Double-Bundle Medial Collateral Ligament Reconstruction Improves Anteromedial Rotatory Instability.

BACKGROUND: New techniques have been proposed to better address anteromedial rotatory instability in a medial collateral ligament (MCL)-injured knee that require an extra graft and more surgical implants, which might not be feasible in every clinical setting. PURPOSE: To investigate if improved resistance to anteromedial rotatory instability can be achieved by using a single-graft, double-bundle (DB) MCL reconstruction with a proximal fixation more anteriorly on the tibia, in comparison with the gold standard single-bundle (SB) MCL reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator in intact knee, superficial MCL/deep MCL-deficient, and reconstruction states. Three different reconstructions were tested: DB MCL no proximal tibial fixation and DB and SB MCL reconstruction with proximal tibial fixation. Knee kinematics were recorded at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8 N·m of valgus rotation (VR), 5 N·m of external tibial rotation, 5 N·m of internal tibial rotation, combined 89 N of anterior tibial translation and 5 N·m of external rotation for anteromedial rotation (AMR) and anteromedial translation (AMT). The differences between each state for every measurement were analyzed with VR and AMR/AMT as primary outcomes. RESULTS: Cutting the superficial MCL/deep MCL increased VR and AMR/AMT in all knee positions except at 90° for VR (P < .05). All reconstructions restored VR to the intact state except at 90° of knee flexion (P < .05). The DB MCL no proximal tibial fixation reconstruction could not restore intact AMR/AMT kinematics in any knee position (P < .05). Adding an anterior-based proximal tibial fixation restored intact AMR/AMT kinematics at ≥30° of knee flexion except at 90° for AMT (P < .05). The SB MCL reconstruction could not restore intact AMR/AMT kinematics at 0° and 90° of knee flexion (P < .05). CONCLUSION: In this in vitro cadaveric study, a DB MCL reconstruction with anteriorly placed proximal tibial fixation was able to control AMR and AMT better than the gold standard SB MCL reconstruction. CLINICAL RELEVANCE: In patients with anteromedial rotatory instability and valgus instability, a DB MCL reconstruction may be superior to the SB MCL reconstruction, without causing extra surgical morbidity or additional costs.

Effect of a Partial Superficial and Deep Medial Collateral Ligament Injury on Knee Joint Laxity.

BACKGROUND: Injuries to the medial collateral ligament (MCL), specifically the deep MCL (dMCL) and superficial MCL (sMCL), are both reported to be factors in anteromedial rotatory instability (AMRI); however, a partial sMCL (psMCL) injury is often present, the effect of which on AMRI is unknown. PURPOSE: To investigate the effect of a dMCL injury with or without a psMCL injury on knee joint laxity. STUDY DESIGN: Controlled laboratory study. METHODS: Sixteen fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator. The anterior cruciate ligament (ACL) was cut first and last in protocols 1 and 2, respectively. The dMCL was cut completely, followed by an intermediary psMCL injury state before the sMCL was completely sectioned. Tibiofemoral kinematics were measured at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8 N·m of valgus rotation (VR), 4 N·m of external tibial rotation, 4 N·m of internal tibial rotation, and combined 89 N of anterior tibial translation and 4 N·m of external tibial rotation for both anteromedial rotation (AMR) and anteromedial translation. The differences between subsequent states, as well as differences with respect to the intact state, were analyzed. RESULTS: In an ACL-intact or -deficient joint, a combined dMCL and psMCL injury increased external tibial rotation and VR compared with the intact state at all angles. A significant increase in AMR was seen in the ACL-intact knee after this combined injury. Cutting the dMCL alone showed lower mean increases in AMR compared with the psMCL injury, which were significant only when the ACL was intact in knee flexion. Moreover, cutting the dMCL had no effect on VR. The ACL was the most important structure in controlling anteromedial translation, followed by the psMCL or dMCL depending on the knee flexion angle. CONCLUSION: A dMCL injury alone may produce a small increase in AMRI but not in VR. A combined dMCL and psMCL injury caused an increase in AMRI and VR. CLINICAL RELEVANCE: In clinical practice, if an increase in AMRI at 30° and 90° of knee flexion is seen together with some increase in VR, a combined dMCL and psMCL injury should be suspected.

Quantitative MRI Analysis of Patellofemoral Joint Cartilage Health 2 Years After Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Tenodesis.

