Does Donor Age of Nonirradiated Achilles Tendon Allograft Influence Mid-Term Results of Revision ACL Reconstruction?

Purpose The purpose of the present study was to investigate if the donor age of nonirradiated Achilles tendon allograft could influence the clinical results of revision anterior cruciate ligament (ACL) reconstruction. Methods All patients that underwent ACL revision between 2004 and 2008 with at least 4 years of follow-up were included. For all the patients that met the inclusion criteria, the age of the graft donor was obtained from the tissue bank. Lysholm score was administered to patients that met inclusion criteria. In addition, patients were divided in two groups based on the donor age (<45 years vs. ≥45 years), and the baseline characteristics and outcomes were compared. Results Fifty-two patients were evaluated at a mean 4.8 ± 0.8 years follow-up with Lysholm score. The Lysholm significantly improved from 62.3 ± 6.6 at preoperative status to 84.4 ± 12.3 at final follow-up. The mean donor age was 48.7 ± 8.4 years; a significant difference in Lysholm score was noted between patients that received an allograft with a donor age <45 years (14 patients; 27%) and those receiving an allograft with a donor age ≥45 years (38; 73%) (89.5 ± 3.2 vs. 80.1 ± 11.1, respectively; p = 0.0469). The multiple regression model showed the donor age, the final follow-up, and the preoperative Lysholm score as significant predictors of postoperative Lysholm score ( p < 0.0002). Conclusion Donor age of nonirradiated Achilles tendon allograft influenced the mid-term results of revision ACL reconstruction, thus advising the use of grafts from young donors. Level of Evidence Level III, retrospective comparative study.

Medial Meniscus Radial Tear: A Transtibial 2-Tunnel Technique.

Complete radial tears of the medial meniscus significantly decrease the meniscal tissue's ability to dissipate tibiofemoral loads and have been described as functionally similar to a total meniscectomy, predisposing patients to early osteoarthritis. At present, no consensus exists regarding the optimal surgical treatment of a radial meniscal tear. Current repair techniques have led to a reportedly high rate of incomplete healing or healing of the meniscus in a nonanatomic, gapped position, which compromises its ability to withstand hoop stresses. Improvement regarding the ability to repair and heal medial meniscus radial tears has the potential to result in enhanced preservation of the articular cartilage in the medial compartment of the knee. This technical description details a method for repairing radial tears of the medial meniscus using a transtibial 2-tunnel technique.

Anterolateral Biplanar Proximal Tibial Opening-Wedge Osteotomy.

Proximal tibial anterolateral opening-wedge osteotomies have been reported to achieve successful biplanar lower-extremity realignment. Indications for a proximal tibial anterolateral osteotomy include symptomatic genu recurvatum with genu valgus alignment, usually in patients with a flat sagittal-plane tibial slope. The biplanar approach is able to simultaneously address both components of a patient's malalignment with a single procedure. The correction amount is verified with spacers and intraoperative imaging, while correction of the patient's heel height is simultaneously measured. A plate is secured into the osteotomy site, and the site is filled with bone allograft. The anterolateral tibial osteotomy has been reported to be an effective surgical procedure for correcting concomitant genu recurvatum and genu valgus malalignment.

Anatomic Double-Bundle Posterior Cruciate Ligament Reconstruction.

The posterior cruciate ligament (PCL) is known to be the main posterior stabilizer of the knee. Anatomic single-bundle PCL reconstruction, focusing on reconstruction of the larger anterolateral bundle, is the most commonly performed procedure. Because of the residual posterior and rotational tibial instability after the single-bundle procedure and the inability to restore the normal knee kinematics, an anatomic double-bundle PCL reconstruction has been proposed in an effort to re-create the native PCL footprint more closely and to restore normal knee kinematics. We detail our technique for an anatomic double-bundle PCL reconstruction using Achilles and anterior tibialis tendon allografts.

