Osteochondral Allograft Transplantation for Treatment of Focal Patellar Osteochondral Lesion.

Patellar osteochondral lesions are common and particularly disabling injuries that can affect young and highly active patients. If enough functional impairment, ranging from difficulty climbing stairs to pain with squatting, is present, surgical treatment may be warranted. For the treatment of these lesions, various techniques have been described, including autologous osteochondral transplantation, as well as microfracture surgery. However, these are not without disadvantages. Although morbidity is noted in cases of autologous osteochondral transplantation, uncertain and possibly unsustainable results are associated with the microfracture procedure. Therefore, we present an alternative surgical treatment option for this pathology. The objective of this Technical Note is to describe our preferred approach for an osteochondral allograft transplant procedure to treat a focal patellar osteochondral lesion.

Arthroscopic Bony Resection for Treatment of Symptomatic Bipartite Patella.

Bipartite patella is a common pathology, affecting 2% to 3% of the population. Usually these cases are bilateral and asymptomatic. However, a patient with a bipartite patella may complain of pain, which is most likely related to fragment mobility. Conservative treatment with physiotherapy, immobilization, and nonsteroidal drugs are encouraged during the initial 6 months following diagnosis. This option is effective in most patients. For patients who do not improve with these conservative measures, surgical intervention is indicated. Many surgical treatment options have been described including excision of the fragment, as well as fixation. Fragment excision has demonstrated positive outcomes and is associated with an asymptomatic return to sport activities. The purpose of this Technical Note is to describe our preferred arthroscopic technique for the treatment of symptomatic bipartite patella.

Simultaneous Bilateral Knee Valgus Stress Radiographic Technique.

The medial collateral ligament is the most commonly injured knee ligament. Valgus stress radiographs are reported to be an effective way to quantify the medial compartment opening. However, most of the techniques require the presence of a physician in the radiograph room to apply a manual valgus stress force, and can only be performed in 1 knee at a time. These techniques, although extremely effective, increase radiation exposure to physicians, are time consuming, and require additional radiographs to compare the side-to-side difference. The purpose of this Technical Note is to describe our preferred valgus stress radiographic technique to evaluate medial side laxity, which offers several advantages compared with conventional manual techniques.

Frog-Leg Test Maneuver for the Diagnosis of Injuries to the Posterolateral Corner of the Knee: A Diagnostic Accuracy Study.

OBJECTIVE: To determine the sensitivity and specificity of a new clinical test for the diagnosis of injuries to the posterolateral corner of the knee by using magnetic resonance imaging (MRI) as the reference standard. DESIGN: Diagnostic accuracy study. SETTING: A tertiary care teaching hospital. PARTICIPANTS: Twelve subjects with chronic instability of the knee and posterolateral corner injury diagnosed by intraoperative findings and 9 subjects without posterolateral corner injury (used as controls). INTERVENTIONS: Injured and uninjured knees were assessed blindly by 2 examiners using a new clinical diagnostic test (the frog-leg test) and the classic varus stress test. MAIN OUTCOME MEASURES: Injuries to the posterolateral corner of the knee identified by the 2 clinical tests. Findings were compared and examined for reproducibility, and kappa statistic was used to assess interobserver agreement. Test results were compared with those of MRI and intraoperative findings to determine diagnostic accuracy. RESULTS: The frog-leg test showed high interobserver agreement (kappa, 0.86), with a high rate (83%-100%) of agreement with the intraoperative diagnosis. The frog-leg test had high sensitivity (91.7%) and specificity (94.5%) for detecting posterolateral corner injuries. The sensitivity of the varus stress test increased from 83.3% to 90.0% when combined with the frog-leg test. CONCLUSIONS: Examiners were able to identify posterolateral corner injuries and differentiate injured from uninjured knees using the frog-leg test, which could potentially be used as an ancillary tool to the varus stress test in diagnosing injuries to the posterolateral corner of the knee. Larger studies are needed to confirm our findings.

Influence of hip restriction on noncontact ACL rerupture.