BACKGROUND: The addition of an iliotibial band-based lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction (ACLR) has been shown to reduce failure rates. However, there are concerns as to the potential overconstraint of tibiofemoral kinematics that may increase the risk of cartilage degradation. To date, no clinical study has investigated the effect of LET on patellofemoral joint articular cartilage health. HYPOTHESIS: It was hypothesized that at 2 years postoperatively, (1) the addition of LET at the time of ACLR would have no effect on cartilage health on magnetic resonance imaging (MRI), and (2) higher cartilage relaxation values would be associated with worse patient-reported and functional outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A subset of patients from the STABILITY 1 randomized controlled trial were included. All patients underwent primary ACLR with a hamstring autograft. Patients were randomized to either LET augmentation or not. Cartilage status in the patellofemoral joint between the ACLR group and ACLR+LET group was compared using 2-year postoperative quantitative MRI and the ACL osteoarthritis scores of both the surgical and the contralateral nonsurgical knees. Objective functional outcomes and patient-reported outcome measures (PROMs) were attained. RESULTS: A total of 92 patients (43 patients in the ACLR group; mean age, 18.9 ± 3.2 years; 60.5% female; and 49 patients in the ACLR+LET group; mean age, 18.7 ± 3.2 years, 63.3% female) were included. No significant differences were seen in the mean values (ms) for adjusted T1ρ/T2 relaxation times in the medial patella (47.8/42.2 vs 47.3/43.2), central patella (45.5/42.5 vs 44.1/42.7), lateral patella (48.2/43.5 vs 47.3/43.0), medial trochlea (54.7/50.9 vs 56.4/50.9), central trochlea (53.3/51.1 vs 53.1/52.0), and lateral trochlea (54.9/52.1 vs 53.9/52.6) between the ACLR and ACLR+LET groups. No difference in overall ACL osteoarthritis scores was observed (P = .99). An increase in medial patellar T2 relaxation times was associated with a decreasing International Knee Documentation Committee score (P = .046), Knee injury and Osteoarthritis Outcome Score (KOOS) Symptoms subscale score (P = .01), and total KOOS (P = .01). CONCLUSION: There was no statistical difference in patellofemoral cartilage health between knees 2 years after primary ACLR with hamstring tendon autograft with or without LET. Statistically significant correlations were found between quantitative MRI relaxation times, functional outcome scores, and PROMs; however, the correlations were weak and the clinical significance is unknown. REGISTRATION: NCT02018354 (ClinicalTrials.gov identifier).

Load Sharing of the Deep and Superficial Medial Collateral Ligaments, the Effect of a Partial Superficial Medial Collateral Injury, and Implications on ACL Load.

BACKGROUND: Injuries to the deep medial collateral ligament (dMCL) and partial superficial MCL (psMCL) can cause anteromedial rotatory instability; however, the contribution of each these injuries in restraining anteromedial rotatory instability and the effect on the anterior cruciate ligament (ACL) load remain unknown. PURPOSE: To investigate the contributions of the different MCL structures in restraining tibiofemoral motion and to evaluate the load through the ACL after MCL injury, especially after combined dMCL/psMCL injury. STUDY DESIGN: Controlled laboratory study. METHODS: Sixteen fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator. Tibiofemoral kinematic parameters were recorded at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8-N·m valgus rotation, 4-N·m external tibial rotation (ER), 4-N·m internal tibial rotation, and a combined 89-N anterior tibial translation and 4-N·m ER for both anteromedial rotation (AMR) and anteromedial translation (AMT). The kinematic parameters of the 3 different MCL injuries (dMCL; dMCL/psMCL; dMCL/superficial MCL (sMCL)) were recorded and reapplied either in an ACL-deficient joint (load sharing) or before and after cutting the ACL (ACL load). The loads were calculated by applying the principle of superposition. RESULTS: The dMCL had the largest effect on reducing the force/torque during ER, AMR, and AMT in extension and the psMCL injury at 30° to 90° of knee flexion (P < .05). In a comparison of the load through the ACL when the MCL was intact, the ACL load increased by 46% and 127% after dMCL injury and combined dMCL/psMCL injury, respectively, at 30° of knee flexion during ER. In valgus rotation, a significant increase in ACL load was seen only at 90° of knee flexion. CONCLUSION: The psMCL injury made the largest contribution to the reduction of net force/torque during AMR/AMT at 30° to 90° of flexion. Concomitant dMCL/psMCL injury increased the ACL load, mainly during ER. CLINICAL RELEVANCE: If a surgical procedure is being considered to treat anteromedial rotatory instability, then the procedure should focus on restoring sMCL function, as injury to this structure causes a major loss of the knee joint's capacity to restrain AMR/AMT.

In Vitro Assessment of Knee Joint Biomechanics Using a Virtual Anterior Cruciate Ligament Reconstruction.

