciate ligament reconstruction using the iliotibial tract. The step up/down activity of normal and operated knees was recorded using lateral fluoroscopy. A customized three-dimensional contour model was created from two orthogonal views of each knee and all six degrees of freedom of knee movement were determined using a model matching technique. Both the normal and the reconstructed knees exhibited posterior condylar translation and internal tibial rotation with knee flexion, consistent with previous reports of normal kinematics. There were no statistically significant differences in the axial rotations or lateral or medial condylar anterior/posterior translations between operated and normal knees or between the two groups of operated knees.
TL;DR: Transchondral drilling (TCD) was proposed in cases of intact or almost intact articular cartilage and was initially conducted under arthrotomy and later by arthroscopy, and evaluation was based on clinical examination and radiography.
Abstract: Osteochondritis dissecans is a rare condition which occurs most frequently in the medial condyle of the knee. Its prognosis remains controversial. We report our experience with transchondral drilling (TCD) for osteochondritis dissecans. The rationale for this low-morbidity procedure is to enhance the healing potential of a lesion which failed to heal after conservative treatment. This multicenter retrospective study examined 24 patients (25 medial condyles), including cases both before (juvenile osteochondritis dissecans, JOCD; n=17) and after closure of the physis (adult osteochondritis dissecans, AOCD; n=8). All patients initially underwent a prolonged conservative treatment. The mean duration of symptoms prior to surgery was 22 months in JOCD and 55 months in AOCD patients. TCD was proposed in cases of intact or almost intact articular cartilage and was initially conducted under arthrotomy and later by arthroscopy. Mean follow-up time was 11.8 years in JOCD and 6 years in AOCD, and evaluation was based on clinical examination and radiography. Excellent clinical results were only observed in the JOCD group (12/17). In the AOCD group 4 patients had a good result and the other 4 a poor result. Radiological findings matched with clinical results. Except for age, factors of poor prognosis were: fissure of the articular cartilage and anterior extension of the lesion. We do not recommend TCD for AOCD. In JOCD, failure after 12 months of conservative treatment should indicate TCD in the cases where the cartilage remains continuous. At this stage there is no indication for more aggressive procedures.
TL;DR: It is demonstrated that periosteum enhances the healing process when a tendon graft is transplanted into a bone tunnel and leads to better biomechanical fixation in a shorter period of time.
Abstract: We examined whether periosteum enhances the healing process of a tendon in a bone tunnel and leads to better biomechanical fixation in a shorter period of time The effect of the periosteum-wrapped tendon on tendon-to-bone healing was analyzed in 20 New Zealand white rabbits The animals were divided into two groups, a periosteum-wrapped group and a control group The two legs were operated on in the same manner The long digital extensor tendon was harvested and transplanted into the proximal tibial tunnel One limb was transplanted with the tendon wrapped with periosteum, while the other was without periosteum The healed tendon-bone attachment was evaluated after 3 and 6 weeks by histological examination and biomechanical testing At all time points histological examination demonstrated more extensive bone formation around the tendon with closer apposition of new bone to the tendon in the periosteum-wrapped limb than in the control limb Biomechanical testing demonstrated higher tendon pullout strength in the periosteum-wrapped limb at all time points, with statistically significant differences between the periosteum-wrapped limb and the control limb after 3 and 6 weeks Histological and biomechanical data suggest superior healing at the periosteum-wrapped side These findings demonstrate that periosteum enhances the healing process when a tendon graft is transplanted into a bone tunnel
TL;DR: The purpose of this technical report is to review the difficulties with the femoral pin and its insertion site from a historical perspective, and to identify the load force required from biological tissue to permanently deform the pin.
Abstract: The complexity of human tibiofemoral joint motion is now better understood with the advancement of new methodologies to measure tibiofemoral kinematics in vivo. Marker clusters anchored to stainless steel bone pins inserted directly into the femur and tibia provide the most sensitive and accurate means for directly measuring skeletal tibiofemoral joint motion. Despite its invasiveness, this technique has been successful, although complications have been reported with the femoral pin and its insertion site. The purpose of this technical report is twofold: to review the difficulties with the femoral pin and its insertion site from a historical perspective, and to identify the load force required from biological tissue to permanently deform the pin. In addition, proposals in the advancement of this method are discussed in the context of reducing impingement with the femoral pin and the Iliotibial band. Because stainless steel exhibits plastic behaviour with no sharp yield point, Apex self-drilling/self-tapping bone pins underwent incremental loading on an Instron materials testing machine. Loads were transmitted perpendicular to the pin with the threads partially exposed and fully secured in vice. Since the accuracy of our combined stereophotogrammetry and Optoelectric motion analysis was less than 0.4 mm, it was decided that plastic deformation occurred after deflections of 0.4 mm. With exposed threads, deflections larger than 0.4 mm were observed at 150 N and 100 N when loads were applied at 15 mm and 20 mm from the vice (representative of where the tissue came in contact with the pin). Loads greater than 200 N produced deflections less than 0.2 mm when threads were fully inserted. The 90 Hz resonant frequency for the marker cluster-bone pin complex is beyond the spectrum of human movement and can be lowpass filtered. To reduce impingement and pin bending, one solution may be to implant pins with a shorter threaded section. By completely penetrating the bone, only the smooth surface of the pin is exposed which is more resistant to bending. Otherwise pins with larger diameters and longer longitudinal incisions about the femoral insertion site are an alternative. Lengthening the longitudinal incisions about the insertion site, and correctly aligning and inserting the femoral pin between the Iliotibial band and quadriceps tendon may diminish impingement. Performing dynamic open chain flexion and extension movements while on the operating table may aid in aligning the pin at the incision site. This may stretch the IT band and quadriceps tendon and may guide the femoral pin into a more optimal position prior to it being inserted into the cortex of the bone.
