Küntscher nails with static cement spacer: A simple technique in periprosthetic knee infections with massive bone loss and instability.

BACKGROUND: Two-stage revision for periprosthetic knee infection is challenging in cases of massive bone loss and instability. The present study aims to describe our experience with an alternative technique of reinforced cement spacer, usually necessary in these situations, focusing on its advantages and clinical results. METHODS: We retrospectively identified all patients who underwent a two-stage revision for periprosthetic knee infection using two intramedullary Küntscher nails as reinforcement from January 2010 to September 2018. From each medical record, we extracted the type of explanted prosthesis, isolated micro-organism, number of cement spacers before index procedure (and related episodes of spacer dislocation) and final treatment. RESULTS: Twelve patients were identified, mean age of 64.0 years (range 39-85). In four of them, the reinforced spacer was used twice for persistent infection, with a total of 16 procedures performed and no cases of dislocation. Ten patients were finally treated with reimplantation or arthrodesis with intramedullary nails, whereas an above-knee amputation was necessary for two patients. Infection was eradicated in 10 patients out of 12 (83%) at a mean follow up of 34.3 months (range 10-62). CONCLUSIONS: This technique is an effective alternative to traditional spacers in cases of massive bone loss, producing a mechanically stable joint and preserving adequate tissue tensions. The construct is technically easy to perform and, not less importantly, to remove during stage 2. Further studies, with larger groups, are necessary to determine its validity.

Anterior cruciate ligament revision with Achilles tendon allograft in young athletes.

BACKGROUND: Return to sport after revision ACL reconstruction is a controversial topic, several studies reported the results of different techniques and graft in sportsman, presenting an incredibly wide range of return to the same pre-injury activity level, from 0% to 100%. The purpose of this study was to evaluate the clinical outcomes and return to sport rate in young athletes after non anatomic double-bundle revision ACL reconstruction with Achilles allograft. HYPOTHESIS: The present revision technique was effective in terms of stability, return to sport and functional outcomes. MATERIAL AND METHODS: All the athletes undergone Revision ACL reconstruction with non-irradiated Achilles tendon allograft with a non-anatomical double-bundle technique were included in the study. A split Achilles tendon allograft was used to reproduce the anteromedial (AM) bundle using the over-the-top position, while the posterolateral (PL) bundle was reconstructed through a femoral tunnel located in the anatomical PL footprint. Sport activity, knee function with Lysholm score, knee laxity and re-injury or re-operations were evaluated. RESULTS: Twenty-six athletes (23 males, three females) with a mean age of 23.4±3.6 years were evaluated at a mean follow-up of 6.0±1.6 years. Overall 69% of patients returned to sport both at elite (44%) or county level (56%) after a mean 6.7±1.5 (3-9 range) months. The mean Lysholm score showed a significant improvement from 64.4±8.1 at pre-operative status to 83.8±11.3 at final follow-up (P<.0001). Seven patients (30%) were rated as excellent, nine (39%) as good, five (22%) as fair and 2 (9%) as poor. Three patients (12%) experienced a further graft rupture after a mean 2.6 years, (3.5 months-48 months range) and two had >5mm side-to-side difference at KT-1000. Therefore, the overall survival rate at mean six years follow-up was 81%. CONCLUSION: The ACL revision with a double-bundle technique using Achilles tendon allograft was successful in 81% of athletes at six years mean follow-up. TYPE OF STUDY AND LEVEL OF EVIDENCE: Retrospective case series, level IV.

Concurrent femoral and tibial osteotomies versus soft tissue balance in total knee arthroplasty: A technical case report.

This case report outlines some of the challenges as well as limitations in correction of osteoarthritis of the knee in combination with extra-articular deformities,and provides a novel and straightforward surgical solution in overcoming these challenges. We describe the case of a 37-year-old male who suffered from advanced bilateral tri-compartmental knee arthritis due to untreated bloodstream-sourced osteomyelitis after birth. Radiographs and surgery confirmed extremely severe deformities. We performed two different surgical techniques in order to correct extra-articular deformities (one-stage approach of concurrent tibial and femoral osteotomy and total knee arthroplasty on one side, and soft tissue balancing with "pie-crusting technique" plus total knee arthroplasty on the other side), with description of subsequent results at 36-months follow-up.

DOES TOTAL KNEE REPLACEMENT MODIFY FLEXION AXIS OF THE KNEE ON FRONTAL AND AXIAL PLANE REGARDLESS FROM LIMB ALIGNMENT?

