Showing papers in "Knee Surgery, Sports Traumatology, Arthroscopy in 2009"
TL;DR: The identification of those athletes at increased risk may be a salient first step before designing and implementing specific pre-season and in-season training programs aimed to modify the identified risk factors and to decrease ACL injury rates.
Abstract: Soccer is the most commonly played sport in the world, with an estimated 265 million active soccer players by 2006. Inherent to this sport is the higher risk of injury to the anterior cruciate ligament (ACL) relative to other sports. ACL injury causes the most time lost from competition in soccer which has influenced a strong research focus to determine the risk factors for injury. This research emphasis has afforded a rapid influx of literature defining potential modifiable and non-modifiable risk factors that increase the risk of injury. The purpose of the current review is to sequence the most recent literature that reports potential mechanisms and risk factors for non-contact ACL injury in soccer players. Most ACL tears in soccer players are non-contact in nature. Common playing situations precluding a non-contact ACL injury include: change of direction or cutting maneuvers combined with deceleration, landing from a jump in or near full extension, and pivoting with knee near full extension and a planted foot. The most common non-contact ACL injury mechanism include a deceleration task with high knee internal extension torque (with or without perturbation) combined with dynamic valgus rotation with the body weight shifted over the injured leg and the plantar surface of the foot fixed flat on the playing surface. Potential extrinsic non-contact ACL injury risk factors include: dry weather and surface, and artificial surface instead of natural grass. Commonly purported intrinsic risk factors include: generalized and specific knee joint laxity, small and narrow intercondylar notch width (ratio of notch width to the diameter and cross sectional area of the ACL), pre-ovulatory phase of menstrual cycle in females not using oral contraceptives, decreased relative (to quadriceps) hamstring strength and recruitment, muscular fatigue by altering neuromuscular control, decreased “core” strength and proprioception, low trunk, hip, and knee flexion angles, and high dorsiflexion of the ankle when performing sport tasks, lateral trunk displacement and hip adduction combined with increased knee abduction moments (dynamic knee valgus), and increased hip internal rotation and tibial external rotation with or without foot pronation. The identified mechanisms and risk factors for non-contact ACL injuries have been mainly studied in female soccer players; thus, further research in male players is warranted. Non-contact ACL injuries in soccer players likely has a multi-factorial etiology. The identification of those athletes at increased risk may be a salient first step before designing and implementing specific pre-season and in-season training programs aimed to modify the identified risk factors and to decrease ACL injury rates. Current evidence indicates that this crucial step to prevent ACL injury is the only option to effectively prevent the sequelae of osteoarthritis associated with this traumatic injury.
782 citations
TL;DR: The first data with 2 year follow-up from the Danish ACL registry is presented, showing specific differences between primary ACL, revision ACL, and multiligament reconstructions.
Abstract: Anterior cruciate ligament (ACL) reconstruction is presently evolving rapidly In order to monitor the developments in surgical methods and clinical outcome, a national clinical database for knee ligament reconstructions was established in 2005 in Denmark This study presents the first data with 2 year follow-up from the Danish ACL registry All orthopaedic departments performing ACL reconstructions in Denmark, inlcuding private clinics, report to the registry The database includes both surgery- and patient-related data The surgeon reports anamnestic, objective knee laxity and operative data including graft and implant choices At 1 year control, complications, reoperations, and objective knee laxity are recorded The patient registers the Knee injury and Osteoarthritis Outcome Score (KOOS) and Tegner function score preoperatively and at 1, 5 and 10 years follow-up During the first 30 months, 5,872 knee-ligament reconstructions were registered A total of 4,972 were primary ACL reconstructions, 443 were ACL revisions and 457 multiligament reconstructions A total of 85% of all knee ligament reconstruction were reported to the database A total of 71% of primary ACL reconstruction used hamstring tendon grafts and 21% used patella tendon graft Meniscus injuries were treated in 35% of all patients A total of 17% had significant cartilage lesions At 2 years follow-up 3% of primary recontructions were revised Follow-up KOOS demonstrated specific differences between primary ACL, revision ACL, and multiligament reconstructions Sports/recreation score were 40, 32, 28 and quality of life score were 40, 32, 33 for the respective groups This study presents the first follow-up data from a national ACL registry These data will become new international reference materials for outcome measures before and after ACL surgery The database will enable future monitoring of ACL reconstruction techniques and outcome
318 citations
TL;DR: Lower extremity plyometrics, dynamic balance and strength, stretching, body awareness and decision-making, and targeted core and trunk control appear to be successful training components to reduce non-contact ACL injury risk factors and prevent non- contact ACL injuries in soccer players, especially in female athletes.
Abstract: Soccer is the most commonly played sport in the world, with an estimated 265 million active soccer players participating in the game as on 2006. Inherent to this sport is the higher risk of injury to the anterior cruciate ligament (ACL) relative to other sports. ACL injury causes a significant loss of time from competition in soccer, which has served as the strong impetus to conduct research that focuses to determine the risk factors for injury, and more importantly, to identify and teach techniques to reduce this injury in the sport. This research emphasis has afforded a rapid influx of literature aimed to report the effects of neuromuscular training on the risk factors and the incidence of non-contact ACL injury in high-risk soccer populations. The purpose of the current review is to sequence the most recent literature relating the effects of prevention programs that were developed to alter risk factors associated with non-contact ACL injuries and to reduce the rate of non-contact ACL injuries in soccer players. To date there is no standardized intervention program established for soccer to prevent non-contact ACL injuries. Multi-component programs show better results than single-component preventive programs to reduce the risk and incidence of non-contact ACL injuries in soccer players. Lower extremity plyometrics, dynamic balance and strength, stretching, body awareness and decision-making, and targeted core and trunk control appear to be successful training components to reduce non-contact ACL injury risk factors (decrease landing forces, decrease varus/valgus moments, and increase effective muscle activation) and prevent non-contact ACL injuries in soccer players, especially in female athletes. Pre-season injury prevention combined with an in-season maintenance program may be advocated to prevent injury. Compliance may in fact be the limiting factor to the overall success of ACL injury interventions targeted to soccer players regardless of gender. Thus, interventional research must also consider techniques to improve compliance especially at the elite levels which will likely influence trickle down effects to sub-elite levels. Future research is also needed for male soccer athletes to help determine the most effective intervention to reduce the non-contact ACL injury risk factors and to prevent non-contact ACL injuries.