An In Vitro Robotic Assessment of the Anterolateral Ligament, Part 2: Anterolateral Ligament Reconstruction Combined With Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Recent biomechanical studies have demonstrated that an extra-articular lateral knee structure, most recently referred to as the anterolateral ligament (ALL), contributes to overall rotational stability of the knee. However, the effect of anatomic ALL reconstruction (ALLR) in the setting of anterior cruciate ligament (ACL) reconstruction (ACLR) has not been biomechanically investigated or validated. PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the biomechanical function of anatomic ALLR in the setting of a combined ACL and ALL injury. More specifically, this investigation focused on the effect of ALLR on resultant rotatory stability when performed in combination with concomitant ACLR. It was hypothesized that ALLR would significantly reduce internal rotation and axial plane translation laxity during a simulated pivot-shift test compared with isolated ACLR. STUDY DESIGN: Controlled laboratory study. METHODS: Ten fresh-frozen cadaveric knees were evaluated with a 6 degrees of freedom robotic system. Knee kinematics were evaluated with simulated clinical examinations including a simulated pivot-shift test consisting of coupled 10-N·m valgus and 5-N·m internal rotation torques, a 5-N·m internal rotation torque, and an 88-N anterior tibial load. Kinematic differences between ACLR with an intact ALL, ACLR with ALLR, and ACLR with a deficient ALL were compared with the intact state. Single-bundle ACLR tunnels and ALLR tunnels were placed anatomically according to previous quantitative anatomic attachment descriptions. RESULTS: Combined anatomic ALLR and ACLR significantly improved the rotatory stability of the knee compared with isolated ACLR in the face of a concurrent ALL deficiency. During a simulated pivot-shift test, ALLR significantly reduced internal rotation and axial plane tibial translation when compared with ACLR with an ALL deficiency. Isolated ACLR for the treatment of a combined ACL and ALL injury was not able to restore stability of the knee, resulting in a significant increase in residual internal rotation laxity. ALLR did not affect anterior tibial translation; no significant differences were observed between the varying ALL conditions with ACLR except between ACLR with an intact ALL and ACLR with a deficient ALL at 0° of flexion. CONCLUSION: In the face of a combined ACL and ALL deficiency, concurrent ACLR and ALLR significantly improved the rotatory stability of the knee compared with solely reconstructing the ACL. CLINICAL RELEVANCE: Significant increases in residual internal rotation and laxity during the pivot-shift test may exist in both acute and chronic settings of an ACL deficiency and in patients treated with isolated ACLR for a combined ACL and ALL deficiency. For this subset of patients, surgical treatment of the ALL, in addition to ACLR, should be considered to restore knee stability.

A Novel Repair Method for Radial Tears of the Medial Meniscus: Biomechanical Comparison of Transtibial 2-Tunnel and Double Horizontal Mattress Suture Techniques Under Cyclic Loading.

BACKGROUND: Complete radial tears of the medial meniscus have been reported to be functionally similar to a total meniscectomy. At present, there is no consensus on an ideal technique for repair of radial midbody tears of the medial meniscus. Prior attempts at repair with double horizontal mattress suture techniques have led to a reportedly high rate of incomplete healing or healing in a nonanatomic (gapped) position, which compromises the ability of the meniscus to withstand hoop stresses. HYPOTHESIS: A newly proposed 2-tunnel radial meniscal repair method will result in decreased gapping and increased ultimate failure loads compared with the double horizontal mattress suture repair technique under cyclic loading. STUDY DESIGN: Controlled laboratory study. METHODS: Ten matched pairs of male human cadaveric knees (average age, 58.6 years; range, 48-66 years) were used. A complete radial medial meniscal tear was made at the junction of the posterior one-third and middle third of the meniscus. One knee underwent a horizontal mattress inside-out repair, while the contralateral knee underwent a radial meniscal repair entailing the same technique with a concurrent novel 2-tunnel repair. Specimens were potted and mounted on a universal testing machine. Each specimen was cyclically loaded 1000 times with loads between 5 and 20 N before experiencing a load to failure. Gap distances at the tear site and failure load were measured. RESULTS: The 2-tunnel repairs exhibited a significantly stronger ultimate failure load (median, 196 N; range, 163-212 N) than did the double horizontal mattress suture repairs (median, 106 N; range, 63-229 N) (P = .004). In addition, the 2-tunnel repairs demonstrated decreased gapping at all testing states (P < .05) with a final measured gapping of 1.7 mm and 4.1 mm after 1000 cycles for the 2-tunnel and double horizontal mattress suture repairs, respectively. CONCLUSION: The 2-tunnel repairs displayed significantly less gapping distance after cyclic loading and had significantly stronger ultimate failure loads compared with the double horizontal mattress suture repairs. CLINICAL RELEVANCE: Complete radial tears of the medial meniscus significantly decrease the ability of the meniscus to dissipate tibiofemoral loads, predisposing patients to early osteoarthritis. Improving the ability to repair medial meniscal radial tears in a way that withstands cyclic loads and heals in an anatomic position could significantly improve patient healing rates and result in improved preservation of the articular cartilage of the medial compartment of the knee. The 2-tunnel repair may be a more reliable and stronger repair option for midbody radial tears of the medial meniscus. Clinical studies are warranted to further evaluate these repairs.