TL;DR: Endoscopic calcaneoplasty is an effective minimally invasive treatment option for patients with retrocalcaneal bursitis and three patients showed clinical improvement and would undergo for the procedure again.
Abstract: We present our technique and preliminary results with endoscopic calcaneoplasty in ten patients resistant for conservative therapy for more than 6 months. All patients showed a Haglund spur on radiography; none had a cavovarus deformity. Follow-up ranged from 2 to 12 months (mean 5.2). All patients showed clinical improvement and would undergo for the procedure again. Three showed a good and seven an excellent result in Ogilvie-Harris score. Postoperative radiographic follow-up showed sufficient bone removal in all cases. Surgery lasted on average 46 min (range 28–84). There were no intra- or postoperative complications. Endoscopic calcaneoplasty is an effective minimally invasive treatment option for patients with retrocalcaneal bursitis.
TL;DR: It seems that further in vivo biomechanical investigation is required to understand the mechanisms of pathological knee joint motions and develop rehabilitation programs, which would delay the progress of developing long-term degenerative diseases.
Abstract: The literature cites numerous studies involving the analysis of movement patterns in anterior cruciate ligament deficient (ACLD) patients. Although several in vivo biomechanical studies have shown that ACLD patients develop protective mechanisms against degenerative diseases, it seems that these adaptations fail to protect the knee from future pathology. Some authors state that ACLD patients adapt to the injury by avoiding quadriceps contraction during gait when the knee is near full extension. However, others have found increased hamstrings and decreased gastrocnemius activity, which normally contribute to the stability of the knee. It seems that further in vivo biomechanical investigation is required to understand the mechanisms of pathological knee joint motions and develop rehabilitation programs, which would delay the progress of developing long-term degenerative diseases.
TL;DR: This study compared the results of subtle CT-guided correction of the tuberosity for objective unstable patella with the results for lateral tracking patellA (potential instability) as described by Dejour (n=16).
Abstract: In patients with either lateral tracking patella or unstable patella the pathological lateral position of the tuberosity can be corrected by a medial transfer. This study compared the results of subtle CT-guided correction of the tuberosity for objective unstable patella (n=27) with the results for lateral tracking patella (potential instability) as described by Dejour (n=16). Follow-up was 37 months. CT revealed a pathological lateralization of the tibial tuberosity–trochlear groove greater than 15 mm in 41 knees. These patients underwent medialization of the tibial tuberosity up to 10–12 mm lateral from the trochlear groove, and 28 patients underwent a distalization to normalize the Caton index to 1.0–1.2. Results were evaluated using Cox' method. Patients with objective patellar instability were rated as 11% excellent, 52% good, 33% fair, and 4% poor. All patients became stable except one who had a 6° valgus alignment. Although 96% had improved stability, 33% of the patients still had pain. The patients with lateral tracking patella (potential instability) were rated as 37.5% excellent, 44% good, and 19% fair. The lower proportion of pain relief in patients with unstable patella is likely the result of the cartilage damage experienced by these patients following multiple dislocations. Thus the patient with lateral tracking patella without patella dislocations must be differentiated from the one with unstable patella. Their prognosis in pain relief is better.
TL;DR: It is believed that normal alignment and orientation of the knee could be precisely established with a circular external fixator, and that some disadvantages such as patella infera, failed correction, and loss of bone in proximal tibia as observed after classic high tibial osteotomy can be avoided.
Abstract: We evaluated the midterm results of high tibial osteotomy in patients with medial compartment arthritis. This study included 53 patients treated with high tibial osteotomy accompanied by either internal fixation (group A, n=26) or Ilizarov-type external fixator (group B, n=27). Clinical assessment of patients was performed using Hospital of Special Surgery scoring. Radiography was based on orientation angles of the knee (medial proximal tibial angle, lateral distal femoral angle, posterior proximal tibial angle) and mechanic axis alignment test. We used the Insall-Salvati index to determine patellar height. The mean follow-up in group A was 77 months (range 63-118) and that in group B 72 months (range 61-113). The patients of group B demonstrated better results in terms of Hospital of Special Surgery score, alignment of lower extremity, and preventing of progression of arthritis. We believe that normal alignment and orientation of the knee could be precisely established with a circular external fixator, and that some disadvantages such as patella infera, failed correction, and loss of bone in proximal tibia as observed after classic high tibial osteotomy can be avoided. Furthermore, progression of arthritis can be prevented if the mechanical axis passes through the lateral compartment of the knee.
TL;DR: It is suggested that treatment by early arthroscopic stabilization and rehabilitation after primary traumatic anterior dislocation of the shoulder does not enhance proprioception more than standard immobilization and rehabilitation.
Abstract: This randomized clinical trial compared the effect of early arthroscopic stabilization and rehabilitation vs. standard immobilization and rehabilitation on measures of shoulder proprioception. Subjects with primary traumatic anterior dislocations of the shoulder were randomized into one of two groups: standard therapy of immobilization and rehabilitation (n=13) or arthroscopic stabilization followed by rehabilitation (n=11). At a minimum of 3 months posttreatment (mean 19 months) proprioception was evaluated using threshold to detection of passive motion (TTDPM) and reproduction of passive positioning (RPP) at 30° and 60° external rotation. There were no statistically significant differences between surgical and standard treatment groups in either TTDPM or RPP at start positions of 30° and 60°. These findings suggest that treatment by early arthroscopic stabilization and rehabilitation after primary traumatic anterior dislocation of the shoulder does not enhance proprioception more than standard immobilization and rehabilitation.