316 citations
TL;DR: A systematic review of the morphology of the ACL femoral origin and tibial insertion as reported in the literature to understand the individual variations in size and shape.
Abstract: Transtibial single bundle anterior cruciate ligament (ACL) reconstruction has been the gold standard for several years. This technique often fails to restore native ACL femoral origin and tibial insertion anatomy of the ACL. Recently, there is a strong trend towards a more anatomical approach in single and double bundle ACL reconstruction. Using the anatomic double bundle structure of the ACL as a principle, the entirety of both tibial insertion and femoral origin of both bundles, the posterolateral and anteromedial, may be restored. Reflected by recent publications over the past two years, there is an increasing interest in the anatomy of the ACL. In the current study, a PubMed literature search was performed looking for measurements of the ACL femoral origin and tibial insertion. These studies show a large variability in the size and the anatomy of the femoral origin and tibial ACL insertion using different methods and specimens. The diversity of reported measurements makes clinical application of these data difficult at best. Thus, it is of paramount importance to understand the individual variations in size and shape of the ACL femoral origin and tibial ACL insertion. This study is a systematic review of the morphology of the ACL femoral origin and tibial insertion as reported in the literature.
231 citations
TL;DR: None of the short- or mid-term clinical and histological results of these tissue-engineering techniques with scaffolds were reported to be better than conventional ACI, however, some studies suggest that these methods may reduce surgical time, morbidity, and risks of periosteal hypertrophy and post-operative adhesions.
Abstract: The purpose of this paper is to review the basic science and clinical literature on scaffolds clinically available for the treatment of articular cartilage injuries. The use of tissue-engineered grafts based on scaffolds seems to be as effective as conventional ACI clinically. However, there is limited evidence that scaffold techniques result in homogeneous distribution of cells. Similarly, few studies exist on the maintenance of the chondrocyte phenotype in scaffolds. Both of which would be potential advantages over the first generation ACI. The mean clinical score in all of the clinical literature on scaffold techniques significantly improved compared with preoperative values. More than 80% of patients had an excellent or good outcome. None of the short- or mid-term clinical and histological results of these tissue-engineering techniques with scaffolds were reported to be better than conventional ACI. However, some studies suggest that these methods may reduce surgical time, morbidity, and risks of periosteal hypertrophy and post-operative adhesions. Based on the available literature, we were not able to rank the scaffolds available for clinical use. Firm recommendations on which cartilage repair procedure is to be preferred is currently not known on the basis of these studies. Randomized clinical trials and longer follow-up periods are needed for more widespread information regarding the clinical effectiveness of scaffold-based, tissue-engineered cartilage repair.
205 citations
TL;DR: The use of growth factors from platelets seems to improve tissue healing in anterior cruciate ligament repair, and the signal intensity of the fibrous interzone (FIZ) in the femoral tunnels was evaluated.
Abstract: Recently, the use of hamstring tendons in anterior cruciate ligament repair has been increasing. However, tendon-to-bone healing occurs slowly, which can be a problem to an early return to sport activities. The use of growth factors from platelets seems to improve tissue healing. We enrolled 40 patients in a prospective study that were submitted to an anatomic reconstruction of the anterior cruciate ligament. Patients were sequentially enrolled into four groups: group A without platelet-rich plasma (PRP); group B with PRP in femoral tunnels at the end of surgery; group C with PRP in femoral tunnels at the end of surgery and intra-articular at 2- and 4 weeks after surgery; group D with PRP activated with thrombin in the femoral tunnels. All patients underwent magnetic resonance imaging of the knee 3 months after surgery to evaluate the signal intensity of the fibrous interzone (FIZ) in the femoral tunnels. We did not find any difference among the groups when comparing the signal intensity of the FIZ on magnetic resonance imaging.
197 citations
TL;DR: Drilling the femoral tunnel through the anteromedial arthroscopy portal results in a radiographic femoral bone tunnel position which is suggested to allow stabilization of both anterior tibial translation and rotational instability when using a single bundle reconstruction technique.
Abstract: Correct placement of the tibial and femoral bone tunnel is prerequisite to a successful anterior cruciate ligament (ACL) reconstruction. This study compares the resulting radiographic femoral bone tunnel position of two commonly used techniques for arthroscopically assisted drilling of the femoral bone tunnel: the transtibial approach or drilling through the anteromedial arthroscopy portal. The resulting bone tunnel position was assessed in postoperative knee radiographs of 70 patients after ACL reconstruction. Three independent observers identified the femoral bone tunnel and determined its position in the lateral and A–P view. Differences in femoral tunnel position between transtibial and anteromedial drilling were evaluated. In the sagittal plane, significantly more femoral bone tunnels were positioned close to the reference value using an anteromedial drilling technique (86%) when compared to transtibial drilling (57%). Drilling through the transtibial tunnel resulted in a significantly more anterior position of the femoral tunnel. In the frontal plane, femoral bone tunnels which were placed through the anteromedial arthroscopy portal displayed a significantly greater angulation towards the lateral condylar cortex (50.92°) when compared to transtibial drilling (58.82°). In conclusion, drilling the femoral tunnel through the anteromedial arthroscopy portal results in a radiographic femoral bone tunnel position which is suggested to allow stabilization of both anterior tibial translation and rotational instability when using a single bundle reconstruction technique. Further studies may evaluate if there are any clinical advantages using the anteromedial portal technique.