An In Vitro Robotic Assessment of the Anterolateral Ligament, Part 1: Secondary Role of the Anterolateral Ligament in the Setting of an Anterior Cruciate Ligament Injury.

BACKGROUND: Recent investigations have described the structural and functional behavior of the anterolateral ligament (ALL) of the knee through pull-apart and isolated sectioning studies. However, the secondary stabilizing role of the ALL in the setting of a complete anterior cruciate ligament (ACL) tear has not been fully defined for common simulated clinical examinations, such as the pivot-shift, anterior drawer, and internal rotation tests. HYPOTHESIS: Combined sectioning of the ALL and ACL would lead to increased internal rotation and increased axial plane translation during a pivot-shift test when compared with isolated sectioning of the ACL. STUDY DESIGN: Controlled laboratory study. METHODS: Ten fresh-frozen human cadaveric knees were subjected to a simulated pivot-shift test with coupled 10-N·m valgus and 5-N·m internal rotation torques from 0° to 60° of knee flexion and a 5-N·m internal rotation torque and an 88-N anterior tibial load, both from 0° to 120° of knee flexion via a 6 degrees of freedom robotic system. Kinematic changes were measured and compared with the intact state for isolated sectioning of the ACL and combined sectioning of the ACL and ALL. RESULTS: Combined sectioning of the ACL and ALL resulted in a significant increase in axial plane tibial translation during a simulated pivot shift at 0°, 15°, 30°, and 60° of knee flexion and a significant increase in internal rotation at 0°, 15°, 30°, 45°, 60°, 75°, 90°, 105°, and 120° when compared with the intact and ACL-deficient states. Based on the model results, ALL sectioning resulted in an additional 2.1 mm (95% CI, 1.4-2.9 mm; P < .001) of axial plane translation during the pivot shift when compared with ACL-only sectioning, when pooling evidence over all flexion angles. Likewise, when subjected to IR torque, the ACL+ALL-deficient state resulted in an additional 3.2° of internal rotation (95% CI, 2.4°-4.1°; P < .001) versus the intact state, and the additional sectioning of the ALL increased internal rotation by 2.7° (95% CI, 1.8°-3.6°; P < .001) versus the ACL-deficient state. CONCLUSION: The results of this study confirm the ALL as an important lateral knee structure that provides rotatory stability to the knee. Specifically, the ALL was a significant secondary stabilizer throughout flexion during an applied internal rotation torque and simulated pivot-shift test in the context of an ACL-deficient knee. CLINICAL RELEVANCE: Residual internal rotation and a positive pivot shift after ACL reconstruction may be attributed to ALL injury. For these patients, surgical treatment of an ALL tear may be considered.

High rate of implant loosening for uncemented resurfacing-type medial unicompartmental knee arthroplasty.