Understanding the biomechanical impact of injuries and reconstruction of the anterior cruciate ligament (ACL) is vital for improving surgical treatments that restore normal knee function. The purpose of this study was to develop a technique that enables parametric analysis of the effect of the ACL reconstruction (ACLR) in cadaver knees, by replacing its contributions with that of a specimen-specific virtual ACLR that can be enabled, disabled, or modified. Twelve ACLR reconstructed knees were mounted onto a motion simulator. In situ ACLR graft forces were measured using superposition, and these data were used to design specimen-specific virtual ACLRs that would yield the same ligament force-elongation behaviors. Tests were then repeated using the virtual ACLR in place of the real ACLR and following that in ACL deficient knee by disabling the virtual ACLR. In comparison to the ACL deficient state, the virtual ACLRs were able to restore knee stability to the same extent as real ACLRs. The average differences between the anterior tibial translation (ATT) of the virtual ACLR versus the real ACLR were +1.6 ± 0.9 mm (p = 0.4), +2.1 ± 0.4 mm (p = 0.4), and +1.0 ± 0.9 mm (p = 0.4) during Anterior drawer, Lachman and Pivot-shift tests, respectively, which is small in comparison to the full ATT range of motion (ROM) of these knees. Therefore, we conclude that a virtual ACLR can be used in place of real ACLR during biomechanical testing of cadaveric knees. This capability opens the door for future studies that can leverage parameterization of the ACLR for surgical design optimization.

Lateral Extra-articular Tenodesis Does Not Decrease Graft Failure in Revision Anterior Cruciate Ligament Reconstruction When Combined With Quadriceps or Patellar Tendon Grafts.

PURPOSE: To compare return-to-sport (RTS) rates, graft failure rates, and clinical outcomes in patients who underwent revision anterior cruciate ligament reconstruction (R-ACLR) with additional lateral extra-articular tenodesis (LET) versus isolated R-ACLR. METHODS: A retrospective review of the medical records of patients who underwent R-ACLR with or without a modified Lemaire LET procedure was performed. Seventy-four patients with at least 2 years of follow-up who had high-grade positive pivot-shift test findings were included. Concomitant procedures such as meniscectomy and meniscal repair were collected, along with any complications and/or graft failure. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee Subjective Knee Form score were collected. The ability to RTS was defined as fully, partially, or not returned. RESULTS: Of the patients, 39 underwent isolated R-ACLR (mean age ± standard deviation, 29.2 ± 12.2 years) whereas 35 underwent an additional LET procedure (mean age, 24.6 ± 7.4 years). The mean length of follow-up in the R-ACLR group was 56.6 ± 26.5 months compared with 44.3 ± 17.6 months in the R-ACLR-LET group (P = .02) (range, 24-120 months). Patient-reported outcome measures were higher in the R-ACLR-LET group, with the KOOS Activities of Daily Living (93.5 ± 2.0 vs 97.2 ± 1.6, P = .03) and KOOS Sport (63.0 ± 3.6 vs 74.3 ± 3.8, P = .05) subdomain scores reaching the level of statistical significance. No differences were found in the other KOOS subdomain scores or the International Knee Documentation Committee scores. Failure rates were not significantly different between the groups (12.8% for R-ACLR vs 11.4% for R-ACLR-LET, P = .99). There were 13 patients (72.2%) in the R-ACLR group and 14 patients (60.8%) in the R-ACLR-LET group who did not RTS. CONCLUSIONS: R-ACLR with additional LET showed similar failure and RTS rates to isolated R-ACLR after failed ACLR. The R-ACLR-LET group showed better functional results with significantly higher KOOS subdomain scores for activities of daily living, as well as sports and recreation. However, this study was unable to recommend the modified Lemaire LET procedure to be routinely used in R-ACLR patients. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Closing-Wedge Posterior Tibial Slope-Reducing Osteotomy in Complex Revision ACL Reconstruction.

Background: A posterior tibial slope (PTS) >12° has been shown to correlate with failure of anterior cruciate ligament (ACL) reconstruction (ACLR). PTS-reducing osteotomy has been described to correct the PTS in patients with a deficient ACL, mostly after failure of primary ACLR. Purpose: To report radiologic indices, clinical outcomes, and postoperative complications after PTS-reducing osteotomy performed concurrently with revision ACLR (R-ACLR). Study Design: Case series; Level of evidence, 4. Methods: A review of medical records at 3 institutions was performed of patients who had undergone PTS-reducing osteotomy concurrently with R-ACLR between August 2010 and October 2020. Radiologic parameters recorded included the PTS, patellar height according to the Caton-Deschamps Index (CDI), and anterior tibial translation (ATT). Patient-reported outcomes (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]), reoperations, and complications were evaluated. Results: Included were 23 patients with a mean follow-up of 26.7 months (range, 6-84 months; median, 22.5 months). Statistically significant differences from preoperative to postoperative values were found in PTS (median [range], 14.0° [12°-18°] vs 4.0° [0°-15°], respectively; P < .001), CDI (median, 1.00 vs 1.10, respectively; P = .04) and ATT (median, 8.5 vs 3.6 mm, respectively; P = .001). At the final follow-up, the IKDC score was 52.4 ± 19.2 and the KOOS subscale scores were 81.5 ± 9.5 (Pain), 74 ± 21.6 (Symptoms), 88.5 ± 8 (Activities of Daily Living); 52.5 ± 21.6 (Sport and Recreation), and 48.8 ± 15.8 (Quality of Life). A traumatic ACL graft failure occurred in 2 patients (8.7%). Reoperations were necessary for 6 patients (26.1%) because of symptomatic hardware, and atraumatic recurrent knee instability was diagnosed in 1 patient (4.3%). Conclusion: Tibial slope-reducing osteotomy resulted in a significant decrease of ATT and can be considered in patients with a preoperative PTS ≥12° and ≥1 ACLR failure. In highly complex patients with multiple prior surgeries, the authors found a reasonably low graft failure rate (8.7%) when utilizing PTS-reducing osteotomy. Surgeons must be aware of potential complications in patients with multiple previous failed ACLRs.