195 citations
TL;DR: Early ACL reconstruction is therefore a recommended option in skeletally immature patient and Objective IKDC and radiological results were similar in both groups.
Abstract: The purpose of this study was to compare two different strategies of management for ACL rupture in skeletally immature patient. In group 1, patients were treated in a children hospital by ACL reconstruction with open physis. In group 2, patients were treated in an adult hospital by delayed reconstruction at skeletal maturity assessed radiologically. Fifty-six consecutive patients were included in this retrospective study. Mean time from injury to surgery in group 1 and 2 was, respectively, 13.5 and 30 months. Patients from group 2 exhibited a higher rate of medial meniscal tears (41%) compare to group 1 (16%) and higher rate of meniscectomy. Both groups had the same rate of lateral meniscal tears. A temporary tibial valgus deformity was reported which was subsequently spontaneously resolved. No definitive growth disturbance was noticed. At 27 months mean follow-up, a best subjective IKDC score was found in group 1. Objective IKDC and radiological results were similar in both groups. Early ACL reconstruction is therefore a recommended option.
193 citations
TL;DR: The purpose of this paper is to review the literature on MSC-based cell therapy for articular cartilage repair to determine if it can be an alternative treatment for cartilage injury and require randomized clinical trials to evaluate the effectiveness.
Abstract: Articular cartilage injury remains one of the major concerns in orthopaedic surgery. Mesenchymal stem cell (MSC) transplantation has been introduced to avoid some of the side effects and complications of current techniques. The purpose of this paper is to review the literature on MSC-based cell therapy for articular cartilage repair to determine if it can be an alternative treatment for cartilage injury. MSCs retain both high proliferative potential and multipotentiality, including chondrogenic differentiation potential, and a number of successful results in transplantation of MSCs into cartilage defects have been reported in animal studies. However, the use of MSCs for cartilage repair is still at the stage of preclinical and phase I studies, and no comparative clinical studies have been reported. Therefore, it is difficult to make conclusions in human studies. This requires randomized clinical trials to evaluate the effectiveness of MSC-based cell therapy for cartilage repair.
179 citations
TL;DR: Knee function at a minimum of 2 years after surgery disclosed a Lysholm score of a median of 83, a Tegner activity score of 5, and above 83% on all single leg hop tests compared to the uninjured side, lower in the patients with a knee dislocation caused by high-energy trauma compared to low energy trauma.
Abstract: Dislocation of the knee is a relatively rare injury with modern arthroscopic techniques, operative reconstruction has become the standard of care. The primary aim of this study was to prospectively follow a large, consecutive series of patients with knee dislocation to document associated injuries, surgical treatment, knee function, and knee osteoarthritis (OA) at a minimum of 2 years follow-up. Hundred and twenty-two consecutive patients with a traumatic knee dislocation (Schenck II-IV) were treated at the Oslo University Hospital, Ulleval, between May 1996 and December 2004. Follow-up evaluation of 85 patients consisted of evaluation of knee joint laxity using the KT1000, the Lachman test, the pivot shift test, the reversed pivot shift, the posterior drawer test, the dial test, and the varus-valgus tests compared to the uninjured knee. Knee function was evaluated using the Lysholm score, the Tegner activity level score, the IKDC2000 score, and four single leg hop tests. Radiographic evaluation was performed using the Kellgren & Lawrence classification grade 0-4. Knee function at a minimum of 2 years after surgery disclosed a Lysholm score of a median of 83, a Tegner activity score of 5, and above 83% on all single leg hop tests compared to the uninjured side. Knee function was lower in the patients with a knee dislocation caused by high-energy trauma compared to low energy trauma. Eighty-seven percent had Kellgren & Lawrence grade 2 or higher for the injured knee compared to 35% for the uninjured knee.
160 citations
TL;DR: In this paper, the authors examined the influence of clinical, radiological and prosthetic design factors upon flexion following knee replacement and found a moderate correlation between 12-month range of movement and posterior tibial slope.
Abstract: We have attempted to quantify the influence of clinical, radiological and prosthetic design factors upon flexion following knee replacement. Our study examined the outcome following 101 knee replacements performed in two prospective randomized trials using similar cruciate retaining implants. Multivariate analyses, after adjusting for age, sex, diagnosis and the type of prosthesis revealed that the only significant correlates for range of movement at 12 months were the difference in posterior condylar offset ratio (p < 0.001), tibial slope (p < 0.001) and preoperative range of movement (p = 0.025). We found a moderate correlation between 12-month range of movement and posterior tibial slope (R = 0.58) and the difference of post femoral condylar offset (i.e, post-operative minus preoperative posterior condylar offset, R = 0.65). Posterior condylar offset had the greatest impact upon final range of movement highlighting this as an important consideration for the operating surgeon at pre-operative templating when choosing both the design and size of the femoral component.
TL;DR: A detailed anatomical analysis of the medial patellofemoral ligament, especially its femoral attachment, its relationships with the vastus medialis obliquus and the medial collateral ligament is performed, with the objective of improving its surgical reconstruction.