PURPOSE: To determine the medium-term implant survivorship, the clinical results and the failure mechanisms of a novel unicompartmental arthroplasty for uncemented resurfacing of the medial tibio-femoral compartment. METHODS: Seventy-six consecutive patients were prospectively evaluated with a mean final follow-up of 6 years (SD 5.3 months). In 44 patients, the diagnosis was osteoarthritis, and in 32 patients, it was avascular necrosis of the medial femoral condyle. The Hospital for Special Surgery Score was used for objective clinical evaluation, and a self-administered visual analogue scale was used to quantify residual pain at each observation point. Implant survivorship was determined assuming revision for any reason as endpoint. RESULTS: Nineteen patients were revised (6 with osteoarthritis and 13 with avascular necrosis of the medial femoral condyle). The mean interval time from index surgery to revision was 11.2 months (SD 4.66 months). Implant survivorship was higher in patients with osteoarthritis with respect to those with avascular necrosis of the medial femoral condyle (p = 0.018). Aseptic loosening was the most frequent failure mechanism. Femoral component loosening was reported in five patients and tibial component loosening was reported in other six patients. Assuming revision for any reason as endpoint, an implant survivorship of 74.3 % at 6-year follow-up was determined. In the remaining 57 patients, satisfactory clinical results were obtained. Hospital for Special Surgery Score and visual analogue scale for residual pain showed significant improvements (p < 0.03 and p < 0.045, respectively). CONCLUSIONS: At the present time, the standard cemented implants and the conventional designs for unicompartmental knee replacement still represent the optimal solution. The authors do not recommend the widespread use of this technique. LEVEL OF EVIDENCE: IV.

Clinically relevant anatomy and what anatomic reconstruction means.

BACKGROUND: Within the past 20 years, knee ligament injuries have been increasingly reported in the literature to be treated with anatomic reconstructions over soft tissue advancements or sling-type procedures to recreate the native anatomy and restore knee function. Historically, early clinician scientists published on the qualitative anatomy of the knee, which provided a foundation for the initial knee biomechanical studies in the nineteenth and twentieth centuries. Similarly, the work of early sports medicine orthopaedic clinician scientists in the late twentieth century formed the basis for the quantitative anatomic and functional robotic biomechanical studies found currently in the sports medicine orthopaedic literature. The development of an anatomic reconstruction first requires an appreciation of the quantitative anatomy and function of each major stabilizing component of the knee. PURPOSE: This paper provides an overview of the initial qualitative anatomic studies from which the initial knee ligament surgeries were based and expands to recent detailed quantitative studies of the major knee ligaments and the renewed recent focus on anatomic surgical reconstructions. CONCLUSIONS: Anatomic repairs and reconstructions of the anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament and posterolateral corner attempt to restore knee function by rebuilding or restoring the native anatomy. The basis of anatomic reconstruction techniques is a detailed understanding of quantitative knee anatomy. Additionally, an appreciation of the function of each component is necessary to ensure surgical success. LEVEL OF EVIDENCE: V.

MRI evaluation of a collagen meniscus implant: a systematic review.

PURPOSE: Good clinical results have been demonstrated in numerous clinical studies using the collagen meniscus implant (CMI); however, the MRI behaviour of the scaffold, evaluated with Genovese score, is limited to a few cases series. The purpose was to evaluate, using the Genovese score, the MRI behaviour of the CMI at different follow-up periods and investigate possible differences in the behaviour of lateral and medial CMI. METHODS: A comprehensive search was performed on PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using various combinations of the following keywords: "collagen meniscus implant" or "collagen meniscal implant". All the studies evaluating medial or lateral CMI using Genovese score for MRI were included in the systematic review. RESULTS: Six studies have been included in the systematic review, with no RCT's. The pooled number of patients involved in CMI surgery was 194 (83 % medial and 17 % lateral), with a mean age at surgery of 37.7 years. Concomitant procedures raged from 11 to 52 %. CMI morphology was grade 1 in 0, 2.7, 5.9, 0, 16.7 %, respectively, at 6 months, 1, 2, 5, 10 years. It was grade 2 in 12.5, 60.9, 60.3, 74.4, 75 %, respectively, at 6 months, 1, 2, 5, 10 years and grade 3 in 87.5, 36.4, 33.8, 25.6, 8.3 % at the same time points. CMI signal intensity was grade 1 in 80, 18.2, 25, 11.1, 22.2 %, respectively, at 6 months, 1, 2, 5, 10 years. It was grade 2 in 20, 78.2, 54.7, 55.6, 66.7 %, respectively, at 6 months, 1, 2, 5, 10 years and grade 3 in 0, 3.6, 20.3, 33.3, 11.1 % at the same time points. Slight differences were found between medial and lateral CMI in size and signal intensity. CONCLUSIONS: Higher rates of scaffolds with reduced size and with an MRI signal intensity more similar to normal meniscus were reported at longer follow-up compared with initial evaluations. Correlation between MRI findings and gross CMI appearance has not been reported. LEVEL OF EVIDENCE: IV.

