Periprosthetic supracondylar femoral fractures following total knee arthroplasty: clinical comparison and related complications of the femur plate system and retrograde-inserted supracondylar nail.

BACKGROUND: The purpose of this study is to analyze the clinical results and related complications of the femur plate system (FP) and the retrograde-inserted supracondylar nail (RISN). MATERIALS AND METHODS: The study included 42 cases of periprosthetic supracondylar femoral fractures (PSF) proximal to posterior stabilized total knee arthroplasty between 2005 and 2009. Twenty-four cases of PSF were treated with the FP, and the other 18 cases were treated with the RISN. This study cohort was divided into subgroups according to the AO classification. We retrospectively compared the clinical results between the FP and RISN group. RESULTS: There were no significant differences between the two groups in terms of time of clinical union (p = 0.649). In the subgroup analysis, the mean operation time was significantly different only in subgroup A1 (p = 0.03). Complications were seen in 29.2 % (7/24) of patients in the FP group and 27.8 % (5/18) in the RISN group. The age during the index TKA and fracture fixation was a significant risk (p = 0.008) factor for complications between the two groups. No significant differences were found in the other factors between the two groups. The p value for operative time (p = 0.223), immobilization period (p = 0.129), ROM (p = 0.573), KSS (p = 0.379), KSS functional scores (p = 0.310) and time to union (p = 0.649). CONCLUSION: Clinical results did not differ according to the treatment methods used. Fixation method and fracture type did not cause an increase in the complication rate, but there was a trend toward higher non-union rates with the FP method and higher re-fracture rate with the RISN method. Noting the fact that only increasing age correlated with an increased complication rate, more careful attention should be paid to elderly patients in terms of both prevention and surgical care. LEVEL OF EVIDENCE: Level III, therapeutic study.

Meniscectomy of horizontal tears of the lateral meniscus anterior horn using the joystick technique.

Unstable inferior leaves of the anterior horn in horizontal tears of the lateral meniscus are challenging lesions for most orthopedic surgeons due to the poor viewing angle and the instability of these lesions. Resection of an exact volume is required for the successful treatment of horizontal tears in the lateral meniscus anterior horn. We report a method based on the joystick technique.

An early sign of intraarticular fracture of the lateral tibial plateau during opening wedge high tibial osteotomy.

Intraarticular fracture of the lateral tibial plateau is one of the serious complications in medial opening wedge high tibial osteotomy (HTO). We present a case of fracture of the lateral tibial plateau during medial opening wedge HTO. The authors have found the early fracture sign, uneven divergence gap of proximal and distal parts during enlargement of the osteotomy site with a dilatator, a useful marker for early detection and prevention of fracture extending.

The paradoxical McMurray test for the detection of meniscal tears: an arthroscopic study of mechanisms, types, and accuracy.

BACKGROUND: Meniscal tears are very common. The so-called paradoxical McMurray test has been described and found to be positive for three different types of meniscal tears. However, to our knowledge, no study has evaluated the accuracy of this test. The purpose of the present study was to evaluate the accuracy of the paradoxical McMurray test compared with the conventional McMurray test. We also sought to determine whether there are other types of meniscal tears that would show positive results on the paradoxical McMurray test. METHODS: The authors evaluated 628 patients with meniscal tears (Group I) and 387 patients without meniscal tears (Group II), as confirmed by arthroscopy performed from June 2000 to May 2006. The results of both clinical examinations (the conventional and the paradoxical McMurray test) were recorded, and the paradoxical phenomenon as seen during arthroscopy was described. The sensitivity and specificity of each test were calculated and statistically analyzed. RESULTS: The average patient age (and standard deviation) was 41.9 ± 15.6 years (range, ten to sixty-six years) in Group I and 40.3 ± 12.9 years (range, fifteen to sixty-three years) in Group II. The sensitivities of the McMurray test and the paradoxical McMurray test for diagnosing a meniscal tear were 41.9% (263 of 628) and 12.3% (seventy-seven of 628), respectively. The specificities of the two tests were 76.7% (297 of 387) and 99.2% (384 of 387), respectively. Compared with the conventional McMurray test, the paradoxical McMurray test showed significantly lower sensitivity but higher specificity. Apart from the three previously reported types of meniscal tears, a new type of meniscal tear in a discoid lateral meniscus also showed positive results with the paradoxical McMurray tests. CONCLUSIONS: In conclusion, a positive paradoxical McMurray test is reliable for diagnosing a meniscal tear that has a large displaced meniscal flap. A long radial tear in the posterior one-third of the discoid lateral meniscus is a new type of meniscal tear with positive results on the paradoxical McMurray test.

The influence of posterolateral rotatory instability on ACL reconstruction: comparison between isolated ACL reconstruction and ACL reconstruction combined with posterolateral corner reconstruction.