Abstract: The purpose of the present study, based on 23 cadaveric knees, was to perform a detailed anatomical analysis of the medial patellofemoral ligament (MPFL), especially its femoral attachment, its relationships with the vastus medialis obliquus (VMO) and the medial collateral ligament, with the objective of improving its surgical reconstruction. The femoral insertion of the MPFL was defined using an orthonormal frame centered on the middle of the femoral MPFL insertion. The whole measurements were taken using a millimetric compass with a precision of +/-1 mm. The MPFL was always observed, its length was 57.7 +/- 5.8 mm, the junction between the VMO and the MPFL always present measured 25.7 +/- 6.0 mm. When it comes to MPFL reconstruction, the key point is its positioning in the femoral insertion because it is this insertion that is going to restore isometry. By using the orthonormal frame it has to be positioned 10 mm behind the medial epicondyle and 10 mm distal to the adductor tubercle.
TL;DR: Patients with patellofemoral instability patients, most would benefit from a deepening trochleaplasty as the surgical procedure of choice to correct dysplasia, and a more objective assessment of the trochlear pathology is possible.
Abstract: Different surgical techniques have been described to correct trochlear dysplasia, without clear descriptions of the various types of trochlear dysplasia. In describing trochlear dysplasia, there exist no clear criteria to distinguish between decreased trochlear depth (heightened trochlea floor) and flattened lateral and/or medial condylar height. The current study aims to build a database of axial MRI measurements of normal and abnormal trochlear shape to create a foundation for the selection of the necessary surgical correction to more normal trochlear anatomy. We prospectively examined 152 subjects: 30 patients with patellar instability due to trochlea dysplasia and 122 subjects without any symptoms or objective findings related to the patellofemoral joint. MRI was performed in both groups. The height of the medial and lateral condyle, and the center of the trochlea was measured on axial MR images. The height of these different locations was compared to the total width of the femoral condyle and expressed in percentages. The statistical analysis was conducted with the Student’s t test at SPSS software. For intraobserver reliability 20 randomly taken MRI were evaluated twice. The intraobserver reliability was determined by calculating the kappa values investigated parameter. In normal subjects, the height of the lateral condyle was 81% of the width of the femoral condyle (100 units),the trochlear central height was 73%, the medial condylar height was 76%. In patients with patellar instability, the lateral condylar height was 82% and showed no significant difference compared to the normal group (P = 0.082). The trochlear central (77%) and medial condylar height (79%) were significantly different (P < 0.001) compared to the normal subjects. The location of pathology in patients with patellar instability was decreased lateral condylar height in five cases (16.6%) and decreased central/medial height in 25 cases (83.4%). A height of the lateral condyle <77% was documented to be pathologic. There was also a significant difference (P < 0.001) between males and females comparing the different heights of the trochlea to the total width of the femoral condyle. The resultant percentages of all three height measurements, the lateral, central, and medial heights, were greater in males than in females. The intraobserver reliability was perfect for all investigated parameters. In conclusion, (1) the presented measurement scheme on axial MRI is a reliable method to calculate the height of the trochlea in different locations, (2) a more objective assessment of the trochlear pathology is possible, (3) in five of six cases the pathology is located in the center and/or medial trochlea, and (4) in our series of patellofemoral instability patients, most would benefit from a deepening trochleaplasty as the surgical procedure of choice to correct dysplasia.
TL;DR: This study evaluated the performance outcomes of professional basketball players in the National Basketball Association (NBA) who underwent microfracture and found that on return to competition player performance and minutes per game are diminished.
Abstract: Surgical treatment for chondral defects of the knee in competitive running and jumping athletes remains controversial. This study evaluated the performance outcomes of professional basketball players in the National Basketball Association (NBA) who underwent microfracture. Data from 24 professional basketball players from 1997 to 2006 was obtained and analyzed. NBA player efficiency ratings (PER) were calculated for two seasons before and after injury. A control group of 24 players was used for comparison. Study group and control group demographics including age, NBA experience, and minutes per game demonstrated no statistical difference. Mean time to return to an NBA game was 30.0 weeks from the time of surgery. The first season after returning to competition PER and minutes per game decreased by 3.5 (P 0.05) and 3.0 min (P < 0.26), respectively. A multivariant comparison versus controls demonstrated that power rating during the 2 years after surgery decreased by 3.1 (P < 0.01); while minutes per game decreased by 5.2 (P < 0.001). Twenty-one percent (n = 5 of 24) of the players treated with microfracture did not return to competition in an NBA game. On return to competition player performance and minutes per game are diminished.
TL;DR: The lower hamstring muscle power, and the lower hamstring to quadriceps ratio in the HT graft group than in the PT graft group 3 years after ACL reconstruction, reflect imbalance of knee muscles after reconstruction with HT graft that may have a negative effect on dynamic knee-joint stabilization.