PURPOSE: This study investigated variables associated with hip restriction (reduced range of motion) in a group of soccer players presenting with noncontact rerupture of the anterior cruciate ligament (ACL) and compared results with a group of sport-matched healthy professional athletes. METHODS: In this case series, 28 male soccer players with noncontact ACL rerupture were examined for clinical hip range of motion findings potentially associated with ACL rerupture, namely anterior knee displacement, internal-external hip rotation, and cruciate ligament insufficiency. Results were compared with data obtained from 27 healthy professional players. Patients presenting gross surgical errors (e.g. poorly positioned tunnel) or reporting major accidents affecting the lower limbs, such as leg or ankle fractures, were excluded from analysis. Internal-external rotation was measured in the supine position, with knee and hip at 90° of flexion. ACL insufficiency was assessed using the Pivot Shift test and the Lachman's test with the aid of a Rolimeter RM(®) arthrometer and confirmed by magnetic resonance imaging. RESULTS: The most prevalent finding was a significantly lower mean internal-external hip rotation in the rerupture group (45.0°) when compared with healthy professional soccer players (56.2°). CONCLUSION: Assessing hip restriction in patients presenting noncontact ACL rerupture showed to be extremely important during ACL reconstruction planning.

Pull-out technique for plantar plate repair of the metatarsophalangeal joint.

Plantar plate rupture is a common cause of forefoot pain, multiplanar malalignment, subluxation, or dislocation of the metatarsophalangeal joint (MTPJ). The treatments that have been described for MTPJ instability of lesser toes include amputation, lengthening and/or tendon transfer, periarticular soft-tissue release (capsule, collateral ligaments, and plantar plate), colateral ligament reconstruction, metatarsal shortening osteotomy, and suture of plantar plate lesion. This article outlines the anatomy, pathogenesis, and diagnosis of plantar plate rupture, and describes a new technique that combines joint decompression by Weil osteotomy with a plantar plate repair using a pull-out technique.

Conventional rotator cuff repair complemented by the aid of mononuclear autologous stem cells.

PURPOSE: To investigate the behavior of rotator cuff tears treated with conventional repair technique with the aid of autologous bone marrow mononuclear cells (BMMC). METHODS: Fourteen consecutive patients (9 women, 5 men, mean age of 59.2 years) with complete rotator cuff tears (mean preoperative UCLA score of 12 ± 3.0) were fixed by transosseous stitches through mini-open incision, with subsequent injection of BMMC into the tendon borders, obtained from the iliac crest just prior to surgery. Magnetic resonance images (MRI) were acquired before and after surgery and evaluated by two musculoskeletal radiologists regarding new postoperative findings of patients treated with BMMC. RESULTS: After a minimum 12-month follow-up period, the UCLA score increased from 12 ± 3.0 to 31 ± 3.2. Clinical findings remained unaltered in the following year in all but one patient (13/14). MRI analysis after a 12-month follow-up period demonstrated tendon integrity in all cases (14/14), presence of low-signal intensity areas along the supraspinatus tendon and distal muscle belly in 8 cases (8/14), and high-intensity blooming small round artifact at the bursal and tendon topography in 11 cases (11/14). Six patients (6/14) showed formation of a high-signal intensity zone at the critical zone. Clinical findings remained unaltered in the following year in all but one patient, who relapsed into loss of strength and pain, being considered a bad result. CONCLUSION: Implantation of BMMC in rotator cuff sutures appears to be a safe and promising alternative to other biological approaches currently used to enhance tissue quality in affected tendons.

Radiographic findings in restrained hip joints associated with ACL rupture.

Although decreased hip range of motion has been detected in many soccer players with noncontact anterior cruciate ligament (ACL), it is not clear whether it is associated with bone spurs, capsular soft tissue stiffness or both. Our aim was to investigate abnormal radiographic findings in soccer players with limited hip range of motion and noncontact ACL injury. Fifty consecutive male soccer players with restricted hip range of motion and noncontact ACL injury were subjected to radiographic examination to identify bone changes that could be associated with decreased hip range of motion. Of 50 patients, 56% revealed abnormal radiographic findings: pericapsular calcifications or acetabular rim osteophytes (24%), femoral neck deformity (10%), femoral neck and acetabular rim disorders (18%), neck groove caused by impingement (4%). Radiographic evaluation of those individuals showed a high number of bone abnormalities around the hip joint. This was considered to be an important finding to guide a decision-making process between three different approaches: changing the type of sports practiced, undergoing a more restrictive surgery (such as a double-bundle intra-articular reconstruction or an intra plus extra technique) or the onset of a hip-stretching program in addition to the conventional ACL rehabilitation protocol. In this last option, ACL-operated patients without radiographic hip abnormalities may have better outcomes for their decreased hip range of motion when submitted to a stretching program targeting the prevention of rotational overload on the reconstructed intra-articular grafts. The decision-making process concerning soccer players with ACL ruptures should take into consideration the amount of motion-limiting abnormalities around the hip joint.