The optimal reference for rotational positioning of femoral component in total knee replacement (TKR) is debated. Navigation has been suggested for intra-op acquisition of patient’s specific kinematics and functional flexion axis (FFA). The main purpose of the present study is to prospectively investigate whether pre-operative FFA in patients with osteoarthritis (OA) and varus alignment changes after TKR and whether a correlation exists between post-op FFA and pre-op alignment. A navigated TKR was performed in 108 patients using a specific software to acquire passive joint kinematics before and after TKR. The knee was cycled through three passive range of motions (PROM), from 0° to 120°. FFA was computed using the mean helical axis algorithm. The angle between FFA and surgical TEA was determined on frontal (αf) and axial (αa) plane. The pre- and post-op hip-knee-ankle angle (HKA) was determined. Post-op FFA was different from pre-op FFA only on frontal plane. No significant difference was found on axial plane. No correlation was found between HKA-pre and αA-pre. A significant correlation was found between HKA-pre and αF–pre. The study concluded that TKR modifies FFA only on frontal plane. No difference was found on axial plane. Pre-op FFA is in a more varus position respect to TEA. The position of FFA on frontal plane is dependent on limb alignment. The present study has demonstrated TKR modifies the position of FFA only on frontal plane. The position of FFA on axial plane is not dependent on the amount of varus deformity and is not influenced by TKR. Level of evidence, IV, case series.

New cell-based technologies in bone and cartilage tissue engineering. II. Cartilage regeneration.

A tissue engineering, cell-based therapeutic approach could be essential for extensive bone or cartilage reconstruction. This article is divided in two chapters and describes new cell-based surgical techniques for cartilage and bone reconstruction. The second part of the article, regarding cartilage repair, describes a new arthroscopic surgical technique for tissue engineered cartilage grafting. A 3-dimensional hyaluronic acid support is used for autologous chondrocyte culturing. The technique reduces morbidity of classic autologous implant avoiding open surgery and periosteal flap use. With this technique is possible to reduce the patient morbidity, time and cost of surgery.

New cell-based technologies in bone and cartilage tissue engineering. I. Bone reconstruction.

A tissue engineering, cell-based therapeutic approach could be essential for extensive bone or cartilage reconstruction. This article is divided in two chapters and describes new cell-based surgical techniques for cartilage and bone reconstruction. In the first part on bone reconstruction, marrow-derived osteogenic progenitor cells combined with hydroxyapatite were utilized. The validity of this model has been shown for the repair of critical size bone defects in large size animal models. We used this cell-based therapeutic approach to treat 3 patients with large bone defects, achieving bone reconstruction.

Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons.

Numerous surgical procedures have been developed and used for anterior cruciate ligament (ACL) reconstruction. Patellar tendon is probably the most common graft used, but gracilis and semitendinous tendons present some interesting advantages: small incision, large graft when doubled, characteristics close to ACL, rapid harvest. We describe a combined intra- and extra-articular arthroscopic ACL reconstruction using hamstring tendons which includes some original steps. The tendons are harvested, leaving the distal insertion intact, and sutured together. After drilling of the tibial tunnel, an over-the-top arrangement is formed, creating a groove in the posterolateral aspect of the femur. The tendons are then fixed with double staples in the groove, and their remaining part is fixed distally to Gerdy's tubercle passing under the fascia, but over the lateral collateral ligament (LCL). This technique ensures sufficient strength in the graft and permits correction of any associated instability, because of the presence of the extra-articular portion of the tendons. Furthermore, the over-the-top arrangement reduces trauma and possible pitfalls related to tunnel construction and permits isometry of the extra-articular portion to be established. Forty patients involved in sports activity were prospectively selected and evaluated at a minimum 2 years' follow-up. IKDC score and Lysholm score were used for clinical evaluation, and the KT-2000 was used for instrumental laxity measurements. Resumption of sport and time to that point were recorded as well as Tegner activity score. We had 92.5% normal and fairly normal knees according to IKDC score and only 7.5% abnormal knees. Mean Lysholm score was 95. Mean Tegner score was 7.2. KT-2000 showed a mean injured/uninjured difference of 2.1 mm. In all, 90% of patients resumed sports at the same level, 67.5% in 3-4 months and 27.5% in 4-6 months. The highly satisfactory results of this series with no major complications confirm the reliability of this technique and the possibility of guaranteeing functional behaviour in the knee.

Total knee arthroplasty without patellar resurfacing in active and overweight patients.

Overweight patients are often considered poor candidates for total knee arthroplasty (TKA). A retrospective study of this was done on 47 osteoarthritic knees treated by TKA without patella resurfacing between March 1991 and June 1993. The Hospital for Special Surgery (HSS) rating system was used for clinical evaluation, and radiographs to study the degree of osteoarthritis and radiolucency. Correlations between overweight, range of motion (ROM) and stage of patellar damage and other measured variables (HSS score, patellar pain and radiolucency) were studied. Overweight was not correlated with HSS score, radiolucency or patellar pain. ROM was significantly correlated with patellar pain and HSS score, with better results in patients with ROM between 90 degrees and 110 degrees. Therefore, we believe that TKA in osteoarthritic knees can lead to successful results, even in active or overweight patients.