Osteochondral Allograft Transplant for Combined Medial and Lateral Patellar Cartilage Lesions: The Osteochondral Wide Lesion (OWL) Technique.

Symptomatic articular cartilage injuries are often seen in young active patients and athletes. Magnetic resonance imaging screening examinations have frequently identified such lesions in athletic patients. Patellofemoral chondral defects were previously identified as the most common knee cartilage lesion in high-level athletes. Chondral defects measuring 2 cm2 or greater and complex cartilage defects involving bone loss are ideally replaced with fresh osteochondral allograft. We describe a technique indicated for patients with symptomatic and recurrent anterior knee pain associated with osteochondral patellar defects including the lateral and medial patellar facets. Patients who have undergone previous interventions, including membrane techniques, microfracture, or autologous chondral transplantation, without clinical benefit are also eligible to undergo osteochondral allograft transplantation for combined medial and lateral patellar cartilage lesions, that is, the osteochondral wide lesion (OWL) technique.

Treatment of Distal Patellar Tendon Chronic Rupture: The X-Wave Technique.

Injuries to the patellar tendon (PT) are associated with knee function deterioration and loss of the capacity to perform daily and sports activities. Patellar tendon injury is often misdiagnosed at emergency rooms, leading to chronic proximal retraction and a challenging clinical scenario. Proximal PT injuries are more common, while distal ones, which can involve tibial bone avulsion fractures or direct tendon avulsion, are rarer. The low incidence of distal PT rupture and the variety of injury patterns make a personal approach reasonable when based on the intraoperative findings and the surgeon's experience. Our purpose is to describe a surgical technique to restore the knee extensor mechanism after chronic distal PT rupture using two kinds of graft, one as a waveform augmentation of the native tendon and the other as reinforcement in a letter X aspect.

Posterior-Medial Meniscal Root Repair Through Lateral Tibial Tunnel Combined With Medial Opening Osteotomy and Homologous Graft.

When there is a rupture in the meniscal roots or close to them, the menisci suddenly and considerably reduce their capacity to absorb the axial mechanical load that passes through the knee, quickly leading to the development of a process of chondral degeneration. The varus deformity of the lower limb (when the mechanical axis crosses the medial compartment of the knee) favors this type of injury owing to the overload in the medial compartment. When the patient has both varus deformity and medial meniscal posterior root injury, there is a clear indication for surgical realignment of the affected lower limb. There is still not a consensus regarding combining meniscal root repair with corrective osteotomy, although there is a tendency to perform both procedures aiming at long-term joint preservation. We present a safe alternative technique for simultaneous medial meniscal posterior root repair using a lateral tibial transosseous tunnel associated with a valgus-producing high tibial osteotomy with homologous bone grafting, allowing a full return to daily activities and sports.

Biomechanical Assessment of Knee Laxity After a Novel Posterolateral Corner Reconstruction Technique.

BACKGROUND: Different techniques to restore knee stability after posterolateral corner (PLC) injury have been described. The original anatomic PLC reconstruction uses 2 separate allografts to reconstruct the PLC. Access to allograft tissue continues to be a significant limitation of this technique, which led to the development of a modified anatomic approach utilizing a single autologous semitendinosus graft fixed on the tibia with an adjustable suspensory loop to enable differential tensioning of the PLC components. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the modified anatomic technique with the original anatomic reconstruction in terms of varus and external rotatory laxity in a cadaveric biomechanical model. The hypothesis was that both techniques would restore varus and external rotatory laxity after a simulated complete PLC injury. STUDY DESIGN: Controlled laboratory study. METHODS: Eight pairs of fresh-frozen cadaveric knee specimens were tested to compare the 2 techniques. Varus and external tibial rotation laxity of the knee were measured while applying 10-N·m varus and 5-N·m external rotatory torques at 0°, 30°, 60°, and 90° of flexion. These measurements were tested under 3 conditions: (1) intact fibular collateral ligament, popliteal tendon, and popliteofibular ligament; (2) complete transection of the fibular collateral ligament, popliteal tendon, and popliteofibular ligament; (3) after PLC reconstruction with either the modified (n = 8) or the original (n = 8) technique. RESULTS: After PLC reconstruction, varus laxity was restored with no statistically significant differences from the intact condition after both reconstruction techniques. Similar outcomes were observed for external rotation in extension; however, in terms of the external rotation limit with respect to the intact joint, significant reductions of mean ± SD 4.1°± 6.3° (P = .036) and 5.1°± 6.6° (P = .016) were recorded with the modified technique at 60° and 90° of flexion, respectively. No significant effect was observed on the neutral flexion kinematics from 0° to 90° of flexion, and no significant differences were observed between reconstructions (P = .222). CONCLUSION: Both PLC reconstruction techniques restored the normal native varus as compared with the intact knee. Although the modified technique constrained end-range external rotation at 60° and 90° of flexion, no differences were noted with neutral flexion kinematics. Care should be taken when tensioning in the modified technique so that the tibia is in a neutral position to avoid overconstraining the knee. CLINICAL RELEVANCE: The modified technique may prove useful in situations where there are limited graft options, particularly where allografts are not available or are restricted.