Abstract: Hamstring muscles play a major role in knee-joint stabilization after anterior cruciate ligament (ACL) injury. Weakness of the knee extensors after ACL reconstruction with patellar tendon (PT) graft, and in the knee flexors after reconstruction with hamstring tendons (HT) graft has been observed up to 2 years post surgery, but not later. In these studies, isokinetic muscle torque was used. However, muscle power has been suggested to be a more sensitive and sport-specific measures of strength. The aim was to study quadriceps and hamstring muscle power in patients with ACL injury treated with surgical reconstruction with PT or HT grafts at a mean of 3 years after surgery. Twenty subjects with PT and 16 subjects with HT grafts (mean age at follow up 30 years, range 20-39, 25% women), who were all included in a prospective study and followed the same goal-based rehabilitation protocol for at least 4 months, were assessed with reliable, valid, and responsive tests of quadriceps and hamstring muscle power at 3 years (SD 0.9, range 2-5) after surgery. The mean difference between legs (injured minus uninjured), the hamstring to quadriceps (H:Q, hamstring divided by quadriceps) ratio, and the limb symmetry index (LSI, injured leg divided by uninjured and multiplied by 100) value, were used for comparisons between the groups (analysis of variance). The mean difference between the injured and uninjured legs was greater in the HT than in the PT group for knee flexion power (-21.3 vs. 7.7 W, p = 0.001). Patients with HT graft had lower H:Q ratio in the injured leg than the patients with PT graft (0.63 vs. 0.77, p = 0.012). They also had lower LSI for knee flexion power than those in the PT group (88 vs. 106%, p < 0.001). No differences were found between the groups for knee extension power. The lower hamstring muscle power, and the lower hamstring to quadriceps ratio in the HT graft group than in the PT graft group 3 years (range 2-5) after ACL reconstruction, reflect imbalance of knee muscles after reconstruction with HT graft that may have a negative effect on dynamic knee-joint stabilization.
TL;DR: The study confirmed the hypothesis that most of the spinal abnormalities in athletes seem to occur during the growth spurt, since the majority of the abnormalities demonstrated at follow-up MRI after the sports career were present already at baseline.
Abstract: A total 71 male athletes (weight lifters, wrestlers, orienteers, and ice-hockey players) and 21 non-athletes were randomly selected, for a baseline MRI study After 15 years all the participants at baseline were invited to take part in a follow-up examination, including a questionnaire on back pain and a follow-up MRI examination Thirty-two athletes and all non-athletes had disc height reduction at one or several disc levels Disc degeneration was found in more than 90% of the athletes and deterioration had occurred in 88% of the athletes, with the highest frequency in weight lifters and ice-hockey players 78% of the athletes and 38% of the non-athletes reported previous or present history of back pain at baseline and 71 and 75%, respectively at follow-up There was no statistically significant correlation between back pain and MRI changes In conclusion, athletes in sports with severe or moderate demands on the back run a high risk of developing disc degeneration and other abnormalities of the spine on MRI and they report high frequency of back pain The study confirmed our hypothesis, ie that most of the spinal abnormalities in athletes seem to occur during the growth spurt, since the majority of the abnormalities demonstrated at follow-up MRI after the sports career were present already at baseline The abnormalities found at young age deteriorated to a varying degree during the 15-year follow-up, probably due to a combination of continued high load sporting activities and normal ageing Preventive measures should be considered to avoid the development of these injuries in young athletes
TL;DR: There were no significant differences in DVT frequency between the two treatment groups and the incidence of asymptomatic and symptomatic deep venous thrombosis is high after Achilles tendon rupture and there is a need to define the possible benefit ofThromboprophylaxis.
Abstract: Deep venous thrombosis (DVT) is common after lower limb injury, but the effect of prophylactic treatment has not been documented in large randomised trials or meta-analyses. As a result, evidence-based recommendations have not been established. The purpose of this study was to evaluate the incidence of venous thromboembolism in patients with Achilles tendon rupture. A total of 100 consecutive patients with an acute Achilles tendon rupture were included in a prospective study and randomised to either surgical or non-surgical treatment. At 8 weeks after the initiation of treatment, 95/100 patients were screened for DVT using colour duplex sonography (CDS) with blinded interpretation by two experienced examiners and adjudication in cases of disagreement by a third person. A total of 95 patients (79 male and 16 female) with a median (range) age of 41 (24-63) years were screened for CDS at 8 weeks. Of the 95 patients, 32 had a CDS-verified thrombosis, 5 proximal and 27 distal, whereas 3 had non-fatal pulmonary embolism. Surgical treatment was performed in 49 patients, non-surgical in 46. There were no significant differences in DVT frequency between the two treatment groups. The incidence of asymptomatic and symptomatic deep venous thrombosis is high after Achilles tendon rupture and there is a need to define the possible benefit of thromboprophylaxis.
TL;DR: Patients undergoing ACL reconstruction with BPTB non-irradiated allograft or autograft had similar clinical outcomes and gamma irradiation as a secondary sterilizing method is a reasonable alternative, according to the overall IKDC, functional, subjective evaluations and activity level testing.
Abstract: The effect of using gamma irradiation to sterilize bone-patellar tendon-bone (BPTB) allograft on the clinical outcomes of anterior cruciate ligament (ACL) reconstruction with irradiated allograft remains controversial. Our study was aimed to analyze the clinical outcomes of arthroscopic ACL reconstruction with irradiated BPTB allograft compared with non-irradiated allograft and autograft. All BPTB allografts were obtained from a single tissue bank and the irradiated allografts were sterilized with 2.5 Mrad of irradiation prior to distribution. A total of 102 patients undergoing arthroscopic ACL reconstruction were prospectively randomized consecutively into three groups. The same surgical technique was used in all operations done by the same senior surgeon. Before surgery and at the average of 31 months follow-up (range 24-47 months) patients were evaluated by the same observer according to objective and subjective clinical evaluations. Of these patients, 99 (autograft 33, non-irradiated allograft 34, irradiated allograft 32) were available for full evaluation. When compared the irradiated allograft group to non-irradiated allograft group or autograft group at 31 months follow-up by the Lachman test, ADT, pivot shift test and KT-2000 arthrometer testing, statistically significant differences were found. Most importantly, 87.8% of patients in the Auto group, 85.3% in the Non-Ir-Auto group and just only 31.3% in the Ir-Allo group had a side-to-side difference of less than 3 mm according to KT-2000. The failure rate of the ACL reconstruction with irradiated allograft (34.4%) was higher than that with autograft (6.1%) and non-irradiated allograft (8.8%). The anterior and rotational stability decreased significantly in the irradiated allograft group. According to the overall IKDC, functional, subjective evaluations and activity level testing, no statistically significant differences were found between the three groups. However, there was a trend that the functional and activity level decreased and the patients felt uncomfortable more often in the irradiated allograft group. The statistical analysis showed no significant difference between the non-irradiated allograft group and the autograft group according to the aforementioned evaluations, except that patients in the allograft group had a shorter operation time and a longer duration of postoperative fever. When comparing the postoperative duration of fever of the two allograft groups, there was also a trend that the irradiated allograft group was longer than the non-irradiated allograft group, but no significant difference was found. When the patients had a fever, the laboratory examinations of all patients were almost normal (Blood routine was normal, the values of ESR were 5 - 16 mm/h, CRP were 3 - 10 mg/l). On the basis of our study, we concluded that patients undergoing ACL reconstruction with BPTB non-irradiated allograft or autograft had similar clinical outcomes. Non-irradiated BPTB allograft is a reasonable alternative to autograft for ACL reconstruction. While the short term clinical outcomes of the ACL reconstruction with irradiated BPTB allograft were adversely affected with an increased failure rate. The less than satisfactory results led the senior authors to discontinue the use of irradiated BPTB allograft in ACL surgery and not to advocate that gamma irradiation be used as a secondary sterilizing method. Further research into alternatives to gamma irradiation is needed.