Anatomic and nonanatomic double-bundle anterior cruciate ligament reconstruction: an in vivo kinematic analysis.

BACKGROUND: There have been no direct in vivo biomechanical comparisons performed between an anatomic double-bundle (ADB) and a nonanatomic double-bundle (NADB) anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS: There are differences in kinematic outcomes between ADB and NADB ACL reconstruction techniques. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-six consecutive patients (mean age, 30 years; range, 18-32 years; 23 men, 3 women; 17 right knees, 9 left knees) with an isolated ACL injury were included in the study. The first 13 consecutive patients underwent NADB reconstruction (combination of a single-bundle and an over-the-top reconstruction), and the following 13 consecutive patients were treated with an ADB approach (using 2 tibial tunnels and 2 femoral tunnels placed in the center of the native femoral and tibial insertion sites). Grafts were pretensioned at 80 N and secured with cortical fixation systems under manual maximum force tension. Standard clinical laxity and pivot-shift tests were quantified at time zero before and after ACL reconstruction by means of a surgical navigation system dedicated to kinematic assessment; displacement of the medial and lateral compartments during the tests was also analyzed. RESULTS: The ADB-reconstructed knees showed a larger preoperative-to-postoperative difference in anterior-posterior tibial plateau displacement of the medial and lateral compartments when compared with the NADB-reconstructed knees during the internal-external rotation test at 30° of flexion (P < .050). No other significant differences in laxity or pivot-shift values were noted. The mean surgical time for ADB reconstruction was significantly higher than that for NABD reconstruction (62 ± 13 and 43 ± 10 minutes, respectively; P < .0001). CONCLUSION: Results showed a greater anterior-posterior translation of both compartments during the rotational passive laxity test in the ADB reconstruction group or overconstraint caused by the NADB technique. The 2 analyzed double-bundle ACL reconstructions did not show any significant quantitative difference in isolated anterior-posterior laxity and pivot-shift phenomenon at time zero. CLINICAL RELEVANCE: Nonanatomic double-bundle ACL reconstruction can control anterior-posterior laxity and the pivot-shift phenomenon as well as ABD ACL reconstruction.

Minimum thickness of all-poly tibial component unicompartmental knee arthroplasty in patients younger than 60 years does not increase revision rate for aseptic loosening.

PURPOSE: Management of unicompartmental knee osteoarthritis in middle-aged patients is a challenging problem. Despite its functional advantages, UKA still raises questions concerning implant survivorship and an increased revision risk for aseptic loosening mainly due to polyethylene wear. The main purpose of the present study was to investigate whether using the minimum thickness of an all-poly tibial UKA in patients under 60 years of age increases the revision rate for aseptic loosening. The secondary purposes were to compare implant survivorship with data reported in literature and to prospectively evaluate the clinical outcome in this selected group of patients. METHODS: Thirty-three consecutive patients under 60 years of age at the time of surgery with isolated medial compartment osteoarthritis underwent a unilateral medial UKA from 2002 to 2005 and were prospectively followed. A Kaplan-Meier analysis was performed to determine the 8-year implant survivorship with revision for any reason as endpoint. KSS, WOMAC, Tegner-Lysholm, Tegner and VAS scores were prospectively evaluated at 3- to 8-year follow-up. Weight-bearing radiographs were collected pre-operatively and at 3- to 8-year follow-up to prospectively evaluate hip-knee-ankle angle (HKA), femoro-tibial angle (FTA), tibial plateau angle and posterior tibial slope. RESULTS: The 8-year Kaplan-Meier survivorship with revision for any reason as endpoint was 83 %. Five failures were reported, and in 3 patients' aseptic loosening of the tibial component was the reason for failure. All clinical scores significantly improved at 3-year follow-up, and no further modification was demonstrated up to 8-year follow-up. HKA, FTA and TPA had a significant difference at 3-year follow-up with respect to pre-operative values (p < 0.01) and no further difference at 8-year follow-up was found. CONCLUSIONS: The present study failed to demonstrate an increased revision rate for aseptic loosening of the implant in patients under 60 years of age, who received an all-poly tibial component UKA using the minimum thickness of the implant in all cases.