Quadriceps tendon autograft is becoming increasingly popular in revision ACL reconstruction.

PURPOSE: To evaluate trends in revision anterior cruciate ligament reconstruction (ACL-R), with emphasis on intra-articular findings, grafts, and concurrent procedures. It was hypothesized that revision ACL-Rs over time show a trend toward increased complexity with increased use of autografts over allografts. METHODS: This was a two-center retrospective study including patients undergoing revision ACL-R between 2010 and 2020. Demographic and surgical data including intra-articular findings and concurrent procedures were collected and compared for the time periods 2010-2014 and 2015-2020. All collected variables were compared between three pre-defined age groups (< 20 years, 20-30 years, > 30 years), right and left knees, and males and females. A time series analysis was performed to assess trends in revision ACL-R. RESULTS: This study included 260 patients with a mean age of 26.2 ± 9.4 years at the time of the most recent revision ACL-R, representing the first, second, third, and fourth revision ACL-R for 214 (82%), 35 (14%), 10 (4%), and 1 (< 1%) patients, respectively. Patients age > 30 years showed a significantly longer mean time from primary ACL-R to most recent revision ACL-R (11.1 years), compared to patients age < 20 years (2.2 years, p < 0.001) and age 20-30 years (5.5 years, p < 0.05). Quadriceps tendon autograft was used significantly more often in 2015-2020 compared to 2010-2014 (49% vs. 18%, p < 0.001). A high rate of concurrently performed procedures including meniscal repairs (45%), lateral extra-articular tenodesis (LET; 31%), osteotomies (13%), and meniscal allograft transplantations (11%) was shown. Concurrent LET was associated with intact cartilage and severely abnormal preoperative knee laxity and showed a statistically significant and linear increase over time (p < 0.05). Intact cartilage (41%, p < 0.05), concurrent medial meniscal repairs (39%, p < 0.05), and LET (35%, non-significant) were most frequently observed in patients aged < 20 years. CONCLUSION: Quadriceps tendon autograft and concurrent LET are becoming increasingly popular in revision ACL-R. Intact cartilage and severely abnormal preoperative knee laxity represent indications for LET in revision ACL-R. The high rate of concurrent procedures observed demonstrates the high surgical demands of revision ACL-R. LEVEL OF EVIDENCE: Level III.

Clinical outcomes of contemporary lateral augmentation techniques in primary ACL reconstruction: a systematic review and meta-analysis.

PURPOSE: The purpose of this investigation was to systematically review the contemporary literature to determine if a lateral augmentation (LA) added to an Anterior Cruciate Ligament Reconstruction (ACLR) provides better clinical and patient reported outcomes compared to an isolated ACLR. METHODS: A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) criteria. Two authors independently conducted an electronic search using MEDLINE® and Embase® on February 6th, 2021 for level I-III randomized controlled trials (RCT) and prospective cohort studies without randomization, published after 2012 and with a minimum of two year follow-up. Publications were included when they reported on the objective knee stability examination, patient reported outcome scores, return to sports or graft rupture rate of any type of primary, isolated ACLR compared to ACLR combined with any type of LA. RESULTS: A total of 11 studies that reported on a combined total of 1892 unique patients were eligible for data extraction, including five RCTs and six prospective cohort studies. In 6 studies, an Anterolateral Ligament reconstruction (ALLR) was the LA of choice, while the 5 other publications used different types of Lateral Extra-articular Tenodesis (LET). A significant reduction in graft ruptures was found in patients treated with ACLR + LA (3%) compared to isolated ACLR (12%). Rotational laxity was significantly higher in isolated ACLR (14%) compared to ACLR + LA (6%). Addition of a LA reduced anterior translation when assessed via instrumented laxity testing. No significant difference was found in the patient reported outcome scores (IKDC and Tegner) between both patient groups, except for the Lysholm Score which was significant in favour of the ACLR + LA group. CONCLUSION: Combination of a primary ACLR with a LA can significantly reduce the risk of graft rupture and provide better rotatory stability, without jeopardizing patient reported outcomes. LEVEL OF EVIDENCE: Level III, Systematic Review of Level I, II and III studies.