TL;DR: Two patients with overtight medial patellofemoral ligament reconstruction complications demonstrate that the adjustment of the graft tensioning as well as its femoral position are critical steps in MPFL reconstruction.
Abstract: The clinical presentation of an overtight medial patellofemoral ligament (MPFL) reconstruction can differ depending on whether it is too tight in extension (extensor lag) or too tight in flexion (anterior knee pain and loss of flexion). We report one clinical case of each presentation. Both cases were treated with a percutaneous release of the graft. After the release, both patients regained a full active range of motion without residual symptoms. These complications demonstrate that the adjustment of the graft tensioning as well as its femoral position are critical steps in MPFL reconstruction. This procedure requires training and experience in order to avoid early complications related to malposition or inappropriate tensioning of the graft. A surgical management for these overtight reconstructions is recommended, as it will restore function and range of motion, and prevent late patellofemoral degeneration.
TL;DR: The pathogenesis, risk factors, clinical presentation, diagnostic evaluation, treatment protocols and complications of septic knee arthritis after ACL reconstruction are discussed.
Abstract: Although postoperative septic arthritis is rare after ACL reconstruction, it carries a high morbidity that results in poor clinical outcome. Despite low incidence, it is important to recognize that infection and treat it without delay because of devastating consequences, such as loss of hyaline cartilage and arthrofibrosis, in order to avoid osteoarthritis development and near full range of motion achieved. Herein we discuss the pathogenesis, risk factors, clinical presentation, diagnostic evaluation, treatment protocols and complications of septic knee arthritis after ACL reconstruction.
TL;DR: In number of cases, high-grade AC-separations may be associated with traumatic concomitant glenohumeral pathologies resulting from the same trauma impact to the shoulder girdle.
Abstract: The purpose of this study is to investigate the prevalence of concomitant intraarticular lesions to the glenohumeral joint or to surrounding soft tissue structures with non-randomized prospective case series. High-grade acromioclavicular (AC) joint dislocations result from direct or indirect force impact to the shoulder girdle. Fourty consecutive patients (2 female, 38 male) with high-grade acromioclavicular joint dislocations (Rockwood III: n = 3; IV: n = 3; V: n = 34) who underwent diagnostic arthroscopy at the time of acromioclavicular joint repair were evaluated. Associated pathologic lesions were documented and treated by an all-arthroscopic approach. As a result, traumatic intraarticular lesions were found in 15% (n = 6/40) of cases. Two patients had an isolated partial tear of the subscapularis tendon. One patient had a combined tear of the subscapularis and supraspinatus tendon (PASTA type lesion). Two patients showed a type II SLAP-lesion and one patient had a type VI SLAP-lesion. Arthroscopic treatment included rotator cuff reconstruction in two cases and debridement of the partially torn tendon in one case. Two patients underwent an arthroscopic SLAP-repair and in one patient a debridement of a labral flap tear was performed. Acromioclavicular joint reconstruction was achieved via an open technique using suture anchors in 14 cases and via an all-arthroscopic approach using a double Tight-rope technique in 26 cases. To conclude, in number of cases, high-grade AC-separations may be associated with traumatic concomitant glenohumeral pathologies resulting from the same trauma impact to the shoulder girdle. A combined or an all-arthroscopic approach allows to accurately diagnose and treat associated intraarticular pathologies.
TL;DR: An evidence-based review of the outcomes of stable meniscal tears left in situ during ACL surgery, in order to assess the effectiveness of this popular procedure.
Abstract: The presence of peripheral meniscal tears is common at the time of anterior cruciate ligament (ACL) reconstruction. Techniques to preserve the maximum amount of meniscal tissue include “non operative” management (tear left alone, without repair or removal), meniscus repair, partial meniscectomy. There is a lack of consensus guidelines about the management of peripheral stable meniscal tears. When to remove, let alone or repair? We performed an evidence-based review of the outcomes of stable meniscal tears left in situ during ACL surgery, in order to assess the effectiveness of this popular procedure. Clinical and anatomical results (arthrography or second look arthroscopy) were analyzed. Our literature search yielded ten relevant studies (9 level IV, 1 level III). The mean time of follow-up was 16 months. Pain or mechanical symptoms related to the medial tibiofemoral joint were reported in 0–66% of cases. Subsequent medial meniscectomy or repair were performed in 0–33% of cases. Pain or mechanical symptoms related to the lateral tibiofemoral joint were reported in 0–18% cases. Subsequent lateral meniscectomy or repair were performed in 0–22% cases. A complete healing occurred in 50–61% cases for the medial meniscus and in 55–74% cases for the lateral meniscus. No definite conclusion can be made with regard to these results. The conservative approach is more effective for lateral menisci. The rate of bad results for the medial meniscus remains high when a conservative treatment is used. For the medial meniscus, repair of stable peripheral tears may be always indicated to decrease the risk of postoperative pain or subsequent meniscectomy.