Anatomic double-bundle anterior cruciate ligament reconstruction leaving hamstrings tibial insertion intact: technical note.

This article describes an anatomic, double-bundle, arthroscopic anterior cruciate ligament reconstruction technique with hamstrings using second-generation out-in retrograde femoral drills, second-generation cortical femoral suspensory fixation devices with adjustable graft loop length, standard out-in tibial drills, and titanium low-profile tibial staples. Grafts choice is autologous gracilis and semitendinosus tendons. They are harvested through the single minimally invasive tibial incision maintaining their tibial insertion. Sutures are tightened at the free proximal tendon ends to obtain a sufficient strength to traction. The grafts are reflected in two separate loops and linked to femoral adjustable TightRope graft loops. With this method, grafts length can be customized to the anatomy of every knee and their tension can be increased even after graft fixation. The preservation of tendons tibial insertion could improve the neoligamentization process, acting as a tenodesis.

Can the pivot-shift be eliminated by anatomic double-bundle anterior cruciate ligament reconstruction?

PURPOSE: To assess the ability of anatomic double-bundle anterior cruciate ligament reconstruction in eliminating the pivot-shift phenomenon when identified by a quantitative measuring system (computer navigation or magnetic resonance imaging). METHODS: Literature review. Medline, Google Scholar and Cochrane Reviews computerized databases research using the keywords "pivot-shift," "anterior cruciate ligament reconstruction" and "double bundle." Twelve (7 in vitro and 5 in vivo) studies met the inclusion criteria. RESULTS: There was a wide variation in the absolute value of translation and rotation measured after anatomic double-bundle anterior cruciate ligament reconstruction. There were also differences in fixation methods, pivot-shift execution conditions, applied stresses during the pivot-shift, calculation methods and reference systems utilized by measurement systems. CONCLUSIONS: The double-bundle reconstruction was shown to over-constrain the knee with respect to the intact value, especially closer to knee extension. This review demonstrated that anatomic double-bundle anterior cruciate ligament reconstruction is able to eliminate pathological translations and rotations during the pivot-shift phenomenon, as identified by quantitative measurement systems. LEVEL OF EVIDENCE: Review of Level III studies, Level III.

Long-term outcomes after repair of recurrent post-traumatic anterior shoulder instability: comparison of arthroscopic transglenoid suture and open Bankart reconstruction.

PURPOSE: The purpose of this study is to report long-term outcomes of the arthroscopic modified Caspari technique compared to an open capsular shift surgery to treat post-traumatic anterior shoulder recurrent instability. The hypothesis was that the open surgery group would show higher degenerative changes than to the modified Caspari technique group after a follow-up from 10 to 17 years. METHODS: One hundred and ten nonrandomized consecutive patients who underwent a surgical repair of recurrent unilateral anterior shoulder instability between 1990 and 1999 were retrospectively analyzed. Eighty-two patients were available for long-term follow-up. In particular, 49 patients (59.8%) (group A) were treated with arthroscopic transglenoid modified Caspari suturing technique (mean follow-up 13.7 ± 2.2 years), whereas 33 patients (40.2%) (group B) were treated with combined open capsular shift and Bankart repair (mean follow-up 15.7 ± 2.2 years). Patients were evaluated according to the failure rate (re-dislocation), Rowe, UCLA, and Constant scores. Radiological osteoarthritis changes were ranked according to Samilson score. RESULTS: There were no statistically significant differences between the two groups concerning the failure rate (n.s.), Rowe (n.s.), UCLA (n.s.), and Constant (n.s.) scores. Group A: re-dislocation rate 12.5% (6 re-dislocations), Rowe 85.0 ± 22.6, UCLA 26.4 ± 4.8, and Constant 86.3 ± 16.7. Group B: re-dislocation rate 9% (3 re-dislocations), Rowe 83.2 ± 24.4, UCLA 26.9 ± 4.2, and Constant 87.4 ± 14.1. Radiographic findings of osteoarthritis: 2 severe (4%), 4 moderate (8%), and 12 mild (25%) in group A; 2 severe (6%), 4 moderate (12%), and 9 mild (27%) in group B; differences between groups were not statistically significant (n.s). CONCLUSIONS: The results after both techniques were good in majority of patients, with no significant differences in terms of re-dislocation and osteoarthritis development. Compared to the current literature, the recurrence rate was high in both groups. The modified Caspari technique could be an arthroscopic alternative for older, non-athletic shoulders. LEVEL OF EVIDENCE: Therapeutic Study-Retrospective Comparative Study, Level III.