Functional Outcome of Patients Undergoing Knee Arthrodesis after Infected Total Arthroplasty.

Objective Retrospectively assess the functional outcome of patients undergoing arthrodesis after septic failure of total knee arthroplasty. Methods Eighteen patients were evaluated, with a mean time of 3.7 years of follow-up. Arthrodesis surgery was performed using a narrow anterior dynamic compression plate, and medial or external fixator in two planes of the joint (Orthofix Bone Growth Therapy, Lewisville, TS, USA), at the surgeon's discretion. Results The most frequent pathogen found was Staphylococcus aureus methicillin sensitive (38.9%). The mean lower limb discrepancy was 3.63 cm. The mean knee society score was 68 points. According to the visual analog scale for pain, 44% of the patients had a 0 score at the time of assessment, and 22.2% were very dissatisfied, despite the bone healing achieved. Patients were assessed for the ability to walk with or without assistance. Conclusion Knee arthrodesis surgery was effective in controlling the infectious process and decreasing pain complaints, but satisfaction with the procedure was low.

Functional Outcome of Patients Undergoing Knee Arthrodesis after Infected Total Arthroplasty / Resultado funcional dos pacientes submetidos a artrodese de joelho após artroplastia total infectada

Abstract Objective Retrospectively assess the functional outcome of patients undergoing arthrodesis after septic failure of total knee arthroplasty. Methods Eighteen patients were evaluated, with a mean time of 3.7 years of follow-up. Arthrodesis surgery was performed using a narrow anterior dynamic compression plate, and medial or external fixator in two planes of the joint (Orthofix Bone Growth Therapy, Lewisville, TS, USA), at the surgeon's discretion. Results The most frequent pathogen found was Staphylococcus aureus methicillin sensitive (38.9%). The mean lower limb discrepancy was 3.63 cm. The mean knee society score was 68 points. According to the visual analog scale for pain, 44% of the patients had a 0 score at the time of assessment, and 22.2% were very dissatisfied, despite the bone healing achieved. Patients were assessed for the ability to walk with or without assistance. Conclusion Knee arthrodesis surgery was effective in controlling the infectious process and decreasing pain complaints, but satisfaction with the procedure was low.

Resumo Objetivo Avaliar de modo retrospectivo o resultado funcional dos pacientes submetidos a artrodese após falha séptica da artroplastia total de joelho. Métodos Foram avaliados 18 pacientes com tempo médio de 3,7 anos de seguimento. A cirurgia de artrodese foi realizada com placa do tipo dynamic compression plate (DCP) estreita, anterior e medial, ou fixador externo em dois planos da articulação (Orthofix Bone Growth Therapy, Lewisville, TS, EUA), a critério do cirurgião. Resultados O patógeno mais frequentemente encontrado foi o Staphylococcus aureus sensível a meticilina (38,9%). A discrepância de membros inferiores média foi de 3,63 cm. O da knee society score (KSS) médio foi de 68 pontos. Segundo a escala analógica visual de dor, 44% dos pacientes apresentaram pontuação zero no momento da avaliação, e 22,2% estavam muito insatisfeitos a despeito da consolidação óssea obtida. Os pacientes foram avaliados quanto à capacidade de deambular com ou sem auxílio de apoio. Conclusão A cirurgia de artrodese do joelho se mostrou eficiente quanto ao controle do processo infeccioso e diminuição das queixas álgicas, porém a satisfação com o procedimento é baixa.

Protocol for Harvest, Transport and Storage of Human Osteochondral Tissue.

Objective To elaborate a protocol for the harvest, transport, and preservation of human osteochondral tissue for use in tissue banks (TBs). Methods Osteochondral fragments measuring 2 cm 3 of 5 corpse donors aged between 15 and 45 years old were analyzed. The samples were stored in cell preservation medium containing: human albumin, Iscove's and vancomycin preserved at 4°C. The concentration of proteoglycans in the extracellular medium was quantified by the use of Safranin-O, while tissue structural analysis was assessed by histological study with hematoxylin-eosin stained slides. The images obtained were analyzed according to the histological scores of Mankin and the score proposed by the OsteoArthritis Research Society International. The samples were analyzed with 0, 15, 30 and 45 days of preservation. Results The osteochondral fragments studied showed a progressive decrease in proteoglycan concentration with increased preservation time. After 30 days of preservation, structural changes were identified with discontinuity of the cartilage surface layer. According to the results obtained by the Mankin score, there was a statistically significant difference between 15 and 30 days of tissue preservation. Conclusion The protocol described defined knee transport immersed in Lactated Ringer at a controlled temperature of 10° C until its arrival at the TB. After processing, the preservation solution was composed of Iscove's serum-free cell culture medium supplemented with 10% human albumin and 100 µg/ml vancomycin. The tissue was preserved at a temperature of 4°C until the moment of transplantation characterizing the fresh preservation.

Protocol for Harvest, Transport and Storage of Human Osteochondral Tissue / Protocolo para captação, transporte e preservação de tecido osteocondral humano

Abstract Objective To elaborate a protocol for the harvest, transport, and preservation of human osteochondral tissue for use in tissue banks (TBs). Methods Osteochondral fragments measuring 2 cm3 of 5 corpse donors aged between 15 and 45 years old were analyzed. The samples were stored in cell preservation medium containing: human albumin, Iscove's and vancomycin preserved at 4ºC. The concentration of proteoglycans in the extracellular medium was quantified by the use of Safranin-O, while tissue structural analysis was assessed by histological study with hematoxylin-eosin stained slides. The images obtained were analyzed according to the histological scores of Mankin and the score proposed by the OsteoArthritis Research Society International. The samples were analyzed with 0, 15, 30 and 45 days of preservation. Results The osteochondral fragments studied showed a progressive decrease in proteoglycan concentration with increased preservation time. After 30 days of preservation, structural changes were identified with discontinuity of the cartilage surface layer. According to the results obtained by the Mankin score, there was a statistically significant difference between 15 and 30 days of tissue preservation. Conclusion The protocol described defined knee transport immersed in Lactated Ringer at a controlled temperature of 10º C until its arrival at the TB. After processing, the preservation solution was composed of Iscove's serum-free cell culture medium supplemented with 10% human albumin and 100 µg/ml vancomycin. The tissue was preserved at a temperature of 4ºC until the moment of transplantation characterizing the fresh preservation.

Resumo Objetivo Elaborar um protocolo para a captação, transporte e preservação de tecido osteocondral humano para utilização em banco de tecidos (BT). Métodos Foram analisados fragmentos osteocondrais com dimensão de 2 cm3 de 5 doadores cadáveres com idades entre 15 e 45 anos. As amostras foram armazenadas em meio de preservação celular contendo: albumina humana, Iscove's e vancomicina preservados à temperatura de 4ºC. A concentração de proteoglicanos no meio extracelular foi quantificada pelo uso de Safranina-O, enquanto a análise estrutural do tecido foi avaliada através de estudo histológico com lâminas coradas em hematoxilina-eosina. As imagens obtidas foram analisadas segundo os escore histológicos de Mankin e o escore proposto pela OsteoArthritis Research Society International. As amostras foram analisadas com 0, 15, 30 e 45 dias de preservação. Resultados Os fragmentos osteocondrais estudados apresentaram diminuição progressiva na concentração de proteoglicanos com o aumento do tempo de preservação. Após 30 dias de preservação, foram identificadas alterações estruturais com descontinuidade da camada superficial da cartilagem. Segundo os resultados obtidos pelo escore de Mankin, houve diferença com significância estatística entre 15 e 30 dias de preservação do tecido. Conclusão O protocolo descrito definiu o transporte de joelho em bloco imerso em Ringer Lactato em temperatura controlada a 10ºC até sua chegada ao BT. Após o processamento, a solução de preservação foi composta por meio de cultura celular sem soro Iscove's suplementado com albumina humana a 10% e vancomicina 100 µg/mL. O tecido foi preservado à temperatura de 4ºC até o momento do transplante caracterizando a preservação a fresco.

Sinergismo entre o vasto lateral e vasto medial oblíquo durante a marcha após a reconstrução do ligamento cruzado anterior / Synergism between vastus lateralis and vastus medialis oblique during gait after anterior cruciate ligament reconstruction

Objetivo: O objetivo deste estudo foi comparar a co-contração muscular (CCM) e ativação dos músculos vasto lateral (VL) vasto medial oblíquo (VMB) durante a marcha e uma amostra saudável ­ grupo controle (GC) e pacientes submetidos a reconstrução do ligamento cruzado anterior (RLCA). Métodos: Vinte e três indivíduos participaram neste estudo, 14 GC e 9 RLCA. A atividade mioelétrica do VL e VMO foram captados para cálculo da CCM. A razão VL/VMO foi obtida dividindo o sinal normalizado desses dois músculos em cada ponto da curva. O valor da CCM e a relação de ativação na fase de apoio duplo, fase de apoio simples, fase de apoio terminal e fase de balanço foram obtidas pelo cálculo da média aritmética dos valores de intensidade da curva comum em cada intervalo. Resultado: CCM foi significativamente menor no grupo RLCA durante a fase de apoio dupla (p=0.001), efeito máximo (1.72). Não foram encontradas diferenças entre as outras comparações. Conclusão: O resultado desse estudo mostrou que a contração dos músculos VL e o VMO na fase inicial de apoio duplo da marcha foi diferente entre indivíduos saudáveis e submetidos a RLCA. Este achado pode estar relacionado a diminuição da estabilidade patelofemoral durante a resposta a carga, aumentando o potencial risco de desenvolver lesões nesta articulação.

Objective: The aim of this study was to compare vastus lateralis and vastus medialis oblique (VL/VMO) muscle co-contraction (MCC) and activation ratio during gait between healthy subjects- control group (CG), and those with anterior cruciate ligament reconstruction (ACLR). Methods: Twenty-three subjects participated in this study, 14 CG and 9 ACLR. The myoelectric activities of the VL and VMO were captured to calculate the MCC. The VL/VMO ratio was obtained by dividing the normalized signals of these two muscles at each point of the curve. The MCC values and the activation ratio in the initial double limb stance, single limb stance, terminal double limb stance and swing were obtained by calculating the arithmetic mean of the intensity values ​​of the common curve in each interval. Results: MCC was significantly lower in the ACLR group during the initial double limb stance phase (p=0.001), with a high effect size (1.72). No significant differences were found for the other comparisons. Conclusions: The results of this study showed that the VL and VMO muscles co-contraction in the initial double limb stance phase of gait was different between the healthy and ACLR individuals. This finding may be related to lower patellofemoral stability during the loading response, increasing the potential risk for the development of injuries in this joint.

The use of tourniquet during total knee replacement in patients with and without popliteal artery calcification.

OBJECTIVE: Identify the clinical and surgical complications associated with the use of a tourniquet in total knee arthroplasty in patients with or without calcification of the popliteal artery. METHODS: The study was performed retrospectively, analyzing 58 patients with calcification of the popliteal artery and 57 patients as a control group. RESULTS: The case group patients were significantly older than patients in the control group; however, this had no impact on the clinical outcome in the analyzed period.There were no complications during surgery in the groups studied, as there were no statistically significant differences between the incidence of local or systemic intercurrences in the analyzed period. CONCLUSION: This study found low rates of complications in patients undergoing total knee arthroplasties with use of a tourniquet, with or without calcification of the popliteal artery.

OBJETIVO: Identificar as complicações clínicas e cirúrgicas associadas ao uso de torniquete na artroplastia total de joelho em pacientes com ou sem calcificação da artéria poplítea. MÉTODOS: O estudo foi feito de modo retrospectivo, analisou 64 pacientes com calcificação da artéria poplítea e 57 pacientes como grupo controle. RESULTADOS: Os pacientes do grupo de casos eram significativamente mais velhos do que os pacientes do grupo controle. Entretanto, tal fato não teve repercussão quanto ao desfecho clínico no período analisado. Não houve complicações durante o ato cirúrgico nos grupos estudados, bem como não houve diferenças estatisticamente significantes entre a incidência de intercorrências locais ou sistêmicas no período analisado. CONCLUSÃO: O presente estudo observou baixos índices de complicações em pacientes submetidos a artroplastia total do joelho com uso de torniquete com ou sem calcificação da artéria poplítea.

The use of tourniquet during total knee replacement in patients with and without popliteal artery calcification / O uso do manguito pneumático em pacientes submetidos a artroplastia total do joelho com ou sem calcificação da artéria poplítea

ABSTRACT Objective: Identify the clinical and surgical complications associated with the use of a tourniquet in total knee arthroplasty in patients with or without calcification of the popliteal artery. Methods: The study was performed retrospectively, analyzing 58 patients with calcification of the popliteal artery and 57 patients as a control group. Results: The case group patients were significantly older than patients in the control group; however, this had no impact on the clinical outcome in the analyzed period.There were no complications during surgery in the groups studied, as there were no statistically significant differences between the incidence of local or systemic intercurrences in the analyzed period. Conclusion: This study found low rates of complications in patients undergoing total knee arthroplasties with use of a tourniquet, with or without calcification of the popliteal artery.

RESUMO Objetivo: Identificar as complicações clínicas e cirúrgicas associadas ao uso de torniquete na artroplastia total de joelho em pacientes com ou sem calcificação da artéria poplítea. Métodos: O estudo foi feito de modo retrospectivo, analisou 64 pacientes com calcificação da artéria poplítea e 57 pacientes como grupo controle. Resultados: Os pacientes do grupo de casos eram significativamente mais velhos do que os pacientes do grupo controle. Entretanto, tal fato não teve repercussão quanto ao desfecho clínico no período analisado. Não houve complicações durante o ato cirúrgico nos grupos estudados, bem como não houve diferenças estatisticamente significantes entre a incidência de intercorrências locais ou sistêmicas no período analisado. Conclusão: O presente estudo observou baixos índices de complicações em pacientes submetidos a artroplastia total do joelho com uso de torniquete com ou sem calcificação da artéria poplítea.