TL;DR: It was found that a lower femoral tunnel placed single-bundle reconstruction reproduced anteroposterior laxity of the knee and rotational stability as well as double-b Bundle reconstruction after reconstruction intraoperatively.
Abstract: Twenty-six patients with anteroposterior (AP) laxity of the knee, associated with torn anterior cruciate ligament (ACL), were prospectively randomized for arthroscopic lower femoral tunnel placed single- or double-bundle reconstruction using hamstring tendons. We evaluated AP and rotational stabilities under regular loads (a 100-N anterior load and a 1.5-N m external-internal load) before and after ACL reconstruction, comparing single- and double-bundle reconstruction with our original device for applying quantitative tibial rotation and the navigation system intraoperatively. No significant differences were found between the two groups in AP displacement and total range of tibial rotation at 30 degrees and 60 degrees of knee flexion. We found that a lower femoral tunnel placed single-bundle reconstruction reproduced AP and rotational stability as well as double-bundle reconstruction after reconstruction intraoperatively.
TL;DR: There is no correlation between patient-reported knee function in sport and recreation and knee-related quality of life on an average 11.5 years after BPTP ACL reconstruction and the evaluation methods used 2 years after surgery, and the results of KOOS and SF-36 are found.
Abstract: The aim of the present investigation was to study patient-reported long-term outcome after anterior cruciate ligament (ACL) reconstruction. On an average 11.5 years after ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft 56 patients were asked to answer four different questionnaires about their knee function and knee-related quality of life. Another aim was to study whether there were any correlations between clinical tests, commonly used for evaluating patients with ACL injuries, which were performed 2 years after ACL reconstruction, and patient-reported outcome in terms of knee function and knee-related quality of life on an average 9.5 years later. All patients who had unilateral BPTB ACL reconstructions were examined at 2 years and on an average 11.5 years after surgery. At 2 years one-leg hop test for distance, isokinetic muscle torque measurement, sagittal knee laxity, Lysholm knee scoring scale and Tegner activity scale were used for clinical evaluation. At the follow-up on an average 9.5 years later the patients were evaluated with knee injury osteoarthritis outcome score (KOOS), short form health survey (SF 36), Lysholm knee scoring scale and Tegner activity scale. The SF-36 showed that the patients had a similar health condition as an age- and gender-matched normal population in Sweden on an average 11.5 years after ACL reconstruction. There was no correlation between the results of one-leg hop test for distance, isokinetic muscle torque measurement, sagittal knee laxity evaluated 2 years after surgery and the result of KOOS (function in sport and recreation, knee-related quality of life) and SF-36 evaluated on an average 11.5 years after surgery. We also compared patients that 2 years after surgery demonstrated a side-to-side difference in anterior-posterior knee laxity of more than 3 mm with those with 3 mm or less and found no significant group differences in terms of knee function as determined with KOOS. We found no correlation between the results of KOOS and SF-36 at the long-term follow-up and the time between injury and surgery, age at surgery or gender, respectively. We conclude that there is no correlation between patient-reported knee function in sport and recreation and knee-related quality of life on an average 11.5 years after BPTP ACL reconstruction and the evaluation methods used 2 years after surgery.
TL;DR: Although the mechanoreceptors were detected relatively less frequently than expected, the authors consider that it does not negate the necessity of remnant-preserving ACL reconstruction.
Abstract: This study was performed to identify the mechanoreceptors in the tibial remnants of ruptured human anterior cruciate ligaments (ACL) by immunohistochemical staining. Thirty-six specimens of tibial ACL remnants were obtained from patients with ACL ruptures during arthroscopic ACL reconstruction. As control, two normal ACL specimens were taken from healthy knee amputated at thigh level due to trauma. The specimen was serially sectioned at 40 μm. In control group, the average number of sections per specimen was 132, and a total of 264 slices were available. In remnant group, the average number of sections per specimen was 90, and a total of 3,251 slices were available. Immunohistochemical staining was performed to detect the neural element of mechanoreceptors. Histologic examinations were performed under a light microscope and interpreted by a pathologist. Nineteen (8 Ruffini, 11 Golgi) mechanoreceptors were identified in the two normal ACLs, which were evenly distributed at both tibial and femoral attachments. In the remnant group, mechanoreceptors were observed in 12 out of 36 cases (33%), and a total of 17 (6 Ruffini and 11 Golgi) mechanoreceptors observed. No significant differences in the harvest volume, number of sections, age, or time between injury to surgery was observed between the 12 mechanoreceptor-present and the 24 mechanoreceptor-absent ones. The presence of mechanoreceptor at the tibial remnants of torn ACLs was verified. The immunohistochemical staining methodology proved useful, but requires further refinement. Although the mechanoreceptors were detected relatively less frequently than expected, the authors consider that it does not negate the necessity of remnant-preserving ACL reconstruction.
TL;DR: The novel pie crust technique of the superficial MCL is safe, efficient and reliable, provided a medial release of 6–8 mm or less is required, provided the deep medial collateral ligament is released and otseophytes removed.
