Internal rotation of the tibial component is frequent in stiff total knee arthroplasty.

BACKGROUND: Stiffness complicating TKA is a complex and multifactorial problem. We suspected internally rotated components compromised motion because of pain, patellar maltracking, a tight medial flexion gap, and limited femoral rollback on a conforming lateral tibial condyle. QUESTIONS/PURPOSES: We sought to determine: (1) the incidence of internal rotation of the femoral and tibial components in stiff TKAs; (2) if revision surgery that included correction of rotational positioning improved pain, ROM, and patellar tracking; and (3) if revision altered nonrotational radiographic parameters. METHODS: From a cohort of 52 patients with TKAs revised for stiffness, we performed CT scans of 34 before and 18 after revision to quantify rotational positioning of the femoral and tibial components using a previously validated scanning protocol. RESULTS: All 34 patients with TKAs had internal rotation of the summed values for tibial and femoral components (mean, 14.8°; range, 2.7°-33.7°) before revision for stiffness. The incidence of internal rotation was 24 of 34 femoral (mean, 3.1°; internal) and 33 of 34 tibial components (mean, 13.7° internal). Revision arthroplasty improved Knee Society function, knee, and pain scores. Mean extension improved from a contracture of 10.1° to 0.8° and flexion from 71.5° to 100°. Postrevision CT scans confirmed correction of component rotation. Nonrotational parameters were unchanged. CONCLUSIONS: We recommend CT scanning of patients with stiff TKAs before surgical intervention to identify the presence of internally rotated components. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Revision anterior cruciate ligament reconstruction.

Revision reconstruction of the anterior cruciate ligament (ACL) introduces several diagnostic and technical challenges in comparison with primary ACL reconstruction. With the increasing numbers of original reconstructions combined with the continued expectation of high-level athletic participation, revision ACL reconstruction is likely to become more frequent. The purpose of this article was to summarize the causes of failure and the evaluation of the patient with recurrent instability. A review of the literature regarding results after revision ACL reconstruction was performed to assist in the decision-making process and patient counseling. Good results can be obtained in terms of functional stability after revision reconstruction, but chondral and meniscal injury as well as unrecognized associated pathologic instability may play a role in diminished outcomes. In addition, a wide variety of surgical techniques are reviewed to address problems associated with tunnel malposition, widening, and pre-existing hardware.

Femoral radiographic landmarks for lateral collateral ligament reconstruction and repair: a new method of reference.

BACKGROUND: Little work has been made regarding the use of radiographic landmarks in fibular collateral ligament reconstruction. Radiographic tools can be of use to the surgeon in posterolateral reconstruction as secondary checks in the setting of tissue and bony attrition. HYPOTHESIS: Using standardized radiographic imaging, a zone for femoral tunnel placement in lateral collateral ligament (LCL) reconstruction can be identified. STUDY DESIGN: Descriptive laboratory study. METHODS: Eight fresh-frozen unmatched knees, free of any osseous or articular pathological changes, were selected for dissection (mean age, 61.3 years). Skin and surrounding soft tissues were left intact. Subsequent dissection was carried out to identify the true origin of the LCL. A radiographic marker was applied. True lateral radiographs of the distal femur (posterior condyles overlapping) were taken. Digital radiographic images were obtained and analyzed. RESULTS: The Blumensaat line was found to be closely associated with the LCL origin on lateral radiographic imaging. On average, the LCL ligament was found to be 58% (+ or - 4.7%) across the width of the condyle and 2.3 mm (+ or - 2.3 mm) distal to the Blumensaat line. In all specimens, the anatomical LCL origin was found to have less than 5 mm variance from the mean. CONCLUSION: The LCL origin is located within a specific region that is noted to have a small amount of variance. This is of benefit to the clinician in the traumatic and reconstructive setting where the true origin may not be easily identifiable through dissection. CLINICAL RELEVANCE: Intraoperative fluoroscopic imaging can be used as an adjunctive tool for femoral tunnel placement during posterolateral corner and LCL reconstruction.

Anatomical confirmation of the use of radiographic landmarks in medial patellofemoral ligament reconstruction.

BACKGROUND: A recent study has described radiographic landmarks for femoral insertion of the medial patellofemoral ligament. Clinical relevance and application of these landmarks for surgical reconstruction have yet to be determined. HYPOTHESIS: Radiographic landmarks can be used to accurately determine the femoral insertion of the medial patellofemoral ligament in a percutaneous fluoroscopically guided surgical technique. STUDY DESIGN: Descriptive laboratory study. METHODS: The femoral insertion of the medial patellofemoral ligament was estimated using fluoroscopy in 8 fresh-frozen human cadaveric knees. The knees were dissected and the true anatomical medial patellofemoral ligament femoral insertion was identified. Radiographic markers were placed on both the estimated and anatomical medial patellofemoral ligament and a repeat lateral radiograph was performed. Using imaging software, the distance between the true anatomical insertion and the fluoroscopically determined insertion was calculated. Results All 8 points determined by fluoroscopically guided pin placement averaged less than 4 mm from the anatomical insertion. The radiographic landmark method consistently placed the origin on average 2.5 mm anterior and 0.6 mm distal to the anatomical insertion. CONCLUSION: Radiographic landmarks determined by fluoroscopy can be used to accurately reproduce the femoral insertion of the medial patellofemoral ligament in ligament reconstruction. CLINICAL RELEVANCE: Confirming the use of radiographic landmarks to determine the medial patellofemoral ligament femoral insertion may help to increase accuracy and precision in ligament reconstruction and minimize surgical dissection.

2009 survey results: surgeon practice patterns regarding arthroscopic surgery.

A survey was conducted to collect information on the surgical management and practice preferences of the audience members at a recent continuing medical education conference. Participants were polled on a variety of surgical topics, and their responses were recorded using a wireless audience response system. The answers were tabulated and are presented in this report. The majority of respondents preferred an arthroscopic repair for rotator cuff tears (52%) and shoulder instability (71%). Most (50%) perform single-row repair; 33% perform double-row repair. For simple knee arthroscopy, most use preoperative antibiotics (85%), no tourniquet (53%), and no chemical anticoagulation or only compression boots (69%). For cruciate ligament reconstruction, the majority preferred only a preoperative antibiotic (67%), no chemical anticoagulation or only compression boots (56%), and single-bundle reconstruction (88%) using a transtibial femoral tunnel (78%). Most (47%) prefer an all inside suture-based meniscus repair device.

Achilles lengthening/posterior tibial tenotomy with immediate weightbearing for patients with significant comorbidities.

BACKGROUND: Fixed equinovarus deformities can be challenging to treat especially in medically debilitated patients. The purpose of this study was to evaluate Achilles lengthening with posterior tibial tenotomy and immediate weightbearing in this difficult group of patients. MATERIALS AND METHODS: Thirteen extremities in 10 patients underwent Achilles lengthening and posterior tibial tenotomy for fixed equinovarus deformities with significant medical comorbidities. Pre- and postoperative ambulatory status and deformities were noted. RESULTS: Average age at the time of surgery was 65 with an average duration of deformity 6.3 years. The average equinus corrected from 26 degrees to 1.2 degrees and the average varus deformity improved from -8.5 degrees to 2.7 degrees. All patients except one who was wheelchair-bound had a significant improvement in ambulatory status. CONCLUSION: Achilles lengthening with posterior tibial tenotomy allowed for immediate postoperative weightbearing with improvement in deformity and ambulatory status in this complicated patient group.