BACKGROUND: The purpose of the present retrospective study was to evaluate the influence of posterolateral corner reconstruction on anterior cruciate ligament (ACL) reconstruction in terms of anterior laxity and clinical outcomes. We hypothesized that the effects of combined ACL and posterolateral corner reconstruction would be less satisfactory than those of isolated ACL reconstruction in terms of anterior laxity and clinical outcomes. METHODS: We retrospectively studied sixty-nine patients who underwent ACL reconstruction from February 2001 to December 2005. Forty-six patients underwent isolated ACL reconstruction (Group I), and twenty-three patients underwent combined ACL and posterolateral corner reconstruction (Group II). Clinical outcomes were determined from data obtained before surgery and at the time of the twenty-four-month follow-up examination. RESULTS: Postoperatively, the mean side-to-side difference (and standard deviation) in anterior tibial translation, measured with a KT2000 arthrometer, was greater for Group I (2.2 ± 1.0 mm) than for Group II (1.6 ± 0.8 mm) (p = 0.031). Seven knees (15.2%) in Group I and two knees (8.7%) in Group II had grade-1 anterior translation. The mean Lysholm score was 93.2 in Group I and 90.1 in Group II (p = 0.392). Thirty-eight knees (82.6%) in Group I and twenty knees (87.0%) in Group II were classified as normal or nearly normal according to the International Knee Documentation Committee scoring system (p = 0.882). CONCLUSIONS: On the basis of the evaluation of ligamentous laxity with use of the KT2000 arthrometer, we observed that combined ACL and posterolateral corner reconstruction allows less anterior translation than isolated ACL reconstruction. However, we could not identify significant differences between the two groups in terms of functional outcomes.

Clinical comparison of conventional and remnant-preserving transtibial single-bundle posterior cruciate ligament reconstruction combined with posterolateral corner reconstruction.

BACKGROUND: Despite persistent continuity of the attenuated posterior cruciate ligament (PCL) in most PCL insufficient knees, few reconstruction techniques that preserve the PCL remnant have been presented. Furthermore, data regarding the clinical outcomes of these approaches are even more limited, and the clinical validity of remnant preservation has not yet been established. PURPOSE: To compare the clinical outcomes of transtibial PCL reconstructions that incorporate remnant preservation with conventional techniques (in which remnant preservation is not performed). STUDY DESIGN: Cohort study; Level of evidence 3. METHODS: The authors retrospectively evaluated 53 cases of PCL reconstruction with simultaneous posterolateral corner reconstruction. Of these, 23 were performed with a conventional approach without remnant preservation (group C), and 30 incorporated a remnant-preserving technique (group R). In all cases, the minimum follow-up period was 24 months. Each patient was evaluated using the following variables: Lysholm knee score, Tegner activity scale, return to activity, International Knee Documentation Committee (IKDC) knee score and grade, and degree of posterior laxity on stress radiograph. RESULTS: The mean side-to-side differences in posterior tibial translation, Lysholm knee score, return to activity, and objective IKDC grade were similar between group C (4.4 ± 3.0 mm; 82.6 ± 11.0; 21.7%; A and B: 73.9%) and group R (4.1 ± 3.4 mm; 84.1 ± 10.7; 26.7%; A and B: 83.3%; P = .761, .611, .679, .755). However, the final Tegner activity scale, near-return to activity, and subjective IKDC score differed significantly between group C (3.5 ± 0.8; 43.5%; 64.5 ± 8.8) and group R (4.3 ± 1.1; 73.3%; 70.6 ± 7.9; P = .007, .028, .012). CONCLUSION: Techniques combining remnant-preserving transtibial single-bundle PCL reconstruction with posterolateral corner reconstruction resulted in somewhat better activity-related outcomes compared with those of approaches without remnant preservation. However, incorporation of remnant preservation does not appear to provide increased posterior stability or result in clinically superior outcomes versus those of techniques without remnant preservation.

Does physiologic posterolateral laxity influence clinical outcomes of anterior cruciate ligament reconstruction?

BACKGROUND: The purpose of this retrospective study was to evaluate the influence of physiologic posterolateral rotatory laxity on anterior cruciate ligament (ACL) reconstruction in terms of anterior knee stability and clinical outcomes. METHODS: We retrospectively studied 113 patients who had undergone ACL reconstruction between June 2004 and August 2008. Patients were categorized into three groups according to the degree of tibial external rotation at 90° of knee flexion: Group 1 (<40°), Group 2 (40° to 50°), and Group 3 (≥50°). Ligament stability was determined with use of the Lachman test, the pivot-shift test, and KT-2000 arthrometer testing. Function was assessed with use of the Lysholm score and the International Knee Documentation Committee (IKDC) score. Clinical outcomes were determined from data obtained before surgery and at the twenty-four-month follow-up visit. RESULTS: We observed differences in postoperative knee translation between the groups (p < 0.001). A post hoc test showed increased mean knee translation in Group 3 compared with Groups 1 and 2. The degree of external rotation at 90° was positively correlated with anterior knee translation (r = 0.428; p = 0.007). However, there was an inverse correlation with the Lysholm knee scores (r = -0.146; p = 0.015) and IKDC scores (r = -0.205; p = 0.003). CONCLUSIONS: The stability and functional scores after ACL reconstruction had a negative correlation with the degree of external rotation of the tibia at 90° (physiologic posterolateral rotatory laxity). After ACL reconstruction, patients with ≥ 50° of tibial external rotation had increased anterior translation and worse functional outcomes in comparison with those who had < 50° of tibial external rotation.