Abstract: We present an algorithmic release approach to the varus knee, including a novel pie crust release technique of the superficial MCL, in 359 total knee arthroplasty patients and report the clinical and radiological outcome. Medio-lateral stability was evaluated as normal in 97% of group 0 (deep MCL), 95% of group 1 (pie crust superficial MCL) and 83% of group 2 (distal superficial MCL). The mean preoperative hip-knee angle was 174.0, 172.1, and 169.5 and was corrected postoperatively to 179.1, 179.2, and 177.6 for groups 0, 1, and 2, respectively. A satisfactory correction in the coronal plane was achieved in 82.9% of all-comers falling within the 180 degrees +/- 3 degrees interval. An algorithmic release approach can be beneficial for soft tissue balancing. In all patients, the deep medial collateral ligament should be released and otseophytes removed. The novel pie crust technique of the superficial MCL is safe, efficient and reliable, provided a medial release of 6-8 mm or less is required. The release of the superficial MCL on the distal tibia is advocated in severe varus knees. Preoperative coronal alignment is an important predictor for the release technique, but should be combined with other parameters such as reducibility of the deformity and the obtained gap asymmetry.
TL;DR: A 46-year-old athletic patient with large degenerative chondral lesions of the medial femoral condyle, trochlea and patella, which was successfully treated with a closing-wedge high tibial osteotomy and the implant of a newly developed biomimetic nanostructured osteochondral bioactive scaffold, is reported on.
Abstract: We report on a 46-year-old athletic patient, previously treated with anterior cruciate ligament reconstruction, with large degenerative chondral lesions of the medial femoral condyle, trochlea and patella, which was successfully treated with a closing-wedge high tibial osteotomy and the implant of a newly developed biomimetic nanostructured osteochondral bioactive scaffold. After 1 year of follow-up the patient was pain-free, had full knee range of motion, and had returned to his pre-operation level of athletic activity. MRI evaluation at 6 months showed that the implant gave a hyaline-like signal as well as a good restoration of the articular surface, with minimal subchondral bone oedema. Subchondral oedema was almost non-visible at 12 months.
TL;DR: The technique presented here proved to be safe and minimally invasive while delivering good aesthetic results and allowing for the treatment of associated lesions and could benefit from more advanced retention devices, which ought to reduce or avoid migration of the flip buttons.
Abstract: The ideal treatment for acute acromioclavicular joint dislocation is still controversial, both in terms of indications and surgical technique. The clinical and radiographic outcomes of 16 patients affected by acute AC joint dislocation (type III-V) and arthroscopically treated with a coracoclavicular double flip button are presented. Despite the excellent clinical results both in terms of Constant score (mean 97 points) and patient satisfaction, at a mean follow-up of 31 months the radiographs showed partial loss of reduction due to distal migration of the flip button within the upper third of the clavicle in one-fourth of the cases. The technique presented here proved to be safe and minimally invasive while delivering good aesthetic results and allowing for the treatment of associated lesions. Furthermore, the technique could benefit from more advanced retention devices, which ought to reduce or avoid migration of the flip buttons.
TL;DR: Evaluated differences in graft orientation between transtibial (TT) and anteromedial (AM) portal technique using magnetic resonance imaging (MRI) in anterior cruciate ligament (ACL) reconstruction found normal sagittal obliquity is not restored with both techniques.
Abstract: The purpose of this study was to evaluate differences in graft orientation between transtibial (TT) and anteromedial (AM) portal technique using magnetic resonance imaging (MRI) in anterior cruciate ligament (ACL) reconstruction Fifty-six patients who were undergoing ACL reconstruction underwent MRI of their healthy and reconstructed knee Thirty patients had ACL reconstruction using the TT (group A), while in the remaining 26 the AM (group B) was used In the femoral part graft orientation was evaluated in the coronal plane using the femoral graft angle (FGA) The FGA was defined as the angle between the axis of the femoral tunnel and the joint line In the tibial part graft orientation was evaluated in the sagittal plane using the tibial graft angle (TGA) The TGA was defined as the angle between the axis of the tibial tunnel and a line perpendicular to the long axis of the tibia The ACL angle of the normal knee in the sagittal view was also calculated The mean FGA for group A was 72°, while for the group B was 53° and this was statistically significant (P < 0001) The mean TGA for group A was 64°, while for the group B was 63° (P = 0256) The mean intact ACL angle for group A was 52°, while for the group B was 51° The difference between TGA and intact ACL angle was statistically significant (P < 0001) for both groups Using the AM portal technique, the ACL graft is placed in a more oblique direction in comparison with the TT technique in the femoral part However, there are no differences between the two techniques in graft orientation in the tibial part Normal sagittal obliquity is not restored with both techniques
TL;DR: It is suggested that oral contraceptive use did not show any protective effect against ACL injuries nor did self-reported previous knee injuries show any association with ACL injury rate in recreational alpine skiing.
Abstract: Oral contraceptive use and menstrual cycle phase are suggested to influence the risk of anterior cruciate ligament (ACL) injuries in female athletes. However, only few data are available for recreational sports. Therefore, female recreational skiers with a non-contact ACL injury and age-matched controls completed a self-reported questionnaire relating to menstrual history, oral contraceptive use and previous knee injuries. Menstrual history data were used to group subjects into either preovulatory or postovulatory phases of menstrual cycle. Our findings suggest that oral contraceptive use did not show any protective effect against ACL injuries nor did self-reported previous knee injuries show any association with ACL injury rate in recreational alpine skiing. Analysis of menstrual history data revealed that recreational skiers in the preovulatory phase were significantly more likely to sustain an ACL injury than were skiers in the postovulatory phase.