Meniscal allograft transplantation without bone plugs: a 3-year minimum follow-up study.

BACKGROUND: Meniscal allograft transplantation is a viable option for subtotally meniscectomized and totally meniscectomized symptomatic patients and potentially results in pain relief and increased function. HYPOTHESIS: The use of a single tibial tunnel arthroscopic technique without bone plugs will reduce symptoms (pain) and improve knee function at a minimum 3-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty-two meniscal transplantations (16 medial, 16 lateral; 23 men, 9 women) were prospectively evaluated at a minimum of 36 months (mean, 40.4 ± 6.90 months; range, 36-66 months) after surgery. The average age at the time of surgery was 35.6 ± 10.3 years (range, 15-55 years). The transplantation was performed using an arthroscopic bone plug-free technique with a single tibial tunnel plus "all-inside" meniscal sutures. The anterior meniscal horn was sutured to the capsule. Follow-up included a visual analog scale (VAS) score for knee pain and subjective and objective International Knee Documentation Committee (IKDC), Lysholm, Tegner, and SF-36 scores. All patients underwent radiographic and magnetic resonance imaging (MRI) evaluation of the involved knee before the surgery and at the final follow-up. The MRI outcomes were evaluated with the modified Yulish score. RESULTS: Regarding clinical evaluation, there was a significant improvement in scores at follow-up compared with preoperatively: the VAS score decreased from 70.6 ± 21.7 to 25.2 ± 22.7 (P < .0001), the SF-36 physical component score increased from 37.31 ± 7.2 to 49.69 ± 8.3 (P < .0001), the SF-36 mental component score increased from 49.69 ± 10.8 to 53.53 ± 7.5 (P = .0032), the Tegner activity score increased from 3 (range, 3-5) to 5 (range, 3-6) (P < .0121), the Lysholm score increased from 59.78 ± 18.25 to 84.84 ± 14.4 (P < .0001), the subjective IKDC score increased from 47.44 ± 20.60 to 77.20 ± 15.57 (P < .0001), and the objective IKDC score changed from 1 A, 21 B, 6 C, and 4 D to 22 A, 9 B, and 1 C (P < .0001). No significant difference was found in this study between patients who received medial allografts and patients who received lateral allografts. There was no significant difference between outcomes of patients with isolated and combined procedures. The MRI findings showed 69% extruded allografts (8 medial and 14 lateral). In detail, we found 50% of the medial allografts and 87% of the lateral allografts extruded. No significant difference in clinical outcomes and modified Yulish score was found between patients with extruded allografts and with in situ allografts. The MRI results also showed a significant decrease of the modified Yulish score from baseline to 3-year minimum follow-up (P < .0001 for femur and P < .0001 for tibia). Only one patient underwent arthroscopic selective meniscectomy because of a medial posterior horn retear of the graft. One patient developed lack of flexion and underwent an arthroscopic arthrolysis. These 2 patients did not draw benefit from allografting and therefore were considered failures. In all remaining cases (94%), meniscal allograft transplantation was able to reduce symptoms (pain measured by VAS) and improve knee function (as measured by IKDC and Lysholm scores). CONCLUSION: This study found that a single tibial tunnel arthroscopic technique without bone plugs for meniscal allograft transplantation significantly reduced pain and improved knee function in 94% of patients at a minimum 3-year follow-up.

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

The purposes of this paper are to summarize the concepts relating to the use of a combined intra-articular and extra-articular reconstructive procedure in the arthroscopic treatment of a torn ACL and to review several operative techniques utilizing gracilis and semitendinosus tendons that are currently in use to treat this instability. The highly satisfactory results obtained over the time show that a combination of intra- and extra-articular procedures for ACL reconstruction is a valid surgical option.