Arthroscopic management of recurrent anterior dislocation of the shoulder: analysis of technical modifications on the Caspari procedure.

Arthroscopic treatment was performed on 71 patients with recurrent shoulder dislocations; all of the patients had monoplanar anterior instability attributable to arthroscopically diagnosed Bankart lesion. Of the 71 operations, 29 were performed using the original Caspari technique (follow-up, 59 months), and 42 were performed after modifications made in the original technique (follow-up, 38 months), notably improved preparation of the capsular reinsertion zone and increase in the number of monofilament points and their anchorage directly to the bone, on the spine of the scapula. We compared the results obtained in these two differently treated groups, taking into account several factors in the patient's history and clinical condition. These included the number of dislocation episodes before the operation, as well as clinical findings regarding stability, movement, function and pain (Rowe scale score), contralateral shoulder laxity, level of preoperative versus postoperative athletic activity, and postoperative recurrence rate. In the Caspari-treated group, we obtained 66% satisfactory results compared with the 90% obtained in the second group. The recurrence rate was 27% in the first group compared with 4.8% in the second group. These data were statistically significant. No correlation was found between preoperative number of dislocations and recurrence rate, nor for contralateral shoulder laxity. No significant difference was found regarding resumption of sport activity in the two groups. Our data indicate that, with accuracy in patient selection and effective surgical technique, the recurrence rate can be reduced, and results similar to those of the arthrotomic technique may be obtained.

Arthroscopic reconstruction of the anterior cruciate ligament with Leeds-Keio ligament in non-professional athletes. Results after a minimum 5 years' follow-up.

We report our experience using the Leeds-Keio artificial ligament for anterior cruciate ligament (ACL) reconstruction. The study relates the results of the first 40 patients subjected to arthroscopic reconstruction of the ACL with a Leeds-Keio ligament, with a mean follow-up of 73 months. No associated peripheral procedures were carried out on any patient. The average age of the patients at the time of the operation was 31 years (range 26-35 years). The rehabilitation protocol followed by all patients aimed at resumption of sport 4 months after the operation. Clinical assessment included IKDC and the Lysholm scoring scale. The KT-2000 system was used for instrumented evaluation of joint laxity. All patients underwent a radiographic check-up. Clinically there were 55% excellent or good results when using the IKDC scale, while with the Lysholm score, satisfactory results were obtained in 80%. Complete post-traumatic rupture of the ligament was observed in three patients. No patient suffered an episode of either hydrarthrosis or reactive synovitis, which indicates good tolerance to the ligament. The radiographic evaluation of the operated knees showed a close correlation between the appearance of degenerative phenomena and performance of arthroscopic meniscectomy. The results achieved with the Leeds-Keio artificial ligament 5 years after application, although not completely satisfactory and inferior to those obtained with autologous biological ligaments, should be considered an encouragement to promote new efforts in this interesting research field.

Early versus late reconstruction for anterior cruciate ligament rupture. Results after five years of followup.

We investigated the clinical and laxity testing results at 5 years' followup in patients who had early or late anterior cruciate ligament reconstruction. Twenty-three patients (Group I) were treated within 15 days of injury. Fifty-nine patients (Group II) were treated more than 3 months after injury. Patellar tendon reconstruction and fascia lata graft augmented with a ligament augmentation device were the techniques used in both groups. According to the International Knee Documentation Committee rating scale, 17 patients in Group I and 38 patients in Group II had satisfactory results. The Lysholm score was good in all Group I patients and in 55 Group II patients. Flexion-extension deficits were comparable for both groups. Eighteen patients (78%) in Group I demonstrated satisfactory results according to the KT-2000 arthrometer testing, compared with 44 (75%) in Group II. No associated lesions were present in 12 (52%) cases in Group I, compared with 26 (44%) cases in Group II. Return to sports at the preoperative level was obtained by 21 (91%) patients in Group I, compared with 42 (71%) in Group II. The patients who had reconstruction during the early phase returned to sports activities sooner and had better clinical and laxity testing results.

The preliminary results of press-fit knee arthroplasty without a patellar component.

A total of 22 cases of Kinemax prostheses implanted consecutively from January to June 1990 for the treatment of primary gonarthrosis were evaluated; in these cases remodeling of the patella was performed, and the corresponding component of the prosthesis was not used. The mean age of the patients was 64 years, mean follow-up was obtained after 48 months. According to the HSS form results were: excellent: 9 (40.9%); good: 12 (54.5%); fair: 1 (4.6%). The postoperative femorotibial axis measured a mean of 173.8 degrees. There were no complications in the patella, only in 1 case did we observe mild anterior pain. Knee arthroplasty without substitution of the patella seems to guarantee good results in patients with primary gonarthrosis, as long as patellar reconstruction is performed and correct femoropatellar alignment is guaranteed, as well as recovery of the femorotibial axis with accurate positioning of the